Over-centralisation threatens federal health policy Premium

The judgment on domicile-based reservations in post-graduate medical admissions misapprehends the complex relationship between medical education policies and State public health planning

The recent Supreme Court judgment, in Dr. Tanvi Behl vs Shrey Goyal (2025), which struck down domicile-based reservations in post-graduate medical admissions in the respective medical colleges in States, marks a significant shift in India’s medical education policy. The ruling, holding that such reservations violate Article 14 of the Constitution, dismantles a mechanism that States have long relied upon to ensure a stable medical workforce suited to public health needs. While upholding meritocracy, it misapprehends the complex relationship between medical education policies and State public health planning. By entrenching a centralising bias in India’s medical education framework, it risks disincentivising State investment in government medical colleges — transforming competitive federalism into a race to the bottom.

Domicile-based reservations in post-graduate medical courses serve a crucial function in aligning State investment in medical education with health-care personnel retention. States allocate substantial resources to train medical students, expecting that these graduates will contribute to the local health-care system. Given chronic specialist shortages, domicile quotas ensure a predictable supply of doctors familiar with the State’s health-care landscape. The Court’s reliance on Pradeep Jain vs Union of India (1984) to eliminate domicile-based post-graduate reservations overlooks the essential distinction between undergraduate and post-graduate education. Unlike MBBS programmes, where students gain foundational knowledge, post-graduate courses are the primary channel through which States replenish their specialist workforce. Removing domicile quotas disrupts this pipeline, making States becoming increasingly reliant on external recruitment — a process fraught with unpredictability and inefficiencies.

By striking down domicile quotas, the judgment weakens the incentive for States to invest in medical education. A well-functioning system of competitive federalism encourages States to develop robust institutions to attract and retain talent. However, if States cannot ensure that their investment translates into a local specialist workforce, their incentive to fund medical education diminishes. Without domicile reservations, States may deprioritise medical college funding, leading to declining infrastructure and worsening regional health-care disparities. This stands in contrast to premier central institutions such as the All India Institute of Medical Sciences (AIIMS), the Postgraduate Institute of Medical Education and Research (PGIMER), and the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), which are granted selection autonomy. State medical colleges — arguably even more vital to India’s public health architecture — are now denied a similar prerogative, disadvantaging States in planning for their long-term healthcare needs.

Article 21 of the Indian Constitution guarantees the right to life, including access to adequate health care, while public health remains under State legislative competence. Medical colleges are not merely institutions of higher education; they are also a crucial part of the State’s health infrastructure. Viewing them solely as centres for producing medical graduates is a limited perspective. A broader, systems-based approach highlights the connection between the right to life, public health, and medical education. Given the role of State government medical colleges in sustaining public health, it is essential to recognise the State government’s need for autonomy in the selection process at the undergraduate, post-graduate and super-specialty levels. This ensures that medical education aligns with local health-care needs, reinforcing that these institutions serve a greater purpose than academics alone. Excessive centralisation, unwittingly powered by court rulings, restricts States from formulating policies suited to their public health needs and socio-economic circumstances. Legislatures and the judiciary must acknowledge that government medical colleges are integral to State health-care infrastructure.

The Court’s insistence on a rigid meritocratic framework ignores the structural inequities inherent in India’s medical entrance system. An analysis of the National Eligibility cum Entrance Test (Postgraduate), or NEET-PG, results reveals significant flaws in how merit is assessed, including instances where candidates with negative marks qualify due to percentile-based cutoffs.

A recent example from 2023 saw the National Medical Commission, following directives from the Ministry of Health, reduce the qualifying percentile for NEET PG and Super Speciality examinations to zero to fill vacant seats. If undergraduate admissions recognise regional and socio-economic disparities, there is little justification for excluding such considerations from post-graduate admissions. Furthermore, the judgment perpetuates a narrow conception of merit that disregards its social context. As noted in judgments on medical education in cases such as Jagdish Saran & Ors vs Union Of India & Ors (1982), Pradeep Jain (1984), Neil Aurelio Nunes & Ors vs Union of India (2022), and Om Rathod vs The Director General Of Health Services (2024), administrative efficiency should be measured not by abstract merit alone but by outcomes that promote societal good and redress structural inequalities. By prioritising candidates more likely to remain and serve in their home States — as acknowledged by the Economic Survey 2024-25 — domicile-based reservations enhance health-care access and mitigate regional disparities — aligning with a broader, more inclusive definition of merit.

While the Court’s ruling follows precedents from Pradeep Jain and the Constitution Bench, it merits re-evaluation. The original framework, which drew a rigid line between undergraduate and post-graduate admissions, was formulated in a different health-care landscape. Today, retaining specialists within State health systems is more pressing than ever, particularly in light of crises such as the COVID-19 pandemic and the rising burden of non-communicable diseases. Rather than eliminating domicile quotas outright, a more balanced approach would integrate these reservations with public service obligations. For instance, Tamil Nadu’s medical education framework links quotas to service mandates in public institutions, ensuring that State investment yields tangible health-care benefits. Such models deserve greater judicial and policy consideration rather than outright dismissal.