The National Medical Commission Act 2019 did something no Indian health statute had done before: it abolished the regulator of the medical profession outright and built a differently constituted one in its place, rather than amending the old body into a new shape. The Indian Medical Council Act 1956, under which the Medical Council of India had regulated medical education and practice for over six decades, was repealed by Section 60 of the new Act with effect from 25 September 2020, and the Council stood dissolved on the same day. In its place stands a Commission of thirty-three persons, none of them elected by the profession, working through four autonomous boards that divide the work the single Council once held together: undergraduate education, postgraduate education, the assessment and rating of institutions, and ethics with registration. Around that architecture the Act rearranged the profession’s gateways. One entrance test governs admission. One exit test was designed to govern the licence to practise, admission to postgraduate study and the recognition of foreign graduates at a single stroke. A fee guideline power reaches into half the seats of every private medical institution and deemed university. A limited licence creates a category of mid-level practitioner the profession had resisted for a generation. This article is about what the replacement statute actually built, provision by provision, and about the two provisions that drew the fiercest professional opposition, one of which had still not been brought into operation years after the rest of the Act was working.

A reader who wants the head-to-head verdict on the old body against the new one, scored point by point, should go to the comparison of the Medical Council and the National Medical Commission, which owns that question in this series. The task here is different and prior to it: the repeal and replacement itself, what the new law kept, what it discarded, what it added, and how its machinery is arranged, because most public argument about the National Medical Commission proceeds from a description of the Act that the Act does not support. The exit test has not been held. The fee power is a power to frame guidelines for a defined proportion of seats, not a power to fix the fees of every private seat. The state medical councils were not abolished. Each of those corrections matters, and each is made from the text in what follows.

The statute that was repealed, and the record it accumulated

The Indian Medical Council Act 1956 was Act 102 of 1956. It received the assent of the President on 30 December 1956 and reconstituted a Council that had first been created under a 1933 statute. Its scheme was the standard mid-century scheme for a learned profession. A central council, composed predominantly of medical practitioners chosen through election and nomination by universities, state governments and the registered profession, would maintain an Indian Medical Register, recognise medical qualifications granted in India and abroad, prescribe standards of undergraduate and postgraduate education, and grant or withhold the permission on which new colleges, new courses and additional seats depended. State medical councils, constituted under state law, maintained the state registers and exercised disciplinary jurisdiction over practitioners at first instance. The theory was professional self-regulation under a statutory frame: the state set the outer boundaries, and the profession, through its elected council, policed entry, standards and conduct within them.

The composition deserves a closer statement, because the replacement cannot be understood without it. Under the 1956 Act the Council’s membership was assembled from the profession’s own constituencies: representatives of the universities, elected in most states by the registered medical practitioners of the state from among themselves, nominees of the Central Government and of the state governments, and representatives of the medical faculties. Elections by registered practitioners meant that a seat on the regulator was a prize of professional politics, campaigned for within the profession and answerable to it, and the representatives of private medical colleges and their managements were a recognised and growing presence in that electorate as private medical education expanded from the nineteen eighties onwards. The Council worked through committees, among them an executive committee and a postgraduate medical education committee, and its decisions on recognition and permission were recommendations in form for much of its life, since the formal power to permit a new college rested with the Central Government. That distribution changed in 1993, when an amendment inserted Sections 10A, 10B and 10C into the Act and made the Council’s prior permission the operative gate for establishing a medical college, starting a new or higher course and increasing admission capacity, with the Central Government retaining an appellate and directional role. From 1993 the Council was not merely advisory on the question that mattered most to college promoters; it held the gate itself, while remaining a body substantially elected by the world on the other side of the gate.

The functions stacked on that composition were the full stack of a profession’s government. The Council maintained the Indian Medical Register from the state registers. It recognised the qualifications in the schedules to the Act, and negotiated the recognition of Indian qualifications abroad. It prescribed the regulations governing graduate and postgraduate medical education, the curriculum, the minimum standards for institutions and the conditions of admission. It made the regulations on professional conduct, etiquette and ethics under which practitioners were disciplined in the states. It conducted, through its inspectors and visitors, the inspection of institutions on which permission and recognition depended, the celebrated and feared inspection regime in which a college’s continuation turned on the findings of a visiting team on particular days. And it ran, from 2016, the statutory entrance test that the amendment of that year inserted as Section 10D, after the Supreme Court’s review judgment cleared the way for a common entrance examination the Council’s own regulations had attempted and failed to sustain in 2013. A body so composed, doing all of this, was not badly designed for a small and predominantly public profession in 1956. It was badly designed for a large, substantially private and commercially valuable one sixty years later, and the gap between the design’s assumptions and the sector’s reality is the space in which the findings accumulated.

That theory carried the seeds of the failure that eventually ended the statute. The Council that recognised colleges also contained members drawn from the world of private medical education it was recognising. The Council that enforced standards against institutions was elected substantially by the profession those institutions employed and supplied. None of this was hidden, and for decades it was defended as the ordinary arrangement for a self-governing profession, comparable to the arrangements for advocates and chartered accountants. What changed was the accumulation of findings, by courts, by Parliament and by the executive’s own committees, that the arrangement had in practice produced a regulator unable or unwilling to regulate.

The public record of that failure is unusually well documented, and the reform case for the 2019 Act rests on it rather than on assertion. In April 2010 the Central Bureau of Investigation arrested the serving President of the Medical Council of India, Ketan Desai, on charges of accepting a bribe in connection with the recognition of a medical college in Punjab. Within weeks the Central Government dissolved the Council by ordinance and installed a Board of Governors, chaired by the hepatologist Dr S. K. Sarin, to run medical regulation in its place. An elected Council was reconstituted at the end of 2013 under the same 1956 statute, with the same composition and the same incentives, and the experiment of restoration lasted less than five years. In May 2016, deciding Modern Dental College and Research Centre v. State of Madhya Pradesh, the Supreme Court appointed an oversight committee headed by a former Chief Justice of India, Justice R. M. Lodha, to oversee the functioning of the Council, having recorded that the Council had repeatedly been found short of fulfilling its mandated responsibilities. A Constitution Bench does not place a statutory regulator under judicial oversight as a routine step, and the order stands as the judicial system’s own verdict on the 1956 scheme.

Parliament’s verdict was delivered in the same season. The Department-related Parliamentary Standing Committee on Health and Family Welfare, chaired by Professor Ram Gopal Yadav, presented its ninety-second report, on the functioning of the Medical Council of India, to Parliament on 8 March 2016. The Committee found the Council’s performance deeply compromised. It recorded that an elected body dominated by doctors, with a disproportionate presence of the private sector within it, carried a structural conflict the statute did nothing to correct; that the requirements for establishing colleges were rigid, input-based and productive of perverse results; and that the regulatory system for medical education and practice required not repair but restructuring and revamping. The Committee recommended that the government bring a new comprehensive Bill before Parliament at the earliest, that regulators be appointed through an independent selection process rather than elected by the regulated, and that the composition of the regulator be diversified beyond medical practitioners alone. The 2019 Act is, in its architecture, a close implementation of that advice, and its supporters are entitled to say so: the design that the profession experienced as an imposition was substantially the design a parliamentary committee, after hearing the profession, had recommended.

The executive’s own record completes the picture. A group of experts headed by Professor Ranjit Roy Chaudhury, appointed by the Health Ministry in July 2014 to study the 1956 Act, proposed replacing the Council with a National Medical Commission organised in separate verticals for undergraduate education, postgraduate education, assessment and accreditation, and registration. A four-member committee chaired by the Vice Chairman of NITI Aayog then produced, in August 2016, a preliminary report with a draft National Medical Commission Bill attached, proposing among other things a common entrance examination, a common licentiate examination and a power to regulate fees for a proportion of seats in private colleges. By the time the 2019 Bill reached Parliament, the replacement had been drafted, redrafted and publicly debated for five years, and the case against the 1956 Act had been made by a parliamentary committee, a judicial oversight order and two expert processes. Whatever is said against the new statute, and serious things are said below, it was not a replacement improvised in a session.

The making of the replacement

The 2019 Act was the third legislative vehicle for the replacement, not the first, and the two failures before it shaped its drafting. The first was the National Commission for Human Resources for Health Bill 2011, introduced in the Rajya Sabha in December 2011, which proposed a single overarching commission for the health professions that would have displaced not only the Medical Council but the dental, nursing and pharmacy councils as well, substituting nominated bodies for human resource planning, curriculum and quality assurance while confining the elected professional bodies to registration and ethics. The Standing Committee examined that Bill and reported on it in 2013 with substantial reservations, the government of the day let the proposal drop, and the Bill was withdrawn. The episode taught two lessons the later drafters absorbed. An omnibus displacement of every health council at once multiplies the opposition a reform must survive, so the 2019 Act replaced one council and left the others to parallel statutes of their own. And an elected remnant confined to registration satisfied nobody, neither the reformers who wanted the register inside the new architecture nor the profession which read the demotion correctly; the 2019 Act instead brought registration itself inside the new body’s fourth board and gave the state councils, which are the elected element that survives, a defined statutory place beneath it. An intermediate attempt, an amendment of the 1956 Act proposed in the middle of the following decade, was referred to the same Standing Committee and deadlocked there, which is why the expert-group route of 2014, rather than another amendment bill, became the vehicle of the redesign.

The second legislative attempt failed in the ordinary way. The National Medical Commission Bill 2017 was introduced in the Lok Sabha in December 2017 and referred to the same Standing Committee on Health and Family Welfare. The Committee’s report on the Bill, submitted in 2018, recommended substantial changes, among them the removal of a proposed bridge course that would have allowed practitioners of the Indian systems of medicine and homoeopathy to practise modern medicine after a short additional training, a provision that had united the modern profession in opposition. The Bill was not passed, and it lapsed on the dissolution of the Sixteenth Lok Sabha. Two features of that episode matter for reading the enacted Act. The first is that the bridge course died in committee and never returned: the 2019 Act contains no cross-pathy bridge, and the related grievance should be retired. The second is that the 2017 Bill’s other contested device, a separate licentiate examination for the licence to practise, was folded into the design of a single exit test before the Bill returned.

