Over-centralisation threatens federal health policy

Over-centralisation threatens federal health policy
 Source: The Hindu (March 6, 2025)

Context and Background of the Issue

The Supreme Court ruling in Dr. Tanvi Behl vs. Shrey Goyal (2025) struck down domicile-based reservations in post-graduate (PG) medical admissions, arguing that it violated Article 14 (Right to Equality) of the Indian Constitution. This decision impacts federal health policy by reinforcing centralization in medical education and state health workforce planning.

However, the judgment raises critical governance concerns regarding:

1.     The functional role of states in public health planning

2.     The necessity of domicile quotas for regional healthcare sustainability

3.     The impact of absolute meritocracy on equitable medical workforce distribution

Key Concerns Raised by the Judgment

Domicile-Based Reservations & Their Role in State Health Policy

 Purpose of Domicile Quotas in Medical Admissions

·         States invest substantial resources in training medical professionals at government-run medical colleges.

·         Expectation: These doctors serve the state’s healthcare needs after completing education.

·         Given specialist shortages, domicile quotas ensure a stable and regionally distributed supply of doctors familiar with local disease patterns, languages, and healthcare infrastructure.

Impact of Removing Domicile-Based Quotas

Disrupts the Pipeline of Specialist Doctors:

·         Many PG doctors move to other states or prefer private sector jobs, weakening the local healthcare system.

·         Example: In states like Bihar and Odisha, which already suffer from a lack of specialists, this ruling could exacerbate doctor shortages.

Weakens State Investment in Medical Colleges:

• States may reduce funding for medical education since they cannot retain doctors trained in government institutions.
• Could lead to poor infrastructure, fewer faculty members, and declining medical education quality.

Increases Dependence on External Recruitment:

• Recruiting doctors from outside is unpredictable due to linguistic, cultural, and regional health variations.
• Example: Tamil Nadu’s rural healthcare relies heavily on local doctors, and sudden reliance on doctors from other states can disrupt the system.

Over-Centralisation & Federalism

Why is Competitive Federalism Essential in Medical Education?

• Federalism allows states to develop their own healthcare models tailored to regional needs.
• Over-centralisation restricts states from designing policies that address their specific health concerns.
• Example: AIIMS, PGIMER, and JIPMER have autonomous admission policies, but state medical colleges are denied similar flexibility.

Legal Perspective: Role of Public Health in Federalism

Centralization vs. State Autonomy

Public Health is a State Subject (Entry 6, List II, Seventh Schedule)

·         The Indian Constitution gives states the primary responsibility for healthcare.

·         However, medical education falls under the Concurrent List (Entry 25, List III), allowing both the Union and State governments to regulate it.

• Limiting state control over medical education conflicts with their legislative competence in public health policy.
• The ruling restricts states from implementing domicile-based reservations, impacting their ability to retain medical specialists who are trained using state resources.

Article 21 (Right to Life) & Healthcare Access:

• The Supreme Court has previously ruled that adequate healthcare is a fundamental right under Article 21.
• Removing domicile-based quotas could worsen health inequalities, making it harder for states to provide adequate medical care.

Competitive Federalism and Disincentives for States

• Competitive federalism encourages states to invest in medical education to attract talent and improve healthcare.
• However, if states cannot ensure that their investment translates into a stable workforce, they may reduce funding for medical colleges.
• This could widen regional disparities, as poorer states may find it difficult to compete with wealthier states or central institutions like AIIMS, PGIMER, and JIPMER.

Additional Insights

Comparative Example:

• In the USA, states regulate medical licensing to ensure doctors serve in areas where they are most needed.
• In Germany, federal and state governments collaborate to ensure equitable distribution of healthcare professionals.

India’s Health Infrastructure Challenge:

• According to the Rural Health Statistics Report (2023), India faces a shortage of over 80,000 specialist doctors in rural hospitals.
• Centralizing medical education without considering state-specific needs may further exacerbate doctor shortages in underserved areas.

The Fallacy of Absolute Meritocracy

 Understanding the Flaws in India’s Medical Entrance System

• NEET-PG and percentile-based cutoffs are not a perfect reflection of merit.
• NEET-PG 2023: The National Medical Commission had to lower the qualifying percentile to zero to fill vacant PG seats.
• The flaws in entrance exams raise questions about rigid meritocracy when considering healthcare service delivery.

 Is “Merit” Alone Sufficient for Equitable Healthcare?

 Judicial Precedents on Social Context of Merit:

• Jagdish Saran vs. Union of India (1982): Merit should align with national and social goals.
• Neil Aurelio Nunes vs. Union of India (2022): Reservation policies must account for socio-economic inequalities.
• Om Rathod vs. DGHS (2024): Administrative efficiency should not override the goal of inclusive healthcare.

Impact on Regional Disparities:

• The Economic Survey 2024-25 highlights that students with domicile-based PG seats are more likely to serve in their home states.
• Removing these reservations could deprive rural and underserved regions of essential medical professionals.

The Role of Domicile-Based Reservations in Healthcare

The Purpose of Domicile Quotas

• Domicile-based reservations help states retain doctors trained within their own system, particularly in post-graduate and super-specialty courses.
• Unlike undergraduate MBBS courses, where students receive basic medical training, postgraduate courses create specialists who are crucial for a state's long-term health strategy.
• Without these reservations, rural and economically weaker states may suffer from a brain drain, where specialists move to urban centers or other states.

Court’s Rationale and Critique

• The Supreme Court relied on Pradeep Jain vs. Union of India (1984), which ruled against domicile-based quotas for undergraduate medical admissions.
• However, the article argues that post-graduate education is different as it directly impacts the availability of specialists in a state.
• Alternative models, such as public service-linked quotas, could ensure a balance between merit and equitable healthcare distribution.

