Understanding Health Care: Concept, Levels, and Delivery Systems in India

When most people hear the words “health care,” they picture a doctor in a white coat, a hospital bed, or a pharmacy counter. But health care is much broader than the treatment of illness. It includes everything a society does to keep people healthy, restore them when they fall sick, and rehabilitate them afterwards. Understanding how this system is organised – from a sub-centre in a remote village to a super-specialty hospital in a metro city – is essential for anyone studying public health, nutrition, or community development.

What is health care? 🔗

Health care refers to the multitude of services rendered to individuals, families, or communities by health service providers for the purpose of promoting, maintaining, monitoring, or restoring health. It is wider than the term “medical care,” which usually refers only to the personal care given by a doctor or other health professional. Health care covers preventive, promotive, curative, rehabilitative, and increasingly palliative services, delivered by a chain of workers ranging from ASHAs and ANMs in villages to surgeons and researchers in tertiary centres.

The World Health Organization treats access to quality health services as a fundamental human right and a core component of Universal Health Coverage. In practical terms, this means that good health care is not only about curing disease but about clean water, immunisation, nutrition counselling, antenatal check-ups, mental health support, and even health education in schools. It is the sum of all these activities – not just hospitals – that determines a population’s health.

Health care versus medical care 🔗

The two terms are often used interchangeably, but they are not the same. Medical care is largely individual and curative, focused on diagnosis and treatment. Health care is collective and continuous, covering the entire spectrum from prevention to rehabilitation. A pulse-polio booth on a Sunday morning, a school-based deworming day, a Poshan Abhiyaan growth-monitoring camp, and a cardiac bypass surgery are all forms of health care – but only the last one is purely medical care.

Levels of health care 🔗

To make services available to every citizen, modern health systems are organised in three levels – primary, secondary, and tertiary. This three-tier framework was first recommended for India by the Bhore Committee in 1946 and has since been reinforced by successive National Health Policies and the National Health Mission. Each level serves a distinct purpose, but together they form a continuum of care linked by a referral system.

Primary health care 🔗

Primary health care is the first point of contact between an individual and the formal health system. It is essential care made universally accessible to individuals and families in the community, at a cost they can afford. The idea was crystallised globally in the Alma-Ata Declaration of 1978, which committed nations to the goal of “Health for All.”

Primary care handles roughly 80-90% of a community’s health needs. Its services include maternal and child health, immunisation, family planning, treatment of common ailments, control of locally endemic diseases, health and nutrition education, provision of essential drugs, and access to safe water and sanitation. In India, this level is delivered through Sub-Centres, Primary Health Centres (PHCs), and Urban Primary Health Centres, many of which have now been upgraded into Ayushman Arogya Mandirs – formerly known as Ayushman Bharat Health and Wellness Centres.

Secondary health care 🔗

When a condition cannot be managed at the primary level, the patient is referred upward to the secondary level. Secondary care provides more complex curative services through specialists – typically physicians, surgeons, paediatricians, and gynaecologists – supported by basic diagnostic and inpatient facilities. In India, Community Health Centres (CHCs), Sub-Divisional Hospitals, and District Hospitals form the backbone of this tier. A CHC, for instance, covers a population of about 1,20,000 in plain areas and 80,000 in hilly or tribal regions and serves as the First Referral Unit for nearby PHCs, as outlined in the Ministry of Health’s Rural Health Care System documents.

Secondary care is intermediate but vital. It is where most surgeries, deliveries with complications, blood-bank services, and short-stay admissions take place. Without a functional secondary tier, primary care has nowhere to refer its patients and tertiary care quickly becomes overwhelmed.

Tertiary health care 🔗

Tertiary care is the apex of the system – highly specialised, technology-intensive, and usually accessed on referral. It covers procedures like neurosurgery, cardiac bypass, organ transplantation, oncology, and advanced neonatology, alongside medical research and training of health professionals. Premier institutions such as the All India Institute of Medical Sciences (AIIMS), PGIMER Chandigarh, JIPMER Puducherry, large state medical colleges, and the super-specialty wings of major private hospitals deliver this level of care.

One of the major challenges India faces is an “inverted pyramid” of utilisation. Because primary and secondary tiers are sometimes under-equipped, patients with minor ailments often bypass them and crowd tertiary hospitals, leading to long waits, high out-of-pocket spending, and resource wastage. Strengthening the lower tiers is therefore as much about easing pressure on tertiary centres as about expanding rural access.

Health care delivery in India 🔗

India’s public health system is one of the largest in the world by sheer scale. It is organised as a pyramid from the national level down to the village, with each tier feeding into the next through referrals, supervision, reporting, and resource flow. The architecture is shared between the Centre and the States, with health being primarily a State subject under the Constitution.

National and state level 🔗

At the apex sits the Ministry of Health and Family Welfare, supported by directorates, the National Health Mission, the National Centre for Disease Control, ICMR, and autonomous bodies like the National Health Authority that runs PM-JAY. The Centre frames policy, funds national programmes, sets standards, and procures vaccines and key drugs.

