Strengthening tertiary care without a matching primary and secondary care referral system risks overburdening premier institutions. Analyse.

India's health system is meant to work as a pyramid. Primary care sits at the base, district hospitals form the middle, and super-specialty care sits at the top and takes patients on referral. PMSSY has built up the top: 18 of 22 new AIIMS are fully functional, and together they have handled about 6.01 crore OPD consultations since 2021-22 [1]. If the lower tiers stay weak, this rising footfall can turn premier institutes into crowded general OPDs.

How a weak referral chain overburdens the apex

• No gatekeeping: OPD figures count every patient seen without admission. They do not separate patients referred by a lower facility from those who walked in directly [1]. As a result, routine illnesses take up queues meant for complex cases.
• Demand outpaces capacity: Annual OPD rose from 50.03 lakh to 144.96 lakh between 2021-22 and 2025-26 [1]. The CAG found bed shortages of 43–84% in the Phase I AIIMS [2].
• Workforce strain: Faculty posts were 55–83% vacant [2]. Doctors tied up in the OPD have less time for advanced care, teaching and research, the three roles an AIIMS is meant to combine [1].
• Hollow middle tier: When district hospitals lack ICUs, manageable cases get pushed upward. PM-ABHIM's district Critical Care Blocks are explicitly meant to "reduce referrals to higher facilities" [3].

Structural causes

• Federal mismatch: Health is a State subject, but PMSSY is a fully Centre-funded Central Sector Scheme [4]. The Centre builds the top tier, while the lower tiers depend on uneven state capacity.
• Weak upgradation of existing colleges: Only 8 of 19 audited GMCIs had finished their upgrades, and some blocks stood idle for lack of staff and equipment [2].

The counter-view

• Spreading AIIMS across regions also spreads the load. As the network grew from 6 to 18 functional institutes, OPD per institute stayed roughly constant at about 8 lakh a year (approximate calculation) [1][5].

Way forward

• Require referral-based OPD access for non-emergency cases, routed through Ayushman Arogya Mandirs and district hospitals.
• Complete the Critical Care Blocks, and the referral linkages planned for smaller districts [3].
• Publish figures for each AIIMS on beds, filled posts and the share of referred patients, as the CAG's call for evaluation studies implies [2].
• Hire staff before opening an institute, using Standing Selection Committees, deputation and retired faculty [6].

Tertiary capacity is necessary, but it works only as the top of a linked chain of care. If primary and district care are strengthened alongside PMSSY, the new AIIMS can focus on what only they can do. That would move India towards the universal health coverage goal of SDG 3.8.