The National Medical Commission Bill 2019 was introduced in the Lok Sabha on 22 July 2019 by the Minister of Health and Family Welfare, Dr Harsh Vardhan. It was passed by the Lok Sabha on 29 July 2019 and by the Rajya Sabha on 1 August 2019, and it received the assent of the President on 8 August 2019 as Act 30 of 2019. The passage was contested inside and outside the House. Within Parliament, members including Jairam Ramesh protested that the Bill was not being sent to the Standing Committee for examination, and argued in correspondence with the presiding officers that the Committee’s 2016 report on the Council was no substitute for scrutiny of a Bill many of whose provisions, in the opposition’s view, departed from that report. Outside Parliament, the Indian Medical Association organised the largest professional mobilisation against a health statute in decades, a sequence of events that belongs to the account of professional opposition below. The Bill was nevertheless passed with official amendments moved by the government itself, and those amendments are instructive, because they enlarged the states’ voice inside the Commission in the course of passage: the part-time membership of the Commission rose from fourteen in the version approved by the Cabinet to twenty-two in the Act as passed, with the members drawn from state and Union territory nominees in the advisory council raised from six to ten and the members drawn from state medical council nominees raised from five to nine. The enacted Commission is therefore more federal in composition than the Commission the Cabinet had approved, a fact worth holding in mind when the Act is described as a purely centralising instrument.

Commencement was staged, and the staging matters to the series thesis this article carries. By notification S.O. 3162(E) dated 2 September 2019, the provisions constituting the Commission, the advisory council and the autonomous boards, together with the rule-making and regulation-making powers, were brought into force, so that the search committee could be constituted and the new bodies appointed while the old Council still legally existed. The remaining provisions were brought into force with effect from 25 September 2020, and by notification S.O. 3263(E) dated 24 September 2020, issued under sub-section (1) of Section 60 of the new Act, the Indian Medical Council Act 1956 was repealed with effect from 25 September 2020 and the Board of Governors then in supersession of the Council was dissolved. Between those two dates sits the interregnum examined below: from 26 September 2018, when the elected Council was superseded a second time by ordinance, until 25 September 2020, the Medical Council of India existed in law but was governed in fact by a Board of Governors appointed by the Central Government and chaired by Dr V. K. Paul, a member of NITI Aayog. The profession’s regulator was thus government-run for two full years before the replacement statute took over, which complicates any account in which appointed regulation arrived unannounced in September 2020.

What the replacement kept, discarded and added

A repeal and replacement is three distinct moves, and the 2019 Act makes all three legibly. What it kept is the skeleton of the 1956 scheme, because the functions of medical regulation do not change when the regulator does. There is still a central statutory body for the whole country. There are still recognised medical qualifications, listed and maintained, without which practice is barred. There is still a prior-permission regime for new colleges, new courses and increased seats. There are still state medical councils keeping state registers and disciplining practitioners at first instance, and a national register compiled from them. Admissions still run through a single national entrance test, the National Eligibility-cum-Entrance Test, which the 1956 Act had itself absorbed by amendment in 2016. The professional-conduct jurisdiction still begins in the state where the practitioner is registered. Anyone who practised, studied or administered under the old Act recognises the map.

What it discarded is the method of constituting the regulator and the unity of its functions. Election is gone at every level of the central body: every member of the Commission and of its boards is appointed by the Central Government, most of them through a search committee, some ex officio, some from state nominees chosen by rotation. The single council is gone too. The old Council set the curriculum, inspected the colleges, recognised the qualifications and supervised professional ethics within one corporate body, so that a failure of integrity in one function contaminated all of them and a college seeking recognition faced the same institution at every door. The 2019 Act separates those functions into four autonomous boards under one Commission, so that the body that writes the undergraduate curriculum is not the body that inspects colleges, and neither is the body that maintains the register and hears ethics appeals. Also discarded, more quietly, is the profession’s claim to be a constituency: the Act contains no seat that any medical association, council of practitioners or electorate of doctors fills by right.

What it added is the burden of this article. It added, in Section 15, the National Exit Test, a common final year examination with three simultaneous functions. It added, in sub-section (1)(i) of Section 10, a power to frame guidelines for the determination of fees and all other charges for fifty per cent of the seats in private medical institutions and deemed universities. It added, in Section 32, the community health provider, a limited licence to practise medicine at mid-level. It added, in Section 45, an express statutory obligation on the Commission and its boards to obey written directions of the Central Government on questions of policy, with the government’s own decision on what counts as policy made final. And it added a Medical Advisory Council in which every state and Union territory sits, an institution with a voice and no vote that binds.

One addition that did not survive the drafting deserves record, because its absence explains the appellate structure the Act does have. The draft National Medical Commission Bill prepared by the NITI Aayog committee and approved with modifications by a Group of Ministers carried, in addition to the four boards, a separate appellate tribunal, to which appeals from the commission’s decisions would have lain. The enacted Act contains no tribunal. Appeals run instead in a closed administrative loop: from the boards to the Commission, from the Commission to the Central Government, and, in the ethics line, from the state councils to the ethics board and then to the Commission, whose decision in that line is the one decision Section 9 withdraws from the further appeal to the government. The reform drafts thus contemplated an adjudicatory check outside the executive for a regulator the executive appoints, and the statute as enacted replaced that check with the executive itself. Critics of the Act rarely isolate this change, but it belongs in any account of what the replacement discarded, because it determines where a college, a university or a practitioner ultimately carries a grievance against the new regulator: to a court on writ, or to the Ministry whose policy directions bind the body complained against. The honest assessment at the end of this article weighs those additions. First, the machinery must be stated accurately, because each addition is routinely described as larger than the text makes it.

The Commission: composition, appointment and control

Section 3 constitutes the Commission as a body corporate with its head office at New Delhi. Section 4 gives it thirty-three members: a Chairperson, ten ex officio members and twenty-two part-time members, every one of them appointed by the Central Government. The ex officio tenth is the working executive of the system: the Presidents of the four autonomous boards, the Director General of Health Services, the Director General of the Indian Council of Medical Research, a Director of one of the All India Institutes of Medical Sciences nominated by the Central Government, two persons drawn from a named set of national institutes at Chandigarh, Puducherry, Mumbai, Shillong and Kolkata, and a representative of the Health Ministry not below the rank of Additional Secretary. The twenty-two part-time members divide three ways. Three are persons of ability, integrity and standing with special knowledge in fields the Act lists, including management, law, medical ethics, health research, consumer or patient rights advocacy, science and technology and economics; these are the seats through which the Standing Committee’s call for diversity beyond doctors enters the Commission. Ten are appointed on a rotational basis from among the state and Union territory nominees who sit in the Medical Advisory Council as vice-chancellors of health universities, and nine from among the nominees drawn from the elected membership of the state medical councils. Those nineteen state-linked members serve terms of two years, against the standard term discussed below, so the state presence inside the Commission is broad but rotating and brief.

The Chairperson’s qualifications are fixed by sub-section (2) of Section 4, and they are demanding on their face: a medical professional of outstanding ability, proven administrative capacity and integrity, holding a postgraduate degree in a discipline of medical sciences, with not less than twenty years of experience in the field, of which at least ten years must have been as a leader in medical education, the Act explaining that a leader means the head of a department or the head of an organisation. Appointments of the Chairperson, of the three expert part-time members and of the Commission’s Secretary are made on the recommendation of a Search Committee constituted under Section 5. The Committee is chaired by the Cabinet Secretary. It includes three experts with not less than twenty-five years of experience in medical education, public health education and health research, one expert drawn from among the state medical council nominees on the Commission, one person with not less than twenty-five years of standing in management, law, economics or science and technology, and the Secretary of the Health Ministry as convenor-member. The Committee must recommend a panel of at least three names for every vacancy, must satisfy itself that a recommended person holds no financial or other interest likely to prejudice the office, and the Central Government must refer a vacancy to it within one month of its occurrence. The design is therefore neither election nor unmediated nomination: it is appointment from a shortlist prepared by a committee in which the administrative head of the government sits in the chair and medical education experts hold three of the seven seats. Critics and defenders of the Act argue about precisely that distribution, and both can find their evidence in Section 5 itself.

Tenure is deliberately short and deliberately terminal. Under Section 6 the Chairperson and the part-time members other than the rotating state nominees hold office for a term not exceeding four years and are not eligible for any extension or re-appointment, ceasing in any event at the age of seventy. The same section bars a departing Chairperson or member from accepting employment, including as a consultant, in any private medical institution whose matter they dealt with, for two years after demitting office, a cooling-off rule aimed at the door between the regulator and the regulated that the old regime had left open. Removal is by order of the Central Government under Section 7, on grounds that track the standard statutory list: insolvency, conviction of an offence involving moral turpitude in the government’s opinion, physical or mental incapacity, unsoundness of mind declared by a competent court, acquisition of a prejudicial financial or other interest, and abuse of position rendering continuance prejudicial to public interest, with a right to be heard protected for the last two grounds. The Commission must meet at least once every quarter under Section 9, its Chairperson holds general superintendence, direction and control of its administration, and a person aggrieved by a decision of the Commission, other than a decision on a second ethics appeal under sub-section (4) of Section 30, may appeal to the Central Government within thirty days.

