DESK REVIEWS | Does primary care access act as a gatekeeper system for access to secondary and tertiary care?

DESK REVIEW | Does primary care access act as a gatekeeper system for access to secondary and tertiary care?

The primary care system is conceptualized for acting as a gatekeeper system. This is one of the aims in the provision of health care in Brazil. The primary care model is in line with the provision of universal access and comprehensive healthcare, it aims to coordinate  the access to specialist and hospital care, and it promotes actions for health promotion and disease prevention (Paim et al., 2011). Investments and organisational strategies, such as the establishment of the Community Health Agents Programme and the Family Health Strategy – FHS, have been carried out and have been helpful to reorganize primary care clinics to focus on the community and to integrate medical care with health promotion and public health actions (Brazilian Ministry of Health, 2019d; Paim et al., 2011).

In addition, more investments in decentralized and computerized regulatory systems have been made by municipalities. These result in the possibility of monitoring of waiting lists for specialized care, increase of service supply, introduction to clinical guidelines, and use of electronic medical records. These strategies end up integrating primary healthcare with the network of specialised services (Paim et al., 2011). According to a study conducted in four Brazilian capitals, referrals to secondary care services that come from family health care teams are usually more effective and have shorter waiting times (Almeida et al., 2010). Although all these advances have been achieved, it is necessary to remember that the primary care system in Brazil may be circumvented by people willing to pay out-of-pocket to access services immediately.


Almeida, P. F. de, Giovanella, L., Mendonça, M. H. M. de, & Escorel, S. (2010). Desafios à coordenação dos cuidados em saúde: Estratégias de integração entre níveis assistenciais em grandes centros urbanos. Cadernos de Saúde Pública, 26(2), 286–298.

Brazilian Ministry of Health. (2019d). Estratégia Saúde da Família (ESF).

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797.

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).


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 care5(2), 228–233.

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 care8(7), 2169–2172.

Rural Health Information Hub. (2021). Healthcare access in rural communities. RHI Hub. Available from:

Yes. The health service delivery system in Kenya is organized across six levels of care, with the first level at the community level and continuing through primary care services, which include dispensaries (level 2) and health centres (level 3), and county referral health services (level 4 & 5) all the way to the national referral health services (level 6). Higher health care facilities act as referral centres for lower-level facilities. For instance, level 1 is the foundation of health care service delivery and referral to a higher level of care is performed to seek additional services such as diagnosis, treatment, admission or to seek expert opinion (Ministry of Health, 2014d). However, sometimes patients bypass the low-level facilities depending on proximity and go directly to higher levels of care resulting to high caseloads. In some circumstances, referral by a health worker from higher to lower levels of care (except level 1) is made, particularly if the higher health facility is far from the client’s home and the client has been prescribed medicines that are available at a nearby lower health facility.

In terms of private health care, the referral chain is not structured as access to health services is based on proximity and the ability to pay for the services. Some community members access the services of community health providers (residing within their communities) while others visit nearby private clinics where referral to a specialist is made if necessary. However, patients can go directly to a specialist without a referral.


Ministry of Health. (2014d). Kenya Health Sector Referral Strategy. Ministry of Health Division of Emergency and Disaster Risk Management Afya House.


Yes, within the public system (MoH and social security institutions), gatekeeper systems are in place (primary care, secondary, high specialisation), but not in the private sector.