Each state has its own Department of Health and Family Welfare, headed by a minister and a state secretariat, which adapts national programmes to local needs. The state directorate translates policy into action through districts, mobilises a state-level workforce, runs medical colleges, and operates teaching hospitals.

District level 🔗

The district is the principal unit of health administration in India. The Chief Medical Officer (or District Medical and Health Officer) oversees all public health activities within the district. The District Hospital is the secondary referral centre for the entire district and is supported by a network of CHCs and PHCs. District-level offices coordinate disease surveillance, the cold chain for vaccines, training, and data flow to the state.

Block, PHC, and sub-centre level 🔗

Below the district lies the block, which usually has at least one Community Health Centre acting as the First Referral Unit. Each block contains several Primary Health Centres; norms set by the Ministry stipulate one PHC for every 30,000 people in the plains and 20,000 in hilly or tribal areas, while a Sub-Centre serves every 5,000 and 3,000 people respectively. A PHC is staffed by a Medical Officer and about 14 paramedical workers and acts as the referral unit for around six Sub-Centres.

The Sub-Centre, manned by an Auxiliary Nurse Midwife (ANM) and a male health worker, is the most peripheral institution and the actual face of the system in rural India. It is here that immunisation drives, antenatal check-ups, family planning counselling, and basic drug supply happen day after day.

Village level and community participation 🔗

At the village level, the system relies heavily on community-based functionaries. The Accredited Social Health Activist (ASHA), introduced under the National Rural Health Mission in 2005, is a trained female community health volunteer who acts as the bridge between the people and the health system. Anganwadi workers under the Integrated Child Development Services (ICDS) handle supplementary nutrition, growth monitoring, pre-school education, and immunisation support. Village Health, Sanitation and Nutrition Committees (VHSNCs) and Jan Arogya Samitis enable community planning and oversight.

This grassroots layer is what gives the Indian system its reach. A pregnant woman in a remote village may never meet a cardiologist, but she will almost certainly interact with an ASHA, an ANM, and an Anganwadi worker – and through them, with the wider machinery of public health.

The push toward comprehensive primary health care 🔗

The latest major reform is the transformation of Sub-Centres and PHCs into Ayushman Arogya Mandirs under the Ayushman Bharat programme launched in 2018. These centres are designed to deliver Comprehensive Primary Health Care, expanding services beyond maternal and child health to include screening and management of non-communicable diseases, mental health, oral and eye care, palliative care, and basic emergency services. They are supported by a new cadre of Community Health Officers, free essential medicines, free diagnostics, and tele-consultation links to higher centres.

According to a narrative review published in 2024, more than 1.7 lakh Ayushman Arogya Mandirs have been operationalised across the country, reflecting one of the largest primary health care expansions in the world. Alongside this, the Pradhan Mantri Jan Arogya Yojana provides cashless secondary and tertiary care up to ₹5 lakh per family per year to economically vulnerable households, completing the continuum from the village to the hospital.

Equity, integration, and the road ahead 🔗

The guiding principle behind India’s three-tier system is equitable distribution – bringing essential services within reach of every citizen, regardless of where they live or what they earn. Equity, however, is still a work in progress. Rural areas continue to face shortfalls in infrastructure, specialists, and diagnostics, while private providers dominate urban tertiary care. Out-of-pocket expenditure on health remains high, often pushing families into poverty.

Strengthening primary care, integrating AYUSH services, using digital tools like the Ayushman Bharat Digital Mission to connect records across tiers, and improving the referral chain are the major directions of current policy. For students of public health and nutrition, understanding this architecture is the starting point for any meaningful contribution – whether it is designing a nutrition programme, evaluating a vaccination drive, or working with a Panchayat on village health planning.

What do you think? If you had to strengthen one layer of India’s three-tier health system to improve overall outcomes, would you invest in village-level workers like ASHAs, in fully-equipped Community Health Centres, or in tertiary super-specialty hospitals – and why? And how might the answer differ for a rural district in Bihar compared to a metro city like Mumbai?

References

1. https://www.who.int/health-topics/universal-health-coverage
2. https://www.nhp.gov.in/bhore-committee-1946_pg
3. https://www.who.int/teams/primary-health-care/alma-ata-anniversary
4. https://aam.mohfw.gov.in/
5. https://www.mohfw.gov.in/sites/default/files/rural%20health%20care%20system%20in%20india.pdf
6. https://www.aiims.edu/index.php?lang=en
7. https://www.mohfw.gov.in/
8. https://www.pib.gov.in/PressReleasePage.aspx?PRID=1896950
9. https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=150&lid=226
10. https://nhsrcindia.org/practice-areas/cpc-phc/comprehensive-primary-health-care
11. https://pmc.ncbi.nlm.nih.gov/articles/PMC12975087/