The functions of the Commission, listed in Section 10, are supervisory and normative rather than executive: to lay down policies for maintaining high quality and high standards in medical education and to make regulations for that purpose; to lay down policies for regulating medical institutions, medical research and medical professionals; to assess the requirements of healthcare, including human resources and infrastructure, and to develop a road map for meeting them; to frame guidelines and policies for the proper functioning of the Commission, the autonomous boards and the state medical councils; to ensure coordination among the boards; to take measures to secure compliance by the state medical councils with the guidelines and regulations made under the Act; to exercise appellate jurisdiction over the boards; to lay down policies and codes for professional ethics; and, in clause (i) of sub-section (1), to frame the fee guidelines examined below. Above those functions sit the control provisions. Section 45 binds the Commission and the autonomous boards, in the exercise of their powers and the discharge of their functions, by such directions on questions of policy as the Central Government may give in writing, subject to a proviso that they be given an opportunity to express their views before a direction issues, as far as practicable; sub-section (2) makes the Central Government’s decision on whether a question is one of policy final. Section 46 empowers the Central Government to direct a state government to carry out the Act, and the state government is bound to comply. Section 55 is the reserve power: if the Central Government is of opinion that the Commission is unable to discharge its functions, or has persistently defaulted in complying with directions or in discharging its functions, it may, after giving the Commission a reasonable opportunity to show cause, supersede the Commission by notification for a period not exceeding six months, extendable once by a further period not exceeding six months, during which the members vacate office and the Commission’s powers are exercised by persons the government directs, before the Commission is reconstituted by fresh appointment. The regulator that replaced a twice-superseded council is itself supersedeable on the same pattern, by the same government that appoints it. That symmetry is not an oversight in the drafting; it is the drafting’s theory of accountability, and the assessment section takes it up directly.

Beneath the Commission sits a secretariat whose head is appointed on the same insulated pattern as the members. Section 8 provides for a Secretary to head the Commission’s secretariat, appointed by the Central Government in accordance with the search committee procedure of Section 5, for a term of four years without eligibility for extension or re-appointment. The Commission appoints its officers and employees against posts created by the Central Government, and it may engage experts and professionals of integrity and outstanding ability across fields that run from medical education and public health to management, health economics, quality assurance, patient advocacy, finance and law. The accountability paperwork is conventional but complete. Section 44 obliges the Commission to furnish the Central Government with such reports and statements as may be prescribed or directed, and to prepare an annual report of its activities for the government to lay before each House of Parliament. The Commission’s accounts are audited by the Comptroller and Auditor-General of India under Chapter VII of the Act, which also constitutes the National Medical Commission Fund and channels the grants the Central Government makes to the Commission. Section 47 adds a general information duty: the Commission must furnish reports, minutes, abstracts of accounts and other information the government requires, and the government may publish what it receives. The regulator that the old Council’s critics accused of opacity is thus wrapped in the standard apparatus of a modern Indian statutory authority, audit, annual report, laying before Parliament, published declarations of assets by its Chairperson and members under Section 6, and the public-servant status that Section 52 confers on its personnel for the purposes of the penal law. None of that apparatus decides the independence question, which Sections 45 and 55 decide in the government’s favour; but it answers the narrower charge that the Commission is unaccountable, by specifying the forums, Parliament, the auditor and the appellate government, to which its accounts are rendered.

One function in Section 10 deserves separate notice because it has no counterpart in the repealed Act and little counterpart in the Act’s own later practice. Clause (c) of sub-section (1) charges the Commission with assessing the requirements in healthcare, including human resources for health and healthcare infrastructure, and developing a road map for meeting those requirements. The old Council regulated the supply of doctors as a by-product of recognising colleges; it had no statutory duty to plan the workforce. The 2019 Act makes the regulator also the planner, obliged in law to measure the country’s need for medical professionals and to chart the route to meeting it. Whatever use has been made of the duty, its presence in the text marks the conceptual distance between the two statutes: the 1956 Act constituted a council of a profession, while the 2019 Act constitutes an instrument of health policy that also regulates a profession, and much of the argument about the Act is an argument about which of those two things a medical regulator ought to be.

Commencement, repeal and the savings that carried the old law forward

When did the National Medical Commission take over from the Medical Council of India?

On 25 September 2020. By notification under Section 60 of the National Medical Commission Act 2019, the remaining provisions of the Act were brought into force on that date, the Indian Medical Council Act 1956 stood repealed, the Medical Council of India stood dissolved, and the Board of Governors then running it stood dissolved as well.

The constitution provisions had been switched on a year earlier, on 2 September 2019, so that the search committee could be formed and the new bodies appointed in advance of the transfer.

The two-stage commencement is worth pausing over, because it is the point at which this Act departed most creditably from the pattern this series documents in other statutes. Section 1(3) left the appointed day to the government, as Indian Acts routinely do, and the two notifications that resulted were separated by a full year. The first, in September 2019, commenced only the machinery provisions: the definitions clause, the constitution of the Commission and its boards, the search committee, the secretariat provisions, the rule and regulation making powers and the power to remove difficulties. Nothing regulatory changed for any college, student or practitioner on that date; what changed was that the successor existed in law and could be populated. The interval was used as it was designed to be used: the search committee process ran, the Chairperson and members of the Commission and the Presidents and members of the boards were appointed, and the Commission stood constituted before the second notification, in September 2020, brought the operative chapters into force, repealed the 1956 Act and dissolved the Council and the Board of Governors in a single coordinated step. There was no day on which Indian medical education had no regulator, and no interval in which permits, registers or recognitions hung on a body not yet in existence. The contrast with statutes whose substantive provisions have waited years for a commencement notification, a contrast the commencement record collected in this series makes repeatedly, is deliberate in the drafting and was achieved in the execution; whatever is to be said against this Act, it is not a statute that failed to begin.

The repeal itself is executed by Section 60, whose first sub-section provides that with effect from such date as the Central Government may appoint, the 1956 Act shall stand repealed and the Council constituted under it shall stand dissolved. Sub-section (2) carries the standard savings of a repealing statute: the previous operation of the repealed Act and anything duly done under it is unaffected, rights, privileges, obligations and liabilities acquired under it survive, penalties incurred under it remain exigible, and proceedings and remedies in respect of any of them may be instituted, continued or enforced as if the Act had not been repealed. Sub-section (3) empties the old body’s offices: the Chairman and members of the Council, and its officers and employees holding office immediately before the dissolution, vacate on the dissolution. The Board of Governors interregnum needed express treatment because the body actually exercising the Council’s powers in September 2020 was not the Council but the Governors appointed in its supersession, and the notification under Section 60 dissolved them in terms.

Section 61 then performs the two operations that decide what a repeal means in practice. By sub-section (1), the Commission is the successor in interest to the Medical Council of India, including its subsidiaries and owned trusts, and all the assets and liabilities of the Council are deemed transferred to the Commission. By sub-section (2), the educational standards, requirements and other provisions of the 1956 Act and of the rules and regulations made under it continue in force and operate until new standards or requirements are specified under the 2019 Act, and anything done under the old dispensation is deemed done under the corresponding provisions of the new one unless and until superseded. Section 61 further keeps alive the orders, licences, registrations, permissions and recognitions granted under the repealed Act, in force until their expiry, as if they had been issued under the new Act. These clauses explain a fact that puzzles readers who encounter it in litigation: regulations framed by the Medical Council of India, including the Screening Test Regulations of 2002 that govern foreign medical graduates, continue to be applied years after the Council ceased to exist, because Section 61 carries them forward until the Commission replaces them, and the Delhi High Court has expressly traced their survival to that sub-section.

The most consequential transitional clause sits not in Sections 60 or 61 but in Section 33. The first proviso to sub-section (1) of Section 33 provides that a person registered in the Indian Medical Register maintained under the 1956 Act before the coming into force of the new Act, and before the National Exit Test becomes operational, shall be deemed to be registered under the 2019 Act and enrolled in the National Register maintained under it. No doctor had to register again, qualify again or apply again because the regulator changed. The register crossed over by operation of law, and the answer to the recurring question of what happened to registrations made under the old statute is that they continued without interruption, on the new regulator’s book.

What did the Board of Governors do between the Council and the Commission?

From the supersession of the elected Council in September 2018 until repeal took effect in September 2020, the Council’s functions were exercised by a Board of Governors appointed by the Central Government under Section 3A of the 1956 Act, chaired by Dr V. K. Paul. It ran the permission cycle for colleges and seats and supervised the entrance examination regime.

It also issued directions in the Council’s name and held the institution together as a going concern until the Commission could be constituted and take over.

The interregnum matters to the interpretation of the 2019 Act for two reasons. The first is that the two-level structure of the replacement was partly pre-enacted in practice: for two years the profession was already regulated by an appointed body answerable to the government, and the September 2020 transition changed the legal basis and the architecture of appointed regulation more than it changed its daily character. The second is that the Board of Governors period complicates the seat-count and standards claims made for and against the new Act, because several of the reforms the Commission inherited, including the expansion of undergraduate seats that the Health Ministry’s September 2020 statement quantified at about eighty thousand, up from about fifty-four thousand in 2014, were set in motion under the Board. The Board itself left no permanent institutional trace: it was dissolved by the same notification that repealed the parent Act, and Section 61’s succession clause carried its unfinished business to the Commission along with the Council’s.

The four autonomous boards and what each of them decides

Section 16 constitutes the four autonomous boards under the overall supervision of the Commission, each an autonomous body carrying out its functions subject to the regulations the Commission makes. Section 17 gives each board a President and four members, two whole-time and two part-time, the part-time membership including a member chosen from among the elected members of the state medical councils; Section 18 routes the appointment of Presidents and members, other than the state council nominee, through the same Search Committee as the Commission itself, and Section 19 fixes a term not exceeding four years, without extension or reappointment, with part-time members serving two years. The Presidents of the boards sit ex officio on the Commission, which is the structural link between the supervisory body and the four working bodies beneath it.

