Tiered Public-Health Referral System

India’s tiered public-health referral system organises care into primary, secondary and tertiary levels according to the complexity of services required. Patients should enter near their homes, move upward for specialist care when necessary, and return through counter-referral for follow-up, creating a continuum of care.

Primary level: first contact and screening

Sub-health centres and primary health centres provide community outreach, preventive care, basic treatment, screening and referral. For common non-communicable diseases, population-based screening focuses on adults aged 30 years and above, including screening for oral, breast and cervical cancers.

• ASHAs mobilise eligible people, undertake community-based risk assessment and support follow-up.
• Trained primary-care personnel use oral visual examination, clinical breast examination and visual inspection with acetic acid for cervical cancer screening.
• Screening identifies people needing further evaluation; it does not by itself establish a cancer diagnosis.

Secondary and tertiary levels: progressively specialised care

A person with a suspicious or screen-positive finding is referred to a community health centre, district hospital or appropriate higher facility, depending on available services.

• Secondary facilities provide clinical evaluation, diagnostic tests, specialist consultation and inpatient care beyond the primary level.
• Cases needing biopsy, histopathology, staging or specialised treatment are linked to medical colleges or tertiary cancer centres.
• Tertiary facilities provide advanced specialist and super-specialist services; equipped centres may provide surgery, radiotherapy, chemotherapy or other appropriate cancer care.

Referral, counter-referral and continuity

The tiers function as a connected network rather than isolated facilities. Referral moves patients to higher expertise, while counter-referral communicates diagnoses and care plans back to local teams.

• Documentation and patient tracking help primary-care teams reduce delays and loss to follow-up.
• Local teams support treatment adherence, rehabilitation, palliative support and surveillance after specialist care.
• Clear referral criteria allow scarce specialist capacity to be used for patients who genuinely require it.