Health systems in India: primary, secondary and tertiary care

In short

India's public health system is organised in three tiers — primary (sub-centre, PHC, now Ayushman Arogya Mandir), secondary (CHC, sub-district and district hospitals) and tertiary (medical colleges, AIIMS, super-speciality institutes) — each with a defined population norm, staffing pattern and referral role. Public health is a State subject under the Seventh Schedule, so the Centre funds and sets standards (IPHS, NHM) while States deliver, alongside a very large private sector that supplies most outpatient care. Understanding tiers, norms, referral flow and financing is the core of "health systems" or "health care delivery" papers in BPH/B.Sc Public Health and MPH entrance tests, and is asked in interviews for roles in NHM, district programme management units, hospital administration, insurance (PM-JAY/TPA), CSR and health NGOs.

Explained

What a health system is, and how India's is governed

• A health system (WHO definition) is all organisations, people and actions whose primary intent is to promote, restore or maintain health — not just hospitals.
• WHO's six building blocks: service delivery; health workforce; health information systems; access to essential medicines and technologies; financing; leadership/governance. Exam questions often ask these in order.
• Constitutional basis: "Public health and sanitation, hospitals and dispensaries" is State List, Entry 6; "population control and family planning" and medical education are Concurrent List (Entries 20A and 25). Article 47 (DPSP) directs the State to raise nutrition and public health; the right to health is read into Article 21 by courts.
• Centre's instruments: Ministry of Health and Family Welfare (Departments of Health & Family Welfare, Health Research, AYUSH is a separate Ministry); National Health Mission (NHM) with NRHM (2005) and NUHM (2013) sub-missions; National Health Policy 2017; NITI Aayog's Health Index; regulators — National Medical Commission (NMC Act, 2019, which replaced the MCI), National Commission for Allied and Healthcare Professions Act, 2021, National Nursing and Midwifery Commission Act, 2023 (replacing the Indian Nursing Council Act), CDSCO for drugs, AERB for radiation.
• State and district machinery: State Directorate of Health Services and State Health Society → District Health Society / Chief Medical Officer (CMO) or District Medical & Health Officer, District Programme Management Unit → Block (Taluka) Medical Officer → PHC medical officer → sub-centre ANM → ASHA at village level.
• Local bodies: the 73rd and 74th Amendments devolve health, sanitation and nutrition functions to Panchayati Raj Institutions and urban local bodies; Village Health, Sanitation and Nutrition Committee (VHSNC) and Rogi Kalyan Samiti / Patient Welfare Society at facilities handle untied funds.

Primary care: the first tier

• Primary health care (Alma-Ata Declaration, 1978; re-affirmed at Astana, 2018) is essential care made universally accessible, at a cost the community and country can afford, with community participation. Its elements are often remembered as the eight "ELEMENTS" of Alma-Ata (health education, nutrition, safe water and sanitation, MCH including family planning, immunisation, control of local endemic diseases, treatment of common diseases and injuries, essential drugs).
• Primary care ≠ primary health care: primary care is first-contact clinical care; primary health care is a whole strategy with intersectoral action and equity.
• Sub-centre (SC): the most peripheral contact point — norm 1 per 5,000 population in plain areas and 1 per 3,000 in hilly/tribal/desert areas. Staffed by an ANM/MPW(F) plus an MPW(M) (often vacant); provides antenatal care, immunisation, contraception, ORS, basic drugs.
• Primary Health Centre (PHC): norm 1 per 30,000 (plain) / 1 per 20,000 (hilly/tribal); a medical officer, 14-15 staff, 4-6 beds; refers upward and supervises 6 sub-centres. 24×7 PHCs run round-the-clock delivery services.
• Ayushman Arogya Mandir (AAM) — the renamed Health and Wellness Centre (HWC) of Ayushman Bharat (2018): SCs and PHCs upgraded to deliver an expanded package of 12 services — pregnancy/childbirth, newborn and child health, adolescent care, family planning, communicable diseases, common ophthalmic and ENT problems, oral health, elderly and palliative care, emergencies and trauma, mental health, and screening/management of non-communicable diseases (hypertension, diabetes, oral, breast and cervical cancer). The SC-level centre is led by a Community Health Officer (CHO) — a BSc Nursing or Ayurveda graduate with the 6-month Certificate in Community Health.
• Urban primary care under NUHM: Urban PHC per about 50,000 population, Urban CHC per 2.5-5 lakh, with ASHAs and Mahila Arogya Samitis.
• Community health workers: ASHA — one per about 1,000 rural population (one per habitation in tribal areas), an incentive-based volunteer, not a salaried employee; AWW under ICDS (Ministry of Women and Child Development) for supplementary nutrition and pre-school education. The ASHA-ANM-AWW trio is the field front line.