The qualifications for board office repeat the Chairperson’s pattern at one remove of seniority. Under Section 17 the President of each board, and specified members of the two education boards, must be persons of outstanding ability, proven administrative capacity and integrity holding a postgraduate degree in a discipline of medical sciences, with not less than fifteen years of experience in the field, of which at least seven years must have been as a leader in medical education, public health, community medicine or health research. Two exceptions mark the design’s intent to break the profession’s monopoly of the table. The third member of the Medical Assessment and Rating Board need not be a doctor at all: the seat is reserved for a person with a postgraduate degree in management, quality assurance, law or science and technology and fifteen years of experience, seven as a leader, so that the body judging institutions includes a member whose discipline is the judgment of institutions. The third member of the Ethics and Medical Registration Board is similarly opened, to a person with a demonstrated public record of work on medical ethics, or a postgraduate degree in quality assurance, public health, law or patient advocacy with the same experience thresholds. The fourth member of each board, one of its two part-time members, is chosen from among the elected members of the state medical councils in the manner prescribed, which is the boards’ direct line to the practising profession. Section 20 equips each board except the ethics board with advisory committees of experts constituted by the Commission, and the ethics board with ethics committees of experts, and Section 23 vests each President with such administrative and financial powers as the Commission delegates, with power to delegate further to a member or officer of the board. The boards are required by Section 22 to meet at least once a month, against the Commission’s quarterly floor, and to decide by majority. The contrast with the repealed scheme is one of tempo and of composition alike: the old Council’s committees met within a single corporate hierarchy that answered to an elected house, while the boards are small, senior, appointed bodies on statutory meeting cycles, designed for continuous administration rather than periodic professional assembly. A person aggrieved by a decision of an autonomous board may appeal to the Commission within sixty days under sub-section (3) of Section 22, except where Section 28 provides its own permission-appeal ladder.

The Under-Graduate Medical Education Board, under Section 24, determines the standards of undergraduate medical education and oversees everything relating to them. It develops the competency-based dynamic curriculum for the undergraduate course, including the curriculum directed at primary health services, community medicine and family medicine; frames guidelines for setting up institutions that impart undergraduate courses; determines the minimum requirements and standards for conducting courses and examinations; sets norms for infrastructure, faculty and quality; facilitates the development and training of undergraduate faculty; specifies norms for compulsory annual disclosures by institutions; and grants recognition to medical qualifications at the undergraduate level. The Post-Graduate Medical Education Board performs the corresponding functions under Section 25 for postgraduate and super-speciality education: standards, curriculum, guidelines for setting up institutions, minimum requirements, faculty and infrastructure norms, faculty development, disclosure norms, and the grant of recognition to postgraduate and super-speciality qualifications. The two education boards are the Act’s answer to the old Council’s unitary standard-setting: the people who write the curriculum and judge the qualification are separated from the people who inspect the college, which is the next board’s province.

What the two education boards inherited on their first day illustrates the succession clause at work. The undergraduate curriculum in force in September 2020 was the competency-based curriculum introduced for the batch admitted in 2019, a settlement of the predecessor regime prepared under the Board of Governors, which recast the undergraduate course around defined competencies, early clinical exposure and an attitude, ethics and communication strand running through the course. The 2019 Act did not write that curriculum, or any curriculum, into the statute; it assigned the continuing duty to the undergraduate board, which has owned the document since, revising it through its own regulations and guidelines. The pattern is the Act’s standard one and it is worth naming: Parliament in 2019 legislated structures, functions and duties, and left the substantive instruments of medical education, curricula, standards, criteria and codes, to the bodies the Act created, on the theory that a specialist appointed board would keep them better than a legislature or an elected house could. Where the theory has been tested hardest is not in the curriculum but in the ethics code and the exit test, both of which are taken up below; in the quieter province of the education boards the theory has operated as designed, producing a stream of curricular and standards instruments under Section 57’s regulation power and Section 10’s policy direction, none of which required the repeal of anything further.

The Medical Assessment and Rating Board, under Section 26, determines the procedure for assessing and rating medical institutions against the standards laid down under the Act; grants permission for establishing a new medical institution, for starting a postgraduate course and for increasing seats, under Section 28; carries out inspections of institutions for assessment and rating, or entrusts them to other agencies and persons specified by regulations; makes the assessments and ratings public on its website at regular intervals; and, against an institution that fails to maintain the minimum standards set by the education boards, may take measures including issuing a warning, imposing a monetary penalty, reducing the intake of students, stopping admissions, and recommending to the Commission the withdrawal of recognition. The Ethics and Medical Registration Board, under Section 27, maintains the National Register of all licensed medical practitioners under Section 31; regulates professional conduct and promotes medical ethics under the regulations; maintains continuous interaction with the state medical councils to coordinate professional conduct, ethics and the quality of medical services; exercises appellate jurisdiction over the actions of state medical councils under Section 30; and carries the recognition and licensing functions that connect the register to the qualifications the other boards recognise. The four-board structure therefore divides one regulator’s old portfolio by kind of decision rather than by territory: standards in two boards divided by level, institutional judgment in a third, and the register with professional discipline in a fourth.

How long does the Medical Assessment and Rating Board have to decide an application for a new medical college?

Six months. Under Section 28 the Board must consider a scheme for a new college, a new postgraduate course or an increase in seats and approve or disapprove it within six months of receiving it, after first giving the applicant an opportunity to rectify defects found in the scheme.

Silence is treated as a ground of appeal rather than as a pocket refusal: the applicant may go to the Commission within fifteen days of the disapproval or of the lapse of the six months, the Commission must decide the appeal within forty-five days, and a second appeal then lies to the Central Government within thirty days.

The table that follows is the article’s findable artifact. It states, for each body in the new architecture, what that body decides, whom a person deals with for the purposes readers actually have, and what the route was under the statute that was repealed.

Body	What it decides	Who deals with it, and for what	The route under the 1956 Act
The National Medical Commission	Policy, standards frameworks, regulations, fee guidelines, appeals from the boards, ethics codes, the road map for health human resources	A board whose order is challenged, a state council resisting a guideline, a government seeking a policy direction	The Council itself held these functions together, advised by its executive committee
Under-Graduate Medical Education Board	Undergraduate standards and curriculum, minimum requirements for courses and examinations, recognition of undergraduate qualifications	A university or college designing an MBBS course, a student asking whether a qualification counts	The Council’s undergraduate committee and the Council itself
Post-Graduate Medical Education Board	Postgraduate and super-speciality standards and curriculum, recognition of postgraduate qualifications	A college starting an MD, MS or super-speciality course, a diplomate checking a qualification	The Council’s postgraduate committee and the Council itself
Medical Assessment and Rating Board	Permission for new colleges, new courses and more seats, inspection, assessment, rating and publication of ratings, penalties and stoppage of admissions	A trust or government proposing a college, a college facing a penalty or a reduced intake	Application to the Central Government, decided on the Council’s recommendation after inspection
Ethics and Medical Registration Board	The National Register, professional conduct and ethics, appeals from state medical councils	A doctor enrolling or facing an ethics appeal, a patient whose complaint turns on the register	The Council maintained the Indian Medical Register; ethics appeals lay to the Central Government
State Medical Councils	State registers, first-instance discipline for professional or ethical misconduct, compliance with the Commission’s guidelines	A patient complaining about a doctor, a doctor answering a charge, a practitioner registering in a state	The same councils under state law, loosely coordinated with the Council

Two cautions belong with the table. The first is that the boards are autonomous in their allotted functions but not independent of the Commission: Section 10 makes the Commission the coordinator and appellate authority over them, Section 16 places them under its overall supervision, and Section 45 binds them, with the Commission, to the Central Government’s written directions on policy. The second is that the permission route’s centre of gravity moved. Under the 1956 scheme, permission to establish a college was formally granted by the Central Government on the recommendation of the Council; under Section 28 of the 2019 Act, the Medical Assessment and Rating Board grants the permission itself, and the Central Government enters only as the second appellate forum. That inversion, a government deciding on expert advice replaced by an expert body deciding subject to government appeal, is one of the least noticed and most consequential changes the replacement made.

The two examinations: one that runs, and one that does not

Chapter IV of the Act contains the two examinations around which medical education in India is organised, and the contrast between them is the sharpest illustration of this article’s thesis. The law of examinations belongs in part to a neighbouring inquiry: the integrity and malpractice regime of national examinations is treated in the account of the examination malpractice statutes, and the federal contest over admission standards is treated in the education cluster. Here the examinations matter as machinery of this statute: who must take them, what turns on them, and what their legal state is.

Section 14 establishes the National Eligibility-cum-Entrance Test. There is to be a uniform test for admission to undergraduate and postgraduate super-speciality medical education in all medical institutions governed by the Act, and a proviso extends the undergraduate test to all medical institutions governed under any other law for the time being in force, which is the clause that brought the All India Institutes of Medical Sciences and the Jawaharlal Institute of Postgraduate Medical Education and Research, each constituted under its own statute, inside the common entrance. The Commission conducts the test through such designated authority and in such manner as may be specified by regulations, and it specifies by regulations the manner of conducting common counselling by the designated authority, with the designated authority of the Central Government conducting common counselling for the All India seats and the designated authority of the state government conducting it for the seats at the state level. Admission to postgraduate broad-speciality courses is dealt with not in Section 14 but in Section 15, because the Act assigned that function to the exit test, a drafting decision whose consequences run through everything that follows.

The counselling structure Section 14 prescribes tracks the federal division of the seats themselves. Undergraduate seats divide between the all India quota, fifteen per cent of seats in government colleges surrendered to a common national pool, and the state quota comprising the remainder together with the seats of institutions regulated by the states. The designated authority of the Central Government conducts the common counselling for the all India seats and for the seats of deemed universities and central institutions, while the state governments’ designated authorities conduct the counselling for admission at the state level; at the postgraduate level the same division applies between an all India quota of half the government seats and the state quota. The consequence of writing the counselling into the Act, rather than leaving it to scheme and practice as the repealed statute had, is that a challenge to the counselling is a challenge under the statute itself, and the recurring litigation over vacant seats, stray rounds and mop-up rounds is conducted against the background of Section 14 rather than against administrative convention. The statutory counselling also closed one chronic source of abuse in the old regime, in which the gap between a centralised test and decentralised, institution-level admission had allowed the test’s merit order to be defeated at the counselling table.

Is the National Eligibility-cum-Entrance Test conducted by the Commission itself?

Not directly. Section 14 obliges the Commission to conduct the test through such designated authority, and in such manner, as may be specified by regulations. The undergraduate test is administered by the National Testing Agency and the postgraduate tests by the National Board of Examinations in Medical Sciences, each acting as the designated authority.

