Introduction

India’s health governance follows a quasi-federal structure where health is constitutionally a State subject. However, increasing centralisation, particularly in medical education and national health schemes, is raising concerns over States’ autonomy and the effectiveness of federal health policies.

Judicial Push Towards Centralisation

The recent Supreme Court ruling in Dr. Tanvi Behl vs Shrey Goyal (2025) declared domicile-based reservations in post-graduate (PG) medical admissions unconstitutional, citing Article 14 and the principle of meritocracy. This decision, however, overlooks the critical link between State investments in medical education and their ability to retain specialists within local health systems. Domicile quotas served as a strategic tool to ensure a stable, locally adapted healthcare workforce, especially amid chronic specialist shortages.

Striking down such quotas may discourage States from investing in medical institutions if their graduates are siphoned off to other regions. Unlike central institutions like AIIMS or PGIMER, which enjoy selection autonomy, State medical colleges now face limited control over admissions, weakening their role as pillars of regional health systems.

Centralisation Through Policy and Institutions

Beyond judiciary-led centralisation, several national initiatives have expanded the Centre's role:

• National Health Mission (NHM): While implemented by States, funding and guidelines remain Centre-dominated.
• Ayushman Bharat (2018) and AB Digital Mission: These schemes shifted healthcare financing and data control towards the Centre, reducing the relevance of State-run insurance programs.
• National Medical Commission Act (2019): Replacing the MCI, this law enhanced the Centre's control over medical education regulation.
• Epidemic and Disaster Management Acts: Empower the Centre during health emergencies, as witnessed during COVID-19.

Consequences of Over-Centralisation

Excessive centralisation undermines India’s diverse health needs and local governance:

• Limited Responsiveness to Local Needs: Uniform policies ignore State-specific demographics. For instance, Kerala requires elderly care, while Bihar and UP demand maternal and child health focus.
• Reduced Decision-Making Power: States lose flexibility in tailoring central schemes, as seen with Ayushman Bharat PM-JAY.
• Bureaucratic Inefficiencies: Delays in fund disbursal under centrally sponsored schemes hinder timely execution.
• Weakening of Local Health Systems: Panchayats and municipal bodies—crucial to grassroots delivery—are often bypassed in favour of top-down mechanisms.

Meritocracy vs Social Equity

The rigid focus on merit in PG admissions disregards structural inequalities. As seen in recent NEET-PG cutoffs being lowered to zero percentile to fill seats, the current meritocratic model is flawed. Regional representation and public service outcomes should be considered in defining ‘merit’, aligning medical education with societal needs.

Way Forward

• Restore State Autonomy in Admissions: States should be empowered to design admissions aligned with local healthcare priorities.
• Fiscal and Functional Decentralisation: Grant flexibility in using central funds and reduce bureaucratic controls.
• Strengthen Cooperative Federalism: Institutionalise Centre-State coordination in health planning and policy-making.
• Invest in Local Systems: Enhance capacities of State health departments and grassroots governance bodies.

Conclusion

While central guidance is essential for national health objectives, excessive centralisation risks weakening India’s federal health architecture. A balanced approach rooted in cooperative federalism is vital to create an inclusive, efficient, and resilient healthcare system for all.