Secondary care: CHC, sub-district and district hospitals

• Community Health Centre (CHC): norm 1 per 1,20,000 (plain) / 1 per 80,000 (hilly/tribal); 30 beds, with four specialists in the classical norm — physician, surgeon, obstetrician-gynaecologist and paediatrician — plus radiography, laboratory, operation theatre and blood storage. It is the First Referral Unit (FRU) when it provides comprehensive emergency obstetric care, newborn care and blood transfusion round the clock.
• Sub-divisional / sub-district hospital (SDH): about 31-100 beds, serving 5-6 lakh population; takes load off the district hospital and acts as an FRU.
• District hospital (DH): the apex secondary facility, 75-500 beds depending on district population (IPHS sizes it by population and bed-occupancy), with specialists, ICU, blood bank, imaging and a district public health laboratory; also the hub for district-level programme management and medico-legal work.
• Indian Public Health Standards (IPHS): the Ministry's benchmark for infrastructure, human resources, drugs, equipment and quality at each level — first issued 2007, revised 2012, with the 2022 revision aligning standards to AAMs and NCD services and adding a measurable assessment/scoring tool. Facilities are classed "essential" (must have) and "desirable".
• Quality certification: NQAS (National Quality Assurance Standards), Kayakalp (cleanliness), LaQshya (labour room and maternity OT quality), MusQan (child-friendly services) — all run by the Ministry; NABH accreditation for hospitals and NABL for laboratories are voluntary, though PM-JAY and insurers reward them.

Tertiary care and the referral chain

• Tertiary care: specialised, technology-intensive, usually teaching institutions — medical college hospitals, AIIMS network, PGIMER Chandigarh, JIPMER Puducherry, NIMHANS, Tata Memorial, regional cancer centres, and super-speciality blocks built under PMSSY (Pradhan Mantri Swasthya Suraksha Yojana), which both sets up new AIIMS and upgrades existing medical colleges.
• Quaternary/specialised public health institutions: NCDC, NIV Pune, ICMR institutes, the National Institute of Health and Family Welfare (NIHFW) and NCDIR for training and research; Critical Care Blocks in district hospitals under PM-ABHIM.
• Referral system: the intended path is community → SC/AAM → PHC → CHC/FRU → SDH → DH → medical college. A working referral needs a referral slip, transport (108 ambulance, 102/Janani Express for maternity), feedback to the referring unit and a two-way information flow.
• Bypassing: patients routinely skip tiers for perceived quality, drug availability and specialist presence, so tertiary hospitals carry heavy primary-care loads (long OPD queues) while PHC beds stay empty. Gatekeeping — making lower-level clearance necessary — is weak in India unlike the UK NHS.
• Levels of care map onto prevention: primary tier does mostly primary and secondary prevention (immunisation, screening); secondary tier early diagnosis and treatment; tertiary tier disability limitation and rehabilitation.

Private sector, pluralism and mixed provision

• The private sector provides roughly 60-70% of outpatient care and a little under half to about 55-60% of inpatient care nationally (NSS 75th round, 2017-18 and NFHS-5 patterns; shares vary widely by State — Kerala and Tamil Nadu differ sharply from Bihar and Odisha). Treat exact shares as survey-dependent.
• Forms: solo practitioners and nursing homes, corporate chains (Apollo, Fortis, Max, Narayana Health), charitable and mission hospitals (CMC Vellore), ESI and CGHS for defined beneficiaries, Railways/Defence/PSU hospitals, and AYUSH systems (Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy) with their own dispensaries and the National AYUSH Mission.
• Regulation of private care: the Clinical Establishments (Registration and Regulation) Act, 2010 — adopted by some States/UTs only, since health is a State subject; several States run their own nursing-home or clinical-establishment Acts. Other relevant laws: Drugs and Cosmetics Act 1940, PCPNDT Act 1994, MTP Act 1971 (amended 2021), Transplantation of Human Organs Act 1994, Mental Healthcare Act 2017, Epidemic Diseases Act 1897, Biomedical Waste Management Rules 2016 (as amended), Consumer Protection Act 2019 (services include health care), Rights of Persons with Disabilities Act 2016, Food Safety and Standards Act 2006.
• Public-private partnership: diagnostics and dialysis under PPP at district hospitals, free-diagnostics and free-drugs initiatives, empanelment of private hospitals under PM-JAY.