The Commission nevertheless owns the test in law: its uniformity, the counselling structure that Section 14 writes into the Act, and the consequences that admission and exclusion carry.

The entrance test’s own history explains why Parliament legislated it twice. The Medical Council of India first attempted a common entrance examination by regulation, notifying the National Eligibility-cum-Entrance Test for undergraduate admissions in 2010 and for postgraduate admissions in 2012. In Christian Medical College, Vellore v. Union of India, decided in 2013, the Supreme Court struck the notifications down, holding that the Council’s regulation-making power under the 1956 Act did not extend to imposing a single entrance test that displaced the admission processes of the institutions, including minority institutions. A review bench recalled that judgment in 2016, and Parliament then put the test beyond the vires argument by statute: the Indian Medical Council (Amendment) Act 2016 inserted Section 10D into the 1956 Act, mandating a uniform entrance examination for undergraduate and postgraduate admissions, and the Supreme Court in Sankalp Charitable Trust v. Union of India directed the test’s conduct for the admission cycle then in progress. Section 14 of the 2019 Act is therefore the third legal foundation of the same examination, and the most complete: it settles the conducting authority in the Commission acting through a designated authority, writes common counselling into the statute, divides that counselling between the Centre and the states by category of seat, and reaches institutions governed by other laws for undergraduate admissions. The postgraduate broad-speciality entrance was the one element Section 14 deliberately left behind, because Section 15 had assigned its function to the exit test, and it is the element whose legal basis has had to be improvised ever since the exit test failed to arrive: the postgraduate entrance test continues to be conducted each cycle under the authority of the regulations and the transitional savings, filling a place the enacted scheme reserved for a different examination.

Section 15 is the National Exit Test, and it must be stated exactly as enacted before anything is said about its fate. Sub-section (1) provides that a common final year undergraduate medical examination, to be known as the National Exit Test, shall be held for granting licence to practise medicine as medical practitioners and for enrolment in the State Register or the National Register. Sub-section (2) provides that the Commission shall conduct the test through such designated authority and in such manner as may be specified by regulations. Sub-section (3) provides that the test shall become operational on such date, within three years from the date of commencement of the Act, as may be appointed by the Central Government by notification. Sub-section (4) provides that any person with a foreign medical qualification shall have to qualify the test for the purpose of obtaining a licence to practise and enrolment in the registers. Sub-section (5) makes the test the basis for admission to postgraduate broad-speciality medical education in institutions governed by the Act or by any other law, and sub-section (6) applies the common counselling machinery to those admissions, Centre for the All India seats and states for the state-level seats. Section 33 completes the design from the other side: the licence to practise is granted to a person who qualifies the exit test, a foreign graduate who qualified abroad and is recognised as a practitioner there may not enrol after the test becomes operational unless he qualifies it, and the deemed-registration proviso keeps the existing profession registered in the meanwhile.

Three propositions about the exit test must be kept separate, because public discussion persistently merges them. The first is what the Act requires: a single common final year examination carrying the licence, the postgraduate admission ranking and the screening of foreign graduates, to become operational on a date appointed by notification within three years of commencement. The second is what the notifications and regulations state: Section 15 was brought into force on 25 September 2020 with the rest of the Act; the National Exit Test Regulations were published by the Commission in the Official Gazette on 28 June 2023, sketching a two-step examination, the first step a theory examination whose score would serve for postgraduate admission and the second a practical or clinical examination after internship; the All India Institute of Medical Sciences at New Delhi was entrusted with a mock or practice test fixed for 28 July 2023; and by a public notice recording the advice of the Health Ministry dated 11 July 2023, the Commission deferred the examination until further directions from the Ministry, the mock test was cancelled and the fees collected for it were refunded. The third proposition is what remains unnotified: no notification under sub-section (3) of Section 15 has appointed the date on which the test becomes operational, and the test has not been held. The three-year period the sub-section allowed ran from the commencement of the provision in September 2020, and it closed in September 2023 with the appointment of a date still outstanding.

The design notified in the 2023 regulations repays attention because it shows how completely the examination had been specified on paper before it was deferred. Step 1 was a theory examination in the subjects of the final year, to be taken before the internship, and its score was to serve two purposes at once: the qualification for the licence, in conjunction with the second step, and the ranking for postgraduate broad-speciality admission under sub-section (5). Step 2, separated from the first by the internship itself, was to be a practical and clinical examination of the candidate’s fitness to practise. Foreign medical graduates were folded into the same gate, with the regulations requiring them to undergo internship in India as part of the route to the licence. The design’s exposure lay in that coincidence of functions: an examination carrying the licence and the postgraduate ranking together had to be defended as both at once, to cohorts who had entered medical school years before the design existed and on curricula the design had not set, and the deferral of July 2023 was in substance a refusal to run that defence on the first date the regulations had named.

Between the second and third propositions sits the political record, which should be stated with its holders named. Students of the 2019 undergraduate batch, the first cohort the Commission proposed to put through the test, objected that their course had begun on 1 August 2019, before the Act itself was published, and that subjecting them to a licensing examination designed after their admission was a breach of the statute’s own transitional fairness; the Indian Medical Association pressed the objection and its wider case against the examination’s coupling of licence and ranking. The Union Health Minister, Mansukh Mandaviya, announced at an event at the All India Institute of Medical Sciences at Raipur that there would be no National Exit Test for the 2019 batch and that the test would not replace the final year university examinations for them, and the deferral notice followed within days. The Health Ministry thereafter constituted a seven-member committee to examine the preparedness of states and medical colleges for the examination’s implementation for the following batch. The Commission, for its part, opened the design questions to stakeholder consultation, asking whether the test should replace the university final year examination, sit alongside it, or take another form, and its chairpersons have since described the test in public as a novel concept requiring consensus on transition, difficulty and perception before it can be rolled out. None of this is a repeal, a stay or a judicial suspension. It is an executive decision, renewed by silence, not to appoint the date a section of a statute in force has authorised the government to appoint.

What operates in the space the exit test was designed to fill is the previous dispensation, preserved by the Act’s own transitional clauses. The licence to practise still follows enrolment on a state register after a recognised qualification, under the proviso to Section 33. Admission to postgraduate broad-speciality courses still runs through the postgraduate National Eligibility-cum-Entrance Test conducted by the National Board of Examinations in Medical Sciences. Foreign medical graduates still take the screening test under the Screening Test Regulations of 2002, which Section 61 of the Act keeps in force until they are replaced, and the courts have enforced those regulations on that footing. A medical student asking what governs the licence, the postgraduate seat and the foreign degree will therefore find, in every case, the pre-2019 answer, not because the 2019 Act failed to change the law but because the change it enacted is conditioned on an appointment of date that has not been made. Readers keeping their own files of admission notices, counselling schedules and sanction orders across these regimes will find the formats vary from authority to authority, and a reader who has to open a seat matrix in a spreadsheet beside a sanction letter in a presentation can do both in one place through the ReportMedic office file viewer for spreadsheets, documents and presentations, which is the practical companion this series attaches to document-heavy provisions of this kind.

Permission, recognition, the registers and the bar to practice

The working machinery of the Act, the provisions a college administrator or a practitioner touches in an ordinary year, has functioned without interruption since September 2020, and its design repays statement because it differs from the repealed scheme at the points of greatest friction. Permission comes first. Section 28 forbids any person to establish a new medical college, start a postgraduate course or increase the number of seats without the prior permission of the Medical Assessment and Rating Board. The applicant submits a scheme in the form specified by regulations; the Board, having due regard to the criteria specified in Section 29, must approve or disapprove it within six months, and before disapproving must give the applicant an opportunity to rectify the defects found. Approval is the permission. Disapproval, and equally the lapse of six months without a decision, opens an appeal to the Commission to be filed within fifteen days; the Commission must decide within forty-five days; and if the Commission disapproves or lets the period lapse, a second appeal lies to the Central Government within thirty days. The ladder is short, timed at every rung, and treats administrative silence as an appealable event, three features the old regime, in which applications moved between the Council and the Ministry without statutory clocks, did not have. A general account of a given matter in an article of this kind is legal information rather than advice on that matter, and an applicant with a live scheme and a running clock should take advice on the individual case, because limitation periods of fifteen and thirty days forgive nothing.

Recognition is the second machinery. Under Sections 35 to 37, the medical qualifications granted by universities and medical institutions in India are listed and maintained by the two education boards and are recognised qualifications for the purposes of the Act; qualifications granted by institutions outside India are dealt with under Section 36, and qualifications granted by statutory or other bodies in India, the categories listed in the Schedule to the Act, which include the All India Institutes of Medical Sciences, the Postgraduate Institute at Chandigarh, the Jawaharlal Institute at Puducherry, the National Institute of Mental Health and Neuro-Sciences at Bengaluru and the National Board of Examinations, are dealt with under Section 37. Section 38 empowers the Commission to withdraw recognition of a qualification granted in India where the Medical Assessment and Rating Board reports that the institution has failed to comply with the standards, and the withdrawal provisions are matched by a derecognition power for foreign qualifications under Section 39 and special provisions for particular cases under Section 40. Appeals in recognition matters follow the Act’s general pattern, running to the Commission and then to the Central Government, as the Ministry’s appellate arrangements under Sections 35 and 36 record.

