OVER-CENTRALISATION THREATENS FEDERAL HEALTH POLICY

Why in the News?

  • The Supreme Court, in the case Tanvi Behl vs Shrey Goyal (2025), has struck down domicile-based reservations in post-graduate medical admissions.
  • The judgment applies to State government medical colleges, marking a significant shift in India’s medical education policy.
  • The Court held that domicile-based reservations violate Article 14 (Right to Equality) of the Constitution.

About the News

  • This ruling dismantles a key mechanism used by States to secure a stable and locally suited medical workforce for their public health systems.
  • While upholding meritocracy, the judgment overlooks the critical link between medical education policies and State-level public health planning.
  • The decision centralises medical education governance, potentially disincentivising States from investing in government medical colleges.
  • This shift could turn competitive federalism into a race to the bottom, where States lose motivation to invest in public medical education.

OVER-CENTRALISATION THREATENS FEDERAL HEALTH POLICY

DOMICILE QUOTAS IN STATE HEALTH PLANNING

Role of Domicile Quotas:

  • Domicile-based reservations in post-graduate medical courses play a crucial role in aligning State investments in medical education with local health-care workforce retention.
  • States invest significant public funds to train medical students, with the expectation that these doctors will serve the local health system after graduation.
  • Given chronic shortages of specialists, domicile quotas help ensure a predictable supply of doctors who are familiar with the State’s health-care needs and systems.

Misapplication of Legal Precedent:

  • The Supreme Court’s reliance on Pradeep Jain vs Union of India (1984) to strike down domicile-based post-graduate reservations overlooks key differences between undergraduate (MBBS) and post-graduate (specialist) medical education.
  • Post-graduate courses are the primary pipeline for replenishing specialist doctors, unlike MBBS courses that focus on foundational training.
  • Removing domicile quotas disrupts this pipeline, forcing States to rely on unpredictable external recruitment to fill specialist positions.

Impact on State Investments in Medical Education:

  • Without domicile quotas, States lose a critical policy tool for ensuring that public investment in medical colleges translates into a local specialist workforce.
  • This weakens State incentives to fund medical education, which could lead to:
    • Declining infrastructure in government medical colleges.
    • Worsening regional disparities in health-care access.

Disparity with Central Institutions:

  • Premier central institutions like AIIMS, PGIMER, and JIPMER enjoy greater autonomy in selecting candidates aligned with their institutional goals.
  • State government medical colleges — which are even more critical for public health delivery at the grassroots level — are denied this same autonomy.

Constitutional and Public Health Link:

  • Article 21 guarantees the right to life, which includes access to adequate health care — an area where States bear primary responsibility under their legislative competence over public health.
  • Government medical colleges are not just educational institutions, but also serve as vital pillars of State health infrastructure.
  • Viewing them only as academic centres ignores their larger role in public health delivery.

Need for State Autonomy:

A systems-based approach to public health planning highlights the need for State autonomy in:

  • Admissions at undergraduate, post-graduate, and super-specialty levels.
  • Policy formulation suited to local socio-economic and health conditions.
  • Excessive centralisation — reinforced through court rulings — hinders State-specific health strategies, compromising both State-level public health governance and the right to health under Article 21.

Legislative and Judicial Responsibility:

  • Both legislatures and the judiciary must recognise that State government medical colleges are integral components of public health infrastructure, not merely education hubs.
  • Policies and judgments must reflect their dual role in both medical education and sustaining public health systems.

THE FALLACY OF ABSOLUTE MERITOCRACY

Rigid Merit Framework:

  • The Supreme Court’s insistence on strict meritocracy overlooks the structural inequities present in India’s medical entrance system, particularly in NEET-PG.
  • Analysis of NEET-PG results highlights flaws in the merit assessment process, including cases where candidates with negative marks qualify due to percentile-based cutoffs.

Example – NEET PG 2023:

  • In 2023, the National Medical Commission (NMC), following Ministry of Health directives, reduced the qualifying percentile for NEET-PG and Super Speciality exams to zero to fill vacant seats.
  • This demonstrates how merit standards are flexible in practice to accommodate administrative needs.

Inconsistent Approach to Equity:

  • If regional and socio-economic disparities are recognised in undergraduate admissions, there is no strong justification for excluding such considerations in post-graduate admissions.

Narrow View of Merit:

  • The Court’s approach reflects a narrow, decontextualised concept of merit, ignoring how social and economic contexts shape access to opportunities.
  • Landmark judgments — including Jagdish Saran & Ors vs Union of India (1982), Pradeep Jain (1984), Neil Aurelio Nunes & Ors vs Union of India (2022), and Om Rathod vs The Director General of Health Services (2024) — have all recognised that:
  • Administrative efficiency should be measured not just by abstract merit, but by outcomes that: Promote societal good; Redress structural inequalities.

Domicile Reservations and Social Merit:

  • Domicile-based reservations prioritise candidates who are more likely to remain and serve in their home States, enhancing health-care access and reducing regional disparities.
  • This aligns with a broader, more inclusive understanding of merit, which considers social outcomes rather than just exam performance.
  • The Economic Survey 2024-25 also acknowledged the importance of local retention for strengthening regional health systems.

NEED FOR A RECONSIDERATION

Precedent and Changing Context:

  • The Supreme Court’s ruling is based on precedents from Pradeep Jain and the Constitution Bench, but these precedents were framed in a very different health-care context.
  • Today, retaining specialists within State health systems is more urgent than ever, particularly given:
  • The COVID-19 pandemic.
  • The rising burden of non-communicable diseases (NCDs).

Balanced Alternative Approach: Instead of outright elimination, a more balanced approach would:

  • Retain domicile quotas, but link them to public service obligations.
  • Example: Tamil Nadu’s medical education framework ties reservations to mandatory service in public health institutions, ensuring State investment directly benefits the local health-care system.
  • Such innovative models deserve judicial and policy consideration, rather than blanket rejection.

Meritocracy Misapplication: The ruling reflects a well-intentioned but flawed application of meritocracy, which ignores the operational realities of:

  • State public health governance.
  • The State’s role in planning and managing health-care delivery.

Overreach into Policy Design: The judgment blurs the boundary between constitutional interpretation and detailed policy design, which should typically be the domain of legislatures and executive authorities.

  • Risks of Over-Centralisation: By reinforcing centralised control over medical admissions, the ruling risks:
  • Weakening State investment in medical education.
  • Worsening regional health disparities.
  • Eroding competitive federalism.

Call for Reconsideration:

  • A reconsideration of the verdict is essential to ensure States retain autonomy to structure medical education policies aligned with their local health-care needs.
  • The Court’s view that domicile quotas pose a national risk is misguided — instead, excessive centralisation poses a greater threat to federal health policy.

Judicial Doctrine and Health Policy: To build a robust, sustainable health-care system, judicial interpretation must evolve to:

  • Acknowledge the complex interplay between medical education, federalism, and public health governance.
  • Enable States to formulate context-specific policies without unwarranted interference.

Source:https://www.thehindu.com/opinion/lead/over-centralisation-threatens-federal-health-policy/article69295183.ece 

Mains Question (250 words):

Critically examine the Supreme Court’s ruling striking down domicile-based reservations in post-graduate medical admissions. Discuss its implications on public health governance, competitive federalism, and State investment in medical education.