Financing, access and performance

• Total health expenditure is roughly 3.8% of GDP (National Health Accounts 2021-22 estimates), of which government health expenditure is about 1.8-1.9% of GDP and about 48% of the total; out-of-pocket expenditure (OOPE) has fallen to roughly 39-40% of total health expenditure, from about 65% a decade earlier. These are NHA estimates and revised annually — quote the year with the figure.
• National Health Policy 2017 targets: public health spending 2.5% of GDP by 2025, States to spend more than 8% of their budget on health, and two-thirds of resources to primary care.
• Schemes: Ayushman Bharat PM-JAY — ₹5 lakh per family per year of secondary and tertiary hospitalisation cover for the bottom ~40% (SECC-based), extended in 2024 to all citizens aged 70 and above irrespective of income; PM-ABHIM (infrastructure: AAMs, block public health units, critical care blocks, integrated public health labs); Ayushman Bharat Digital Mission (ABHA ID, health facility and professional registries); 15th Finance Commission health grants through local bodies; PMBJP/Jan Aushadhi generic stores; Pradhan Mantri National Dialysis Programme.
• Information systems: HMIS, Reproductive and Child Health (RCH) portal, IDSP/IHIP for disease surveillance, NIKSHAY for TB, Co-WIN/U-WIN for immunisation, Civil Registration System and SRS for vital statistics, NFHS and NSS for survey data.
• Strengths: vast public network and a vertical-programme record (smallpox eradication 1977, polio-free certification 2014, yaws, maternal and neonatal tetanus elimination), low-cost private innovation, large pharmaceutical capacity.
• Weaknesses: human-resource shortfalls (specialist vacancy at CHCs is the worst gap in Rural Health Statistics), urban-rural and inter-State inequity, weak gatekeeping and referral, under-regulated private sector, high OOPE on outpatient care and medicines (which PM-JAY does not cover), and fragmentation across vertical programmes.

Key points

• Health system - all organisations and actions intended to promote, restore or maintain health; WHO's six building blocks are service delivery, workforce, information, medicines, financing, governance.
• Constitutional position - public health is in the State List (Entry 6); family planning and medical education are Concurrent; Article 47 is the DPSP on public health.
• Three tiers - primary (SC, PHC/AAM), secondary (CHC, SDH, district hospital), tertiary (medical college, AIIMS, super-speciality).
• Sub-centre norm - 1 per 5,000 plain / 3,000 hilly-tribal; staffed by ANM; most peripheral contact point.
• PHC norm - 1 per 30,000 plain / 20,000 hilly-tribal; one medical officer, 4-6 beds, supervises 6 sub-centres.
• CHC norm - 1 per 1,20,000 plain / 80,000 hilly-tribal; 30 beds, four specialists; becomes an FRU with 24×7 emergency obstetric care, newborn care and blood storage.
• First Referral Unit (FRU) - the three non-negotiables are 24×7 surgical/obstetric care, newborn care and blood storage/transfusion.
• Ayushman Arogya Mandir - renamed Health and Wellness Centre; 12-service package including NCD screening; CHO-led at sub-centre level.
• ASHA - one per ~1,000 rural population, incentive-based volunteer link worker; ANM is salaried, AWW belongs to ICDS.
• IPHS - Indian Public Health Standards, benchmarks per facility level; 2007, revised 2012 and 2022 (with a scoring tool).
• NHM - umbrella mission with NRHM (2005) and NUHM (2013); funds flow through State and District Health Societies.
• PM-JAY - ₹5 lakh/family/year hospitalisation cover for the poorest ~40%, plus all persons aged 70+ since 2024; it covers hospitalisation, not outpatient care.
• NHP 2017 targets - 2.5% of GDP public health spending, States above 8% of their budget, two-thirds of resources to primary care.
• NHA 2021-22 - total health expenditure ~3.8% of GDP; government share ~48% of THE (1.84% of GDP); OOPE ~39-40%, down from ~65%.
• Alma-Ata 1978 and Astana 2018 - the two declarations defining primary health care; Alma-Ata's slogan was "Health for All by 2000".
• Referral failure - bypassing of PHCs leaves tertiary OPDs overloaded; India has no compulsory gatekeeping.
• Private sector - majority of outpatient care; regulated (where adopted) by the Clinical Establishments Act, 2010, which States must enact or adopt.
• Prevention mapping - primary tier delivers promotion and primary/secondary prevention; tertiary tier handles disability limitation and rehabilitation.