Two features of this machinery mark its distance from the repealed scheme. The first is the rating idea. Under the 1956 Act the state’s knowledge of a college was essentially binary: an institution was permitted and recognised, or proceeded against, and the inspection reports on which those decisions turned were not public documents a student could consult before taking a seat. Section 26 obliges the assessment board not only to assess but to rate, and to make the assessment and ratings of medical institutions available on its website or in the public domain at regular intervals specified by regulations. Regulation by disclosure is a different instrument from regulation by permission: it assumes that applicants, patients and state governments will discipline institutions with information the regulator publishes, and it converts the inspection from an episodic ordeal into a standing public record. The second feature is the position of the student when an institution fails. The old regime’s hardest cases were cohorts admitted to colleges whose recognition later collapsed, leaving graduates holding qualifications of contested value through no fault of their own. Section 49 of the 2019 Act, headed as the completion of courses of studies in medical institutions, addresses the completion of the studies of students caught by such failures, and the withdrawal provisions of Sections 38 and 39 operate within a scheme that has at least named the student’s interest as one the statute protects. The criteria in Section 29, against which the assessment board must judge every permission scheme, complete the picture of an intended discipline: the Board is not left to a general satisfaction but must have due regard to criteria the Act itself specifies, and its reasons are exposed, through the timed appeal ladder, to the Commission and the government in turn.

One further contrast with the repealed scheme belongs to the permission story, because it explains much of the friction the old regime generated. Under the 1956 Act as administered, a new medical college did not receive a settled permission at birth; it received a letter of permission for its first admission and then passed through renewals of permission year by year, each renewal riding on a fresh inspection, until its first batch reached the final year and the qualification could be recognised. The renewal treadmill made inspection an annual event of existential consequence for every young college, multiplied the occasions on which assessors and managements met behind the gate, and produced the recurring litigation in which an academic session turned on whether an inspection had been fairly conducted or a deficiency fairly found. The 2019 Act’s design answers that history at three points. The permission decision is placed on a statutory clock with rectification built in, so that deficiencies are an invitation to cure before they are a ground of refusal. The continuing supervision of a permitted institution is assigned to assessment and published rating rather than to annual permission, so that the state’s knowledge of a college is a graded public record rather than a yearly pass or fail. And the graduated measures in Section 26, warning, monetary penalty, reduction of intake, stoppage of admission and recommendation for withdrawal of recognition, give the board responses proportioned to the failure, where the old scheme’s practical choice had so often been the binary one between tolerating an institution and destroying it. The design has not abolished inspection or its controversies, and assessment visits remain the point of contact at which institutions feel the regulator’s hand most directly; but the legal character of the contact changed with the statute, from a recurring permission to a standing supervision, and that change is one of the replacement’s genuine structural gains.

The third machinery is the register, and it is where the practitioner’s legal existence is kept. Section 31 requires the Ethics and Medical Registration Board to maintain a National Register containing the name, address and all recognised qualifications of every licensed medical practitioner, in the form specified by regulations, including electronic form; the Register is a public document within the meaning of Section 74 of the Indian Evidence Act 1872 and is to be made available to the public on the Board’s website. Every state medical council must maintain and regularly update its State Register in the specified electronic format and supply a copy to the Board, and the Board must ensure electronic synchronisation of the two registers so that a change in one is automatically reflected in the other. Sub-section (8) adds a separate register of the same kind for community health providers, if and when that licence is granted. Section 34 then gives the register its teeth: no person other than a person enrolled in the State Register or the National Register may practise medicine as a qualified medical practitioner, hold an office meant for a physician or surgeon, sign or authenticate a medical or fitness certificate, or give expert evidence on a medical matter in an inquest or a court, and contravention is punishable with imprisonment for a term that may extend to one year, or a fine that may extend to five lakh rupees, or both. The line between the registered profession and everyone else, which the community health provider provision deliberately and controversially blurs at one defined point, is otherwise drawn by Section 34 as sharply as the repealed Act drew it.

The community health provider: Section 32 stated, and both cases at full strength

Section 32 is the provision on which the 2019 protests principally fastened, and it deserves to be quoted in effect before it is characterised. Sub-section (1) empowers the Commission to grant a limited licence to practise medicine at mid-level as a community health provider to such person connected with modern scientific medical profession who qualifies such criteria as may be specified by the regulations, with a proviso capping the number of limited licences at one-third of the total number of licensed medical practitioners registered under Section 31. Sub-section (2) confines the licence to such extent, in such circumstances and for such period as the regulations specify. Sub-section (3) provides that a community health provider may prescribe specified medicine independently only in primary and preventive healthcare, and in cases other than primary and preventive healthcare may prescribe medicine only under the supervision of medical practitioners registered under Section 31. Three features of the text discipline the argument. The licence is a power, not a duty: the Commission may grant it, and only to persons who meet criteria a regulation has yet to specify in operative detail. The class is defined by connection with the modern scientific medical profession, a phrase of studied breadth. And the prescribing right is asymmetric by design: independent in primary and preventive care, supervised everywhere else.

The case for the provision, in its strongest form, is a case about the map of Indian healthcare rather than about the profession. Its starting point is the distribution of doctors. The Health Ministry’s own explanatory material on the 2019 Bill put the doctor-population ratio at one doctor for one thousand four hundred and fifty-six people against the World Health Organization norm of one for one thousand, and the urban to rural doctor density ratio at three point eight to one. In large parts of rural India the practical alternative to a licensed mid-level provider is not a fully qualified doctor but an unqualified and unlicensed practitioner whom the state does not train, does not register, cannot discipline and does not reach; the Indian Medical Association’s own campaigning against unqualified practice concedes the size of that unregulated sector. On this view, a trained cadre with a defined scope, a capped number, a register of its own under sub-section (8) of Section 31, and prescribing rights that expand only under supervision converts an invisible and unaccountable practice into a visible and accountable one, and it follows the route taken by several countries that staff primary care with mid-level cadres working to protocol. The provision’s defenders also point to its setting inside the Act: Section 51 obliges state governments to promote primary healthcare in rural areas, and the community health provider is the licensing instrument of that obligation.

The provision also did not arrive in a vacuum of practice. The Ayushman Bharat programme’s health and wellness centres, the primary care delivery platform the Union government was building in the same years, were designed to be staffed by a mid-level health provider, the Community Health Officer, drawn substantially from nursing graduates and practitioners of the Indian systems who completed a bridge training in public health and primary care. By the time the 2019 Act was passed, the Indian state was therefore already committed, as a matter of delivery policy, to mid-level provision at the first point of care; what it lacked was a licensing frame within the modern medicine statute for any part of that provision, and Section 32 supplied the frame in the most contested possible location, inside the Act that defines who may practise medicine. The government’s defenders made the connected argument in Parliament: that the choice before the House was not between doctors and community health providers, but between community health providers trained, licensed, capped and registered, and the unlicensed practitioners who already serve the villages the doctors do not reach.

The case against, in its strongest form, is the case the Indian Medical Association made in 2019, and it should be stated in the Association’s own terms. Its Emergency Action Committee described Section 32 as a provision that legalises quackery by empowering community health providers to practise medicine, and as the single largest threat to the health of the nation. Dr Santanu Sen, the Association’s national president, said that the section provided for licensing three and a half lakh unqualified non-medical persons to practise modern medicine, that the term community health provider was vaguely defined so as to allow anyone connected with modern medicine to be registered and licensed, and that if the section were not removed the government would have blood on its hands; the Association’s president-elect, Dr Rajan Sharma, made the same charge. The substance beneath the rhetoric has three limbs. A category defined by connection with the profession, with its criteria left to regulations, is a category whose real boundary is set by subordinate legislation after the parliamentary argument is over. A prescribing limit expressed as primary and preventive healthcare is, in the conditions of a rural clinic, difficult to police: the patient does not arrive labelled, and the provider who exceeds the boundary faces a disciplinary machinery that has never demonstrated reach into that setting. And a two-tier licence creates a two-tier standard of care, in which the citizen of a village is statutorily assigned a lesser practitioner than the citizen of a city, a distributive objection the Association framed in the language of equality. Between these two cases this article does not adjudicate, because the brief of a repeal and replacement study is the design and its record. The record itself is part of the design’s fate: the criteria regulations that would give Section 32 operative content have been the subject of official statements about standards for community health providers since the Commission’s constitution, but the licence the section authorises has not been brought into general operation, so the provision stands with the exit test among the parts of the Act that exist as law before they exist as practice, though for different reasons and by a different route.

The fee guidelines and the limits of the fee power

The fee power is the second of the brief’s defining provisions and the one most persistently overstated in summary accounts, which commonly report that the Commission fixes or regulates the fees of private medical colleges generally. The text grants less and does it by a particular instrument. Clause (i) of sub-section (1) of Section 10 lists among the functions of the Commission the framing of guidelines for determination of fees and all other charges in respect of fifty per cent of seats in private medical institutions and deemed to be universities which are governed under the provisions of the Act. The Commission frames guidelines; it does not itself determine any college’s fees, and the guidelines reach a defined half of the seats, not the whole intake. The remaining half is outside the provision, and the determination of fees within the guidelines remains with the fee-regulating machinery of the states. The provision is nevertheless a substantial intervention in private college finances, because a guideline that anchors half an institution’s seats to a public benchmark governs the economics of the whole institution, and because the power was new: the 1956 Act contained nothing like it at the centre, fee control having grown up instead through state legislation and the committee jurisprudence of the courts. The proportion itself has a provenance: the NITI Aayog committee of 2016 had proposed that the new commission be empowered to fix norms for regulating fees for a proportion of seats in private medical colleges while leaving promoters to set the fees of the remainder transparently, and the fifty per cent of the enacted clause is that proposal given a number. The design is thus a deliberate halfway house. A full fee power would have nationalised the price of private medical education and invited the constitutional challenge the TMA Pai line of cases makes available; no fee power would have left the single largest grievance about private medical education, its price, entirely to state committees of uneven vigour. The halfway house has the vices of its position as well as its virtues, since a benchmark for half the seats interacts with the price of the other half in ways a college’s accounts can rearrange, a point the institutions pressed in the litigation and the Commission’s memorandum attempted to meet by barring capitation and other charges outside the fee.

