The health sector in India stands at a critical juncture due to the unitary approach adopted by the Union government. The Constitution of India envisages a federal and decentralised administration in healthcare. On the contrary, in the post-globalisation era, the Union government devised health policies that systematically eroded State autonomy in healthcare and medical education. This has been driven by constitutional amendments, centralised regulatory frameworks, and centralised government schemes that override State-specific needs. It is recommended that constitutional and operational State autonomy in various domains be restored to ensure federal balance, state-specific public health delivery, and improved health care efficiency.
Key concerns
The 42nd Constitutional Amendment (1976) moved medical education from the State List to the Concurrent List, creating a disconnect between public health administration and medical education.
The replacement of the statutory body Medical Council of India (MCI) with the National Medical Commission (NMC), which functions as a sub-unit of the Union Ministry of Health, has reduced proper state representation and autonomy of field experts.
Union government’s National Health Mission has moved from coordination to control, diluting state-led innovations in public health delivery.
Unscientific ideological agendas have been introduced through centralised health education policy, and the Union government is promulgating language imposition through NHM directives (EG, integrating Ayurveda in MBBS curriculum, naming urban wellness centres as Aarogya Mandir).
Restoration of medical education to the State list
The Indian Constitution, in its original form, reflected a quasi-federal structure where states had significant powers in health and education. The rationale was that healthcare delivery and medical training must be adapted to local socio-cultural contexts, disease burdens specific to ethnicity and infrastructure capabilities.
Prior to the 42nd Amendment, medical education was entirely under the State List, allowing states to establish curricula suited to their own health and disease profile; regulate admissions, fees, and institutional governance; and link medical training according to disease epidemiology.
The arrangement shown in the table creates a policy-implementation gap. The Union government frames policy for health care and medical education without proper understanding of State-specific disease profiles, socioeconomic disparities and ethnic genetic diversity.
It is recommended to amend the Constitution to restore medical education from the concurrent list to the State list, and States should be the sole authority to interlink Public Health and Medical education.
From MCI to NMC: Centralisation and its consequences
The Medical Council of India (MCI), established under the Indian Medical Council Act, 1933 (later replaced by the 1956 Act), was created to maintain uniform standards of medical education; recognise medical qualifications across States; and act as a coordinating body between State medical councils and the Union government.
The MCI was composed of elected representatives from all state medical council, university representatives, nominees from the Union government. This representation model ensured that each state had a platform to discuss health education policy at the Union level.
The National Medical Commission Act, 2019, replaced the MCI with the NMC, citing corruption and inefficiency in the MCI. However, in doing so, it replaced elected members with appointed nominees by the Union government. It also brought the commission directly under the Union Ministry of Health & Family Welfare. It limited State governments’ role in framing medical curriculum, guidelines in health services and institutional framework.
The NMC structure includes a Medical Advisory Council (MAC) — with State representation on a rotational basis, in a purely advisory role; four autonomous boards — all appointed by the Union government. The NMC Act effectively uses Entry 66 of the Union List (coordination and determination of standards) to dominate over Entry 25 of the Concurrent List, undermining State participation in health education.
The NEET and NEXT paradigm: Centralised examinations
The NEET examination heavily favours the CBSE/NCERT syllabus. The students from the state board syllabus, especially in the vernacular medium, are placed in a disadvantageous position. Tamil Nadu’s Justice A.K. Rajan Committee Report (2021) found that NEET has disproportionately benefited urban, affluent and english-medium students.
Students from rural and government schools face reduced representation in medical admissions. Post-NEET introduction, the share of government school students in MBBS seats in Tamil Nadu dropped from 14.9% to under 2% (Go TN data, 2021). NEET preparation has created a 1000 crore private coaching market across the country, forcing students into expensive private coaching classes to succeed.
Tamil Nadu’s admission system, based on Class XII performance and reservation policy, produced regionally trained doctors to serve in rural and semi-urban areas — an outcome now undermined.
NEXT will be the one-stop licensing exam. A single test will determine medical practice eligibility risks, excluding competent graduates who may underperform on one day. It is biased towards rote learning. The focus is on exam preparation, which reduces emphasis on clinical skills and patient interaction. It moves away medical graduates from proper patient treating skills to theoretical reading.
Sweeping powers under the NMC Act have enabled easy entry for corporate hospital chains to set up medical colleges. Removal of cap on fees for 50% of seats in private institutions, effectively allowing market- driven price. Less stringent norms for infrastructure and faculty — encouraging for-profit education models.
This has led to high tuition fees in many private medical colleges and deemed medical universities. Increased student debt and pressure to engage in unethical medical practice and view medical care as a return on investment model.
Ideological and cultural centralisation in health policy
Centralisation in health is not limited to funding flows or regulatory powers. In recent years, there has been a significant ideological and cultural centralisation in health policy. This manifests in the imposition of nationally uniform narratives, terminologies, and programme designs that reflect cultural priorities of the Union Government, often without adequate recognition of the diversity of India’s states. Health communication, public campaigns, and even medical curricula are being standardised in ways that undermine linguistic plurality, regional identity, and locally evolved practices.
Several flagship campaigns (e.g., Ayushman Bharat outreach, Ayush wellness drives, national immunisation posters) are first developed in Hindi and English, with secondary translations to other languages. In Tamil Nadu, where Tamil is the medium of health education and public communication, improper translations reduce the effectiveness of awareness programmes. Health hotlines and telemedicine platforms under central control often default to Hindi or English, alienating large sections of Tamil-speaking patients.
Curriculum and medical education content centralisation
The NMC increasingly prescribes uniform textbooks and reference material, many authored with minimal input from southern institutions. This has led to reduced visibility of Tamil Nadu’s contributions to tropical medicine, public health management, and organ transplantation ethics in national curricula
State-specific epidemiological patterns (e.g., high incidence of scrub typhus in Nilgiris, occupational lung diseases in Tamil Nadu’s industrial belts) are underrepresented in centrally developed medical syllabus limiting local preparedness.
Conclusion
A truly federal health system is not an obstacle to national unity—it is its foundation. The framers of our Constitution wisely placed public health in the State List because health challenges vary dramatically across India’s geographies, cultures, and economies.
The High-Level Committee has a historic opportunity to correct the shift towards central dominance in health governance. By reaffirming the constitutional balance, empowering States financially and institutionally, and promoting cooperative—not coercive—federalism, we can ensure that every State’s health system is both locally relevant and nationally integrated.
(Dr. Ezhilan Naganathan, MLA, Thousand Lights Constituency and part-time Member, State Planning Commission, submitted these recommendations on State autonomy in health and medical education to the High-Level Committee on Union –State Relations, Government of Tamil Nadu.)