Public Sector Health Care Delivery in India

India’s public health sector forms the backbone of healthcare delivery for its 1.4 billion citizens. Designed to provide equitable, affordable, and accessible care to every citizen-especially in rural and underserved areas-this system operates through a well-structured network of facilities at different levels. Understanding how these facilities work together can help nursing students and healthcare professionals appreciate the critical role each plays in improving population health outcomes.

The three-tier public health system 🔗

India’s public healthcare infrastructure is organized into a three-tier system designed to ensure healthcare reaches even the most remote areas. This hierarchical structure includes Sub-Centres at the most peripheral level, Primary Health Centres at the intermediate level, and Community Health Centres at the block level. The design ensures that patients receive appropriate care at each level, with referral pathways to higher facilities when needed.

The concept of this tiered system was first recommended in the historic Bhore Committee Report of 1946, which laid the foundation for India’s current health policy framework. The committee envisioned a system where preventive and curative healthcare would be integrated, with health workers on government payrolls ensuring access independent of an individual’s socioeconomic status.

Sub-centres: The first point of contact 🔗

Sub-centres represent the most peripheral and first contact point between the community and the primary health care system. These facilities are established based on population norms-one sub-centre serves approximately 5,000 people in plain areas and 3,000 people in hilly, tribal, or difficult-to-access regions.

Each sub-centre is staffed by a multipurpose health worker (male and female) who provides basic preventive and promotive healthcare services. Their responsibilities include immunization, maternal and child health services, family planning counseling, and health education. As of the latest data, India has over 1,67,275 sub-centres functioning across the country.

Primary Health Centres: The first medical contact point 🔗

Primary Health Centres serve as the cornerstone of rural healthcare in India, functioning as the first point of contact with a qualified doctor. Each PHC covers a population of 30,000 in general areas and 20,000 in hilly or tribal regions. These centres typically have four to six indoor observation beds and offer a comprehensive range of services.

PHCs provide promotive, preventive, curative, and rehabilitative care, including maternal and child health services, immunization, nutrition programs, family welfare services, and treatment of common ailments. Each PHC is headed by a Medical Officer and supported by paramedical staff including nurses, pharmacists, and laboratory technicians. Currently, there are 26,636 PHCs operating in India, with over 12,453 functioning as 24×7 facilities.

Community Health Centres: The referral hub 🔗

Community Health Centres function as the first referral units in the public health system. Each CHC serves a population of 1,20,000 in plain areas and 80,000 in difficult terrain. These are 30-bed hospitals that accept patients referred from PHCs and provide more specialized services.

CHCs are staffed by four specialists-a surgeon, physician, obstetrician-gynecologist, and pediatrician-along with nursing staff and support personnel. They are equipped with X-ray facilities, laboratory services, and operation theatres for minor and major surgeries. CHCs must provide round-the-clock emergency obstetric care, newborn care, and maintain blood storage facilities. India currently has 6,155 CHCs operational across the country.

District hospitals and higher referral facilities 🔗

District hospitals represent the secondary care level, serving as the tertiary referral centres for primary and community health centres. These facilities provide comprehensive care including specialist consultations, advanced diagnostic services, and surgical interventions. With 759 district hospitals functioning in India, they form a crucial link in the referral chain.

Beyond district hospitals, the public health system includes sub-divisional hospitals at the tehsil level, specialized hospitals for specific conditions, and teaching hospitals attached to medical colleges. These tertiary care institutions handle complex cases requiring super-specialty services and advanced technology.

National Health Policy 2017: The guiding framework 🔗

The National Health Policy 2017 represents India’s strategic roadmap for achieving universal health coverage. Its primary goal is to attain the highest possible level of health and well-being for all citizens through a preventive and promotive healthcare orientation, with universal access to quality services without financial hardship.