The jurisprudence is the necessary background, and it is stated here as propositions with their cases named, the fuller treatment belonging to the education cluster. In TMA Pai Foundation v. State of Karnataka, decided in 2002, an eleven-judge bench held that unaided private professional institutions enjoy autonomy in admissions and fee fixation as an aspect of the freedom of occupation, subject to regulation against profiteering and capitation. In Islamic Academy of Education v. State of Karnataka, in 2003, the Court constituted committees for admissions and fees in each state as the machinery of that regulation. In P. A. Inamdar v. State of Maharashtra, in 2005, a seven-judge bench held that the state could not appropriate the seats of unaided private professional colleges, while accepting regulation to prevent profiteering. In Modern Dental College and Research Centre v. State of Madhya Pradesh, in 2016, the Court upheld a state statute regulating admissions and fees in private professional institutions against the autonomy challenge, treating reasonable regulation in the public interest as consistent with the earlier line. The NMC guidelines were framed within that framework: a central guideline power operating alongside state fee committees, over institutions whose constitutional claim to fee autonomy had already been qualified by two decades of decisions.

The guidelines came by office memorandum dated 3 February 2022. After consultation, including an expert committee’s examination of some eighteen hundred responses to a draft, the Commission decided that the fee of the fifty per cent of seats in private medical colleges and deemed universities should be at par with the fee in the government medical colleges of the same state or Union territory; that the benefit should go first to candidates who had taken government quota seats, up to the fifty per cent limit; that where government quota seats numbered less than half the sanctioned strength, the remaining candidates should receive the benefit on merit; and that no capitation fee should be charged. Private institutions challenged the memorandum in the High Courts and carried the question to the Supreme Court: the Kerala High Court clarified that the fee order would not be applicable in Kerala, the Madras High Court, while recording its concern at admissions driven by monetary gain, directed the Commission to revisit its decision and issue a fresh memorandum if necessary, and the Supreme Court took up the examination of the order’s validity. The litigation posture at the end of that sequence is the durable one for a reader to hold: the statutory power in Section 10 stands enacted and unamended, its first major exercise was contested in court from the month it issued, and the practical fee a student pays in a private college is the product of the guideline, the state committee and the litigation together, not of the guideline alone. The question whether the provision has reduced the cost of private medical education is an evidence question on which verdicts in print usually outrun the record; what the record supports is that for the seats within the guideline, a public benchmark exists where none did under the repealed Act.

The states inside a central statute

Medical regulation under the 2019 Act is a field of concurrent operation, and the boundary between central standards and state administration is the same boundary the education cluster traces through the Concurrent List, examined at length in the study of education in the Concurrent List and the federalism of standards. Within this statute the states appear in four places. They appear as nominators: the vice-chancellors of their health universities and the elected members of their medical councils supply nineteen of the Commission’s thirty-three members through the advisory council’s constituencies, and the fourth, part-time member of each autonomous board is chosen from among the elected members of the state medical councils. They appear as advisers: the Medical Advisory Council constituted by Section 11 consists of the Commission’s Chairperson as its ex officio chair, every member of the Commission, one member for each state who is the vice-chancellor of a health university in that state nominated by the state government, one for each Union territory nominated by the Ministry of Home Affairs, one for each state and Union territory drawn from the elected members of its medical council, the Chairman of the University Grants Commission, the Director of the National Assessment and Accreditation Council, and four members nominated by the Central Government from among the directors of the Indian Institutes of Technology, the Indian Institutes of Management and the Indian Institute of Science. Section 12 states the Council’s functions and also its limit: it is the primary platform through which the states and Union territories put forth their views and concerns before the Commission, and it advises the Commission on measures to determine and maintain minimum standards and to enhance equitable access to medical education. It advises; Section 13 requires it to meet at least twice a year; nothing it resolves binds the Commission.

They appear, thirdly, as the first-instance regulators of professional conduct. Section 30 obliges every state government, within three years of the commencement of the Act, to take the steps necessary to establish a state medical council where none exists, and provides that where a state Act confers disciplinary power on the state medical council, the council shall act in accordance with the regulations and guidelines made under the 2019 Act, after giving the practitioner an opportunity of hearing before any action, including a monetary penalty. Until a state council is established, complaints go to the Ethics and Medical Registration Board. A practitioner aggrieved by a state council’s action may appeal to that Board under sub-section (3), whose decision binds the state council unless a second appeal is preferred to the Commission under sub-section (4) within sixty days. And they appear, fourthly, as subjects of direction: Section 46 empowers the Central Government to give such directions as it deems necessary to a state government for carrying out the Act, with which the state government shall comply. The state medical councils, contrary to a widespread summary, were therefore not replaced by the Commission; they were retained, standardised, placed under a national appellate ladder and made answerable to guidelines, which is a significant change of status accomplished without a change of name.

The councils’ continuing place is clearest in the registers, where the 2019 Act replaced a paper chain with an electronic one. Under the repealed Act the Indian Medical Register was a compilation, assembled by the central Council from the state registers, themselves maintained under state law and transmitted upward in a process that left the national record chronically behind the state records. Section 31 inverts the discipline without removing the states from it. Each state council maintains the State Register of licensed practitioners in the electronic form and format specified under the Act and supplies it to the Ethics and Medical Registration Board, which maintains the National Register from them; sub-section (7) requires the electronic synchronisation of the two registers, so that the name, address and recognised qualifications recorded nationally are the name, address and qualifications recorded in the state; and the National Register is declared a public document, published on the Board’s website, where a patient, an employer or a foreign regulator can test a practitioner’s claim to be registered. The practitioner’s daily dealings remain with the state council, which enrols him, records his additional qualifications and issues the certificates on which employment and migration depend; but the record he stands on is a single national record, and the state council’s register keeping is performed to a central specification under a central board’s appellate eye. It is the statute’s federal settlement in miniature: administration in the states, architecture at the centre, and the practitioner’s name in exactly one place in law.

Where should a patient complain about a doctor’s professional misconduct?

With the State Medical Council of the state where the practitioner is registered. Section 30 keeps disciplinary action for professional or ethical misconduct in the state council’s hands at first instance, exercised under the Commission’s regulations and guidelines and only after a hearing. Where no state council exists, the complaint goes to the Ethics and Medical Registration Board.

The doctor under charge, and not only the complainant, is given a defined route upward: an appeal from the state council to that Board, and a second appeal from the Board to the Commission within sixty days.

The parallel commissions of 2020

The 2019 Act was a template as well as a statute. In the following year Parliament enacted the National Commission for Indian System of Medicine Act 2020 and the National Commission for Homoeopathy Act 2020, both receiving assent in September 2020, repealing the Indian Medicine Central Council Act 1970 and the Homoeopathy Central Council Act 1973 respectively and erecting commissions for Ayurveda, Unani, Siddha and Sowa-Rigpa and for homoeopathy on the same model: a nominated commission, autonomous boards dividing education from assessment and registration, common entrance examinations, and state councils retained beneath. The 2019 statute anticipated the family it would head. Section 50 requires joint sittings of the Commission with the central councils for homoeopathy and Indian medicine, as those bodies then stood, at least once a year to enhance the interface between the systems of medicine, a provision that reads oddly against the 2019 protests until its purpose is seen: the interface the Act mandates is deliberative, a sitting, where the lapsed 2017 Bill had proposed a practice right through the bridge course. The replacement of the councils for the other systems on the NMC model also matters to the assessment of the 2019 design, because a legislature that copies a template across three professions within a year has made a considered choice about how professional regulation in India is to be constituted, and the choice was nomination with separated functions in each case. The replication is clause-deep, not merely structural. Each of the 2020 statutes appoints its commission through a search committee on the Section 5 pattern, divides its work among autonomous boards for education, for assessment and rating and for ethics and registration, retains the state councils of the respective systems as the first-instance disciplinary and registering authorities under a national appellate ladder, prescribes a common entrance examination for its undergraduate courses, binds the commission to the Central Government’s written directions on questions of policy in the language of Section 45, and arms the government with a supersession power in the language of Section 55. A reader moving from the 2019 Act to either 2020 Act is reading the same statute re-pointed at a different profession, which is why the 2019 Act’s interpretation will govern the family’s: the first litigation on the directions power, the fee guidelines or the assessment board’s measures under any of the three statutes will be cited under all of them. It also fixes the 2019 Act’s place in the longer history this series records. The councils of the nineteen fifties, elected professional bodies on the model the 1956 Act embodied, have in medicine, in the Indian systems and in homoeopathy all been replaced within fourteen months of one another by nominated commissions on a single template; whatever judgment is passed on the template, its adoption was general, deliberate and complete. The wider architecture of health legislation into which these statutes fit, and the statutes governing drugs, clinical establishments, allied professions and public health that surround them, is mapped in the thematic guide to health legislation in India, to which this article defers for the framework and from which it takes its place as the medical education statute’s specialist study.

The honest assessment of the National Medical Commission Act 2019: a reform with a record, a profession with a grievance, and a test that does not exist

The reform case for the 2019 Act, at its strongest, is that it is a statute built on findings rather than on fashion. The body it abolished had been arrested into disgrace in 2010, placed under a Supreme Court oversight committee in 2016, and condemned in a parliamentary report the same year whose recommendations the new Act substantially enacts: appointment through a selection process rather than election by the regulated, diversity of composition beyond the profession, separation of the functions whose union had made the old Council unaccountable, timed decisions in place of discretionary delay, and a standards regime aimed at outcomes rather than at the inventory of buildings and beds. The structural conflict at the centre of the old design, a profession electing the body that licensed entry to itself and recognised the colleges that employed its members, is not an invention of the Act’s supporters; the Standing Committee identified it, the Roy Chaudhury group identified it, and no serious defence of the 1956 scheme answered it except by pointing to the parallel self-regulation of other professions. On the evidence available to Parliament in 2019, the replacement of the Council was justified, and the particular shape of the replacement, four boards under one commission, was the shape its own expert processes had converged on. The Act also compares instructively with its statutory neighbours: the university system’s standards body considered in the study of the University Grants Commission Act 1956 was constituted from the start as a nominated commission, and Indian higher education never treated election by the regulated as the natural constitution of a standards authority. Medicine, in moving to nomination in 2019, was joining the general pattern of Indian educational regulation rather than departing from it.