Additional Insights

• Alternative Approaches to Addressing Doctor Shortages:
• Bond Systems: Some states like Tamil Nadu and Maharashtra require doctors trained in public institutions to serve in rural areas for a mandatory period.
• Financial Incentives: Offering higher salaries and better working conditions in underserved areas can help retain doctors.
• Decentralized Recruitment: Empowering state medical colleges with greater autonomy in admissions to align with regional needs.

The Myth of Absolute Meritocracy

Flaws in NEET-PG and Postgraduate Admissions

• The NEET-PG system, which replaced state-based medical entrance exams, claims to uphold meritocracy but has several structural inequities:
• Percentile-Based Cut-offs: In 2023, the National Medical Commission lowered the qualifying percentile for NEET-PG to zero to fill vacant seats.
• Urban Bias: Students from wealthier, urban backgrounds with better access to coaching institutes often outperform rural candidates.
• Lack of Regional Consideration: Unlike undergraduate admissions, post-graduate merit rankings do not account for regional or socio-economic disparities.

Merit in Context

• The Supreme Court’s ruling favors a rigid notion of meritocracy, ignoring ground realities.
• Merit must be redefined to include:
• Social responsibility: A doctor serving in a remote area provides more societal value than one practicing in an urban private hospital.
• Contextual performance: Candidates trained in rural medical colleges may be better suited for public healthcare than high scorers from private institutes.

Additional Insights

• Legal Precedents:
• In Neil Aurelio Nunes vs. Union of India (2022), the Supreme Court upheld reservation policies, emphasizing that merit must consider historical and social disadvantages.
• In Om Rathod vs. DGHS (2024), the Court recognized that administrative efficiency must be measured by outcomes, not just exam scores.
• International Practices:
• In Canada, medical students commit to regional service obligations in exchange for subsidized education.
• In Japan, the government assigns medical graduates to rural hospitals for fixed-term service.

Judicial Overreach in Policy Making

Is the Supreme Court Overstepping Its Role?

• The article suggests that the Court’s ruling interferes in policy-making, a function of the executive and legislature.
• While courts must uphold constitutional principles, they should not dictate policy details without considering ground realities.

Legislative and Executive Response

• The Union and State governments should reconsider policy alternatives rather than accepting the ruling as final.
• Some potential approaches:
• Parliamentary Legislation: The Centre could enact a law allowing domicile quotas, providing states more flexibility.
• State-Level Reforms: States could introduce bond-linked reservations, requiring doctors to serve in public health institutions.

Additional Insights

• Doctrine of Separation of Powers:
• The judiciary should focus on constitutional interpretation, not policy formulation.
• Courts in Germany and France rarely intervene in executive healthcare policies, leaving such decisions to elected representatives.

Need for Re-evaluation & Alternative Solutions

Reassessing the Role of Domicile-Based Reservations

·        Instead of Eliminating Domicile Quotas, Introduce a Public Service Commitment Model

ü Tamil Nadu’s Medical Education Framework:

• Links reservation policies with mandatory service in government institutions.
• This ensures a return on state investment while addressing regional doctor shortages.
• Other states can implement similar models, requiring PG students benefiting from domicile quotas to serve in public hospitals for a few years.

ü Decentralised Medical Education Policies

• Grant state medical colleges more autonomy in PG admissions.
• Allow states to frame policies based on their unique public health needs.

ü Judicial Doctrine Needs to Evolve

• Courts must recognize that medical education is not just about producing graduates—it’s about ensuring equitable healthcare access.
• A balanced approach must consider:
• State rights in public health governance.
• Societal impact of medical workforce shortages.
• Structural inequities in medical education.

Conclusion & Future Implications

The Supreme Court ruling, though grounded in constitutional principles, overlooks real-world healthcare challenges. Over-centralisation risks widening regional disparities, weakening federalism, and discouraging state investment in medical education.

Key Takeaways

1.     State autonomy in medical education is critical for effective healthcare governance.

2.     A rigid meritocratic system disregards social context and regional healthcare disparities.

3.     Public service-linked reservation models offer a better alternative to outright quota removal.

4.     Judicial and policy decisions should integrate social justice with healthcare equity.

Final Thought: If India aims to build a sustainable and inclusive healthcare system, judicial and policy frameworks must evolve to accommodate the interplay between medical education, federalism, and public health needs.

Relevance for Competitive Exams

 Polity & Constitution:

• Article 14 (Right to Equality) & Its Interpretation
• Article 21 (Right to Life & Healthcare Access)
• State List vs. Central List in Medical Education

Governance & Public Health:

• Impact of Over-Centralisation on Health Policy
• Federalism & Decentralisation in Medical Education
• State vs. Centre Conflicts in Policy Implementation

 Current Affairs & Judiciary:

• Key Supreme Court Judgments on Medical Education:
• Dr. Tanvi Behl vs. Shrey Goyal (2025)
• Pradeep Jain vs. Union of India (1984)
• Neil Aurelio Nunes vs. Union of India (2022)
• Jagdish Saran vs. Union of India (1982)

Possible Mains Question (UPSC, State PSCs, Judiciary Exams):

 “The Supreme Court’s ruling on domicile-based medical reservations weakens federalism and disrupts state healthcare planning. Critically analyze.”

 Possible Prelims Questions:

Which Article of the Constitution ensures the Right to Life, including healthcare? (Ans: Article 21)
NEET-PG percentile-based cutoffs are criticized for which reason? (Ans: Merit evaluation flaws and exclusion of regional disparities)

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