Formulas and examples

Example 1 - how many facilities a district needs. A plain-area district has a rural population of 24,00,000.

• Sub-centres = 24,00,000 ÷ 5,000 = 480
• PHCs = 24,00,000 ÷ 30,000 = 80
• CHCs = 24,00,000 ÷ 1,20,000 = 20
• Check the internal ratio: 480/80 = 6 sub-centres per PHC and 80/20 = 4 PHCs per CHC — consistent with the norm.

Example 2 - shortfall. The same district actually has 410 sub-centres, 62 PHCs and 11 CHCs.

• Sub-centres: (480 − 410)/480 × 100 = 70/480 = 14.6% shortfall
• PHCs: (80 − 62)/80 × 100 = 18/80 = 22.5% shortfall
• CHCs: (20 − 11)/20 × 100 = 9/20 = 45% shortfall
• Interpretation: the gap widens as you climb the tiers — the national pattern in Rural Health Statistics, where specialist-dependent CHCs are worst served.

Example 3 - district hospital bed indicators. A 300-bed district hospital in a 30-day month records 7,650 inpatient days and 1,275 discharges (including deaths).

• Available bed-days = 300 × 30 = 9,000
• BOR = 7,650 ÷ 9,000 × 100 = 85%
• ALOS = 7,650 ÷ 1,275 = 6.0 days
• Bed turnover = 1,275 ÷ 300 = 4.25 discharges per bed per month
• At 85% BOR the hospital is efficiently used but has little surge room; an outbreak would force referral upward.

Example 4 - catastrophic spending. A household's annual consumption expenditure is ₹2,40,000; it spends ₹32,000 out of pocket on a surgery and follow-up medicines.

• Share = 32,000 ÷ 2,40,000 × 100 = 13.33%
• Above the 10% SDG threshold → catastrophic health expenditure, though below the 25% threshold.
• If PM-JAY had covered the ₹26,000 hospitalisation component, OOPE = ₹6,000 → 2.5% — below the threshold; the residual ₹6,000 of outpatient drugs shows why OOPE stays high even with insurance.

Example 5 - public spending target. A State with a GSDP of ₹10,00,000 crore and a total budget of ₹2,50,000 crore spends ₹14,000 crore on health.

• As % of GSDP = 14,000 ÷ 10,00,000 × 100 = 1.4% (against the NHP 2017 goal of 2.5%)
• As % of budget = 14,000 ÷ 2,50,000 × 100 = 5.6% (against the goal of more than 8%)
• To reach 8% of budget it must spend 0.08 × 2,50,000 = ₹20,000 crore — an increase of ₹6,000 crore.

Where it is used

• Government programme management: District Programme Managers, Block Programme Managers and consultants in NHM/State Health Society roles size facilities against IPHS, compute shortfalls and monitor HMIS indicators.
• Hospital administration: BOR, ALOS and turnover drive bed planning, staffing rosters and NQAS/NABH assessments in district hospitals and private chains (Apollo, Narayana Health, Manipal).
• Health insurance and TPAs: PM-JAY State Health Agencies, insurers and TPAs use empanelment criteria, package rates and referral documentation; claim audit roles need the tier structure.
• Public health research and surveys: NFHS, NSS health rounds, IIPS, ICMR and PHFI studies on access, OOPE and utilisation; evaluation roles at NITI Aayog and State health systems resource centres.
• Development sector: NGOs and foundations (Piramal Swasthya, Jhpiego, PATH, Gates Foundation partners, SEARCH Gadchiroli) that run or support primary-care platforms and ASHA training.
• Pharma, diagnostics and digital health: rural market and access teams, PPP diagnostics operators, and ABDM/ABHA-linked health-tech products that must fit the existing referral chain.

