The public health system in India accommodates direct walk-ins and referred patients at facilities across all levels of care (primary, secondary, and tertiary level facilities). Nevertheless, there is a form of gatekeeping in place, in which public primary care facilities provide referrals to secondary/tertiary facilities. However, in rural areas, due to delays in access, poor availability and quality of services, individuals who can afford private care choose to directly seek secondary/tertiary care services privately after their initial primary care consultations. Whereas, in urban areas, the public is likely to directly access secondary/tertiary facilities because of higher demand for care by specialists and the perception that quality of care is better at higher level facilities (Faizi et el., 2016; Mohan and Kumar, 2019; Rural Health Information Hub, 2021).

In the public health care system in India, a referral chain arrangement exists where community-based providers and facilities provide referral advice for care seeking at the next or ever higher level on a case-to-case basis. The referral linkages are bidirectional and rather more evident for maternal health services, where first referral units have been clearly identified. Although health policies and program designs call for referral-based rationing at different tiers of the system, in practice, care can be directly sought at any health kiosk without referral from lower-level health care provider. For example, in urban areas where tertiary care settings are overburdened, the public prefers these facilities as there is a higher demand for care by specialists than by primary care physicians. It is a prevalent perception that quality of care at higher-level facilities is better than the one available at lower levels. On the other hand, in rural communities, it has been noted that care-seekers usually divert to the private providers after an initial consultation with the primary level facilities, as referral care is perceived as costly and inconvenient (Faizi et el., 2016; Mohan and Kumar, 2019; Rural Health Information Hub, 2021).

References:

Faizi, N., Khalique, N., Ahmad, A., & Shah, M. S. (2016). The dire need for primary care specialization in India: Concerns and challenges. Journal of family medicine and primary care, 5(2), 228–233. https://doi.org/10.4103/2249-4863.192382

Mohan, P., & Kumar, R. (2019). Strengthening primary care in rural India: Lessons from Indian and global evidence and experience. Journal of family medicine and primary care, 8(7), 2169–2172. https://doi.org/10.4103/jfmpc.jfmpc_426_19

Rural Health Information Hub. (2021). Healthcare access in rural communities. RHI Hub. Available from: https://www.ruralhealthinfo.org/topics/healthcare-access