The policy emphasizes several key principles including professionalism, integrity, equity, affordability, and patient-centered care. It proposes increasing public health expenditure to 2.5% of GDP and allocating two-thirds of the health budget to primary healthcare. Specific targets include reducing infant mortality rate to 28 per 1,000 live births, increasing life expectancy to 70 years by 2025, and reducing the total fertility rate to 2.1 at national and sub-national levels.

Ayushman Bharat: Transforming primary healthcare 🔗

Launched in 2018, Ayushman Bharat represents a paradigm shift from selective healthcare to comprehensive service delivery. This flagship program has two complementary components designed to achieve universal health coverage.

Health and Wellness Centres 🔗

The first component involves transforming 1,50,000 existing sub-centres and PHCs into Ayushman Arogya Mandirs (formerly Health and Wellness Centres). These upgraded facilities deliver Comprehensive Primary Health Care spanning preventive, promotive, curative, rehabilitative, and palliative services-all free to users.

The expanded service package includes care in pregnancy and childbirth, neonatal and infant care, childhood and adolescent health services, family planning, management of communicable diseases, screening and management of non-communicable diseases, care for elderly and palliative needs, oral and ENT care, eye care, mental health services, and emergency medical services. As of 2023, over 1,60,480 Ayushman Arogya Mandirs have been operationalized across India.

These centres are led by Community Health Officers-a new cadre of mid-level healthcare providers trained through specialized programs. They work alongside ANMs, ASHAs, and other frontline workers to deliver care closer to communities, ensuring “time to care” within 30 minutes of any habitation.

Pradhan Mantri Jan Arogya Yojana 🔗

The second component, PM-JAY, provides health insurance coverage of Rs. 5 lakh per family per year to over 10 crore poor and vulnerable families for secondary and tertiary hospitalization. This cashless, paperless scheme allows beneficiaries to access services at any empanelled hospital across India, providing crucial financial protection against catastrophic health expenditure.

National Health Mission: Strengthening health systems 🔗

The National Health Mission serves as the primary vehicle for strengthening public health infrastructure. It provides financial and technical support to states for improving facilities, filling human resource gaps, ensuring availability of essential drugs and diagnostics, and enhancing service delivery quality.

Under NHM, high-focus states can allocate up to 33% of their funds for infrastructure, while other states can use up to 25%. The Pradhan Mantri Ayushman Bharat Health Infrastructure Mission, launched with an outlay of Rs. 64,180 crore, further strengthens critical care facilities and primary care infrastructure in both urban and rural areas.

Challenges and the path forward 🔗

Despite significant progress, India’s public health sector continues to face challenges including inadequate infrastructure, shortage of healthcare professionals, and urban-rural disparities in service availability. Many facilities still operate below recommended standards, and the distribution of specialists remains uneven.

However, the systematic approach through policies like NHP 2017 and programs like Ayushman Bharat demonstrates commitment to addressing these gaps. The integration of AYUSH systems (Ayurveda, Yoga, Unani, Siddha, and Homeopathy) alongside modern medicine provides patients with informed choices while leveraging traditional healthcare knowledge.

The focus on community participation through Village Health Sanitation and Nutrition Committees, ASHA workers, and Rogi Kalyan Samitis ensures that healthcare planning responds to local needs. With continued investment and attention to implementation, India’s public health sector is progressively moving toward the goal of accessible, affordable, and quality healthcare for all.

What do you think? How can nursing professionals contribute to strengthening primary healthcare delivery in rural India? What additional measures would help bridge the gap between urban and rural health services?

References

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC5144115/
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4. https://en.wikipedia.org/wiki/Public_health_system_in_India
5. https://pmc.ncbi.nlm.nih.gov/articles/PMC10292032/
6. https://www.pib.gov.in/newsite/Printrelease.aspx?relid=159376
7. https://pmc.ncbi.nlm.nih.gov/articles/PMC7340764/
8. https://nha.gov.in/PM-JAY
9. https://ab-hwc.nhp.gov.in/
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11. https://www.pib.gov.in/Pressreleaseshare.aspx?PRID=1848808
12. https://www.who.int/india/health-topics/primary-health-care