Interview questions

• Q: Name the three tiers of rural health care in India with their population norms. A: Sub-centre 1 per 5,000 (3,000 hilly/tribal), PHC 1 per 30,000 (20,000), CHC 1 per 1,20,000 (80,000).
• Q: What is the difference between primary care and primary health care? A: Primary care is first-contact clinical service; primary health care, as defined at Alma-Ata, is a whole strategy of essential, equitable, affordable care with community participation and intersectoral action.
• Q: What makes a CHC a First Referral Unit? A: Round-the-clock emergency obstetric and surgical care, newborn care and blood storage with transfusion facility — all three must be functional.
• Q: Who leads an Ayushman Arogya Mandir at sub-centre level, and what does it add? A: A Community Health Officer with the Certificate in Community Health; it expands the package from maternal and child health to 12 services including NCD screening, mental health, elderly and palliative care.
• Q: Is health a Central or State subject in India? A: Public health, hospitals and dispensaries are in the State List; family planning and medical education are Concurrent, which is why Centre schemes operate through State Health Societies.
• Q: What are IPHS and why do they matter? A: Indian Public Health Standards — the Ministry's benchmarks for staff, drugs, equipment and infrastructure at each facility level, revised in 2022 with a scoring tool used in facility assessments.
• Q: Why do tertiary hospital OPDs stay crowded if the three-tier system works? A: There is no compulsory gatekeeping, and patients bypass PHCs because of staff absence, drug stock-outs and a preference for specialists, so tertiary centres absorb primary-level cases.
• Q: PM-JAY gives ₹5 lakh cover, yet OOPE is still around 39-40%. Why? A: PM-JAY covers hospitalisation for a defined population; most OOPE is outpatient consultation, diagnostics and medicines, which the scheme does not reimburse.
• Q: Differentiate ASHA, ANM and AWW. A: ASHA is an incentive-based village volunteer link worker (about 1 per 1,000); ANM is the salaried sub-centre health worker; AWW runs the Anganwadi under ICDS in the Women and Child Development ministry.
• Q: A 200-bed hospital has 5,400 inpatient days in 30 days. What is its BOR? A: 5,400 ÷ (200 × 30) × 100 = 90% — high occupancy with little surge capacity.
• Q: Which body replaced the Medical Council of India, and what regulates allied health professionals? A: The National Medical Commission under the NMC Act, 2019; allied and healthcare professionals come under the National Commission for Allied and Healthcare Professions Act, 2021.
• Q: Why is the Clinical Establishments Act, 2010 unevenly enforced? A: Health is a State subject, so each State must adopt or enact it; many States apply their own laws or none, leaving large parts of the private sector lightly regulated.

Common mistakes

• Quoting one population norm for all terrain — the hilly, tribal and desert norms (3,000 / 20,000 / 80,000) are different and are often the marked part of the answer.
• Treating every CHC as an FRU; only those with 24×7 obstetric-surgical care, newborn care and blood storage qualify.
• Calling the ASHA a government employee — she is an incentive-based volunteer, and the AWW is not under the health department at all.
• Confusing NHM components: NRHM (2005) and NUHM (2013) are sub-missions of NHM; PM-ABHIM (infrastructure) and PM-JAY (insurance) are separate pillars of Ayushman Bharat.
• Mixing up NHP 2017 targets with achievements — 2.5% of GDP is a target; actual government health spending is about 1.8-1.9% of GDP.
• Computing BOR against discharges instead of inpatient days, or ALOS against admissions instead of discharges including deaths.
• Quoting expenditure, bed or shortfall figures without the source and year; NHA, Rural Health Statistics and NFHS numbers are revised and differ.

Related topics

Foundations of public health: history, determinants and levels of prevention · Health and education economics · Population and society · National health programmes and disease control · Health management information systems and surveillance · Hospital administration and quality accreditation