The professional objection, at its strongest, is not nostalgia for the Medical Council of India, which the profession’s own leadership could not defend in public by 2019. It is an objection about the direction of the substitution. A regulator whose every member is appointed by the government of the day, through a committee the government’s senior civil servant chairs; a regulator expressly bound by that government’s written directions on questions of policy, with the government the final judge of what is policy; a regulator the same government may supersede for defaulting on those directions; and a regulator empowered to license a mid-level category of practitioner over the profession’s objection: such a body is, in the objectors’ phrase, a regulator of the profession rather than by it, and the loss of professional self-governance is a real change whatever is thought of the body that previously embodied it. The Indian Medical Association’s 2019 campaign expressed this objection alongside the Section 32 charge and the charge that fee control had been diluted in passage to guidelines: in the Association’s words the Bill was anti-poor, anti-student and anti-democratic, and its president Dr Santanu Sen and its secretary general Dr R. V. Asokan carried that case through the July protests, the burning of copies of the Bill at the Association’s branches, the Delhi march of 29 July and the twenty-four hour withdrawal of non-essential services that followed the Lok Sabha’s passage of the Bill. Resident doctors’ associations struck work in the capital as the Rajya Sabha took the Bill up. The objection also has a federal limb, pressed in the parliamentary debate: that a nominated central commission, armed with directions to state governments under Section 46 and appellate power over state councils, moves the centre of gravity of a subject on which states run the hospitals and most of the colleges decisively to New Delhi, the advisory council’s platform notwithstanding. These objections identify real features of the enacted text. They do not answer the record of the body the text replaced, and the two cases have largely been conducted past each other ever since, the government citing 2016 and the profession citing Section 45.

The operating record since 2020 supplies evidence to both. The permission machinery has run at a pace the old regime rarely matched, with the assessment board processing successive cycles of new colleges, new courses and seat increases through the timed ladder of Section 28, and the expansion of undergraduate capacity continuing the trajectory the Health Ministry quantified at the transition, from about fifty-four thousand seats in 2014 to about eighty thousand in 2020. The rating function has begun the publication discipline Section 26 commands. Against that, the ethics code episode of 2023 showed the profession’s objection operating in practice. The Commission notified the Registered Medical Practitioner (Professional Conduct) Regulations in August 2023, a modernised code covering matters from generic prescribing to the practitioner’s presence on social media; the Indian Medical Association objected to several of its provisions, the Health Ministry intervened, and within weeks the Commission held its own regulations in abeyance, leaving the predecessor council’s 2002 ethics regulations, carried forward by Section 61, in operation in their place. A nominated regulator had made a code for the profession, the profession’s association had resisted it, and the government whose directions bind the regulator had settled the contest against its own appointee’s instrument. Defenders of the Act read the episode as accountability working; critics read it as the proof that the Commission’s autonomy ends where organised professional pressure, routed through the Ministry, begins. Both readings are available on the same facts, and the episode is the clearest single demonstration that the directions relationship in Section 45 is not a formality.

The institution itself has been continuous in a way the interregnum never was. The Commission was constituted with effect from the repeal date itself, its first Chairperson appointed through the search committee route the Act prescribes, and its boards populated alongside it, so that the transfer of September 2020 was a change of letterhead laid over an appointment process that had run in advance under the staged commencement. The Commission has since been reconstituted on the expiry of its first term through the same statutory machinery, without ordinance, supersession or judicial rescue, which is itself a datum: the ordinary succession of the body’s membership, the most basic test of an institution’s settling, has occurred under this Act by the Act’s own procedure. A regulator whose predecessor required dissolution by ordinance in 2010, an elected restoration in 2013 and supersession again in 2018 has, under the replacement statute, simply had its terms expire and its vacancies filled. Critics answer that tranquillity purchased by nomination is the tranquillity of a body that need not fear its constituency; the answer is available, and it restates rather than resolves the founding argument, but the institutional fact stands on the record.

The verdict this framework requires is narrower than either case, because it concerns the replacement as an event in the life of a statute. The series to which this article belongs has traced, statute after statute, a characteristic Indian mode of legislative failure in which an Act is passed and its provisions are then brought into force in stages, or not at all, so that the law in the book and the law in operation diverge at the point of commencement. The National Medical Commission Act 2019 is a distinct variant of that problem, and it should be named precisely. Here nothing is unnotified in the commencement sense: every provision of the Act was brought into force, the repeal was executed on a stated date, the successor body was constituted, appointed, housed and set to work, and the machinery of permissions, recognition, registers and counselling has operated under the new Act through successive admission cycles. The statute is fully in force. What has not happened is the creation of the operative machinery of its principal reform. The National Exit Test is not a provision awaiting commencement; Section 15 is in force, and has been since September 2020. It is a mechanism in force and inoperative, dependent on an appointment of date that the executive has chosen, repeatedly and on the record, not to make, because making it would impose the test on a real cohort of students whose objections the political system has been unwilling to override. That is a failure of implementation rather than of commencement, and the distinction matters for anyone assigning responsibility: a commencement failure can be laid at the door of drafting, while this failure belongs to a decision, renewed each admission cycle, that the reform the statute reorganised medical licensing around is not yet one the state is prepared to operate.

The consequence is a statute living a double life, and the double life is the fact a reader should carry away. In its governance dimension the 2019 Act is fully operative and plainly consequential: colleges are permitted, rated and penalised under it, fees are benchmarked under it, the register is kept under it, and the profession’s regulator is the Commission it created. In its licensing dimension the Act is a design awaiting its event: the licence, the postgraduate ranking and the screening of foreign graduates continue to be governed by the arrangements the Act was passed to replace, preserved by its own savings clauses, and the one examination that was to unify them has been announced, regulated for, mock-tested in prospect and deferred. The exit test is the statute, in the sense that the Act reorganised medical education around a single examination that determines the right to practise, entry to postgraduate training and the recognition of foreign graduates; and that examination has not been held, so the statute’s central mechanism has been in force and inoperative for years while every other part of it functions. Whether the deferral is a prudent pause before a difficult reform or the quiet abandonment of the reform itself is a question the passage of admission cycles will answer. The statute, characteristically, has left the answer to a notification.

Frequently Asked Questions

Q: What did the National Medical Commission Act 2019 create?

It created the National Medical Commission, a thirty-three member statutory body corporate constituted under Section 3, together with four autonomous boards beneath it, a Medical Advisory Council in which the states and Union territories sit, and a unified examination and registration architecture for the medical profession. The Commission consists of a Chairperson, ten ex officio members and twenty-two part-time members, all appointed by the Central Government. The Act also created the legal basis for the National Exit Test, the fee guidelines for half the seats in private medical institutions, and a limited licence for community health providers, and it made the Commission the successor in interest of the Medical Council of India.

Q: Which body did the National Medical Commission replace?

It replaced the Medical Council of India, the regulator constituted under the Indian Medical Council Act 1956, which was Act 102 of 1956. Section 60 of the 2019 Act repealed the 1956 Act with effect from 25 September 2020, and the Council stood dissolved on that date, along with the Board of Governors that had been running it in supersession since September 2018. The replacement was of the whole regulatory constitution, not of the functions: standards, recognition of qualifications, permission for colleges and the maintenance of a national register all continued, transferred to a nominated commission and its four boards instead of an elected council.

Q: What are the four autonomous boards under the National Medical Commission?

The Under-Graduate Medical Education Board, the Post-Graduate Medical Education Board, the Medical Assessment and Rating Board and the Ethics and Medical Registration Board, constituted by Section 16 under the overall supervision of the Commission. The two education boards set standards and curricula and grant recognition to qualifications at their respective levels. The assessment board grants permission for new colleges, courses and seats, inspects and rates institutions and penalises failures of standards. The ethics board maintains the National Register, regulates professional conduct and hears appeals from state medical councils. Each board has a President and four members, and its President sits on the Commission.

Q: What is the National Exit Test and has it been held?

The National Exit Test is the common final year undergraduate examination created by Section 15 of the Act. It was designed to serve three purposes at once: granting the licence to practise medicine and enrolment in the State or National Register, providing the basis for admission to postgraduate broad-speciality courses, and screening graduates of foreign medical institutions. The Act required it to become operational on a date appointed by the Central Government within three years of commencement. Regulations for it were published in June 2023 and a mock test was announced and then cancelled. No date has been appointed, and the test has not been held.

Q: Can the National Medical Commission regulate private college fees?

Within a defined limit, yes. Clause (i) of sub-section (1) of Section 10 empowers the Commission to frame guidelines for determination of fees and all other charges in respect of fifty per cent of seats in private medical institutions and deemed to be universities governed by the Act. The Commission frames guidelines; it does not itself fix any college’s fees, and the other half of the seats lies outside the power. By an office memorandum of 3 February 2022 the Commission set the fee for that half at par with the government medical colleges of the same state, a decision private institutions contested in the High Courts and the Supreme Court.

Q: Who are community health providers?

Community health providers are the holders of a limited licence created by Section 32 of the Act. The Commission may grant the licence to practise medicine at mid-level to a person connected with the modern scientific medical profession who qualifies under criteria specified by regulations, and the number of such licences may not exceed one-third of the licensed medical practitioners on the National Register. A provider may prescribe specified medicine independently only in primary and preventive healthcare, and in all other cases only under the supervision of a registered medical practitioner. The Indian Medical Association opposed the provision in 2019 as the licensing of unqualified practice; its supporters defend it as a regulated answer to the shortage of doctors in rural primary care.

Q: Can the central government direct the National Medical Commission?

Yes, on questions of policy. Section 45 provides that the Commission and the autonomous boards shall, in exercising their powers and discharging their functions, be bound by such directions on questions of policy as the Central Government may give in writing, after giving them an opportunity to express their views as far as practicable. The government’s decision on whether a question is one of policy or not is final. Section 46 separately empowers the Central Government to direct a state government to carry out the Act. The Commission is therefore a statutory regulator with a statutory subordination, and the directions power is the textual centre of the debate about its independence.

Q: What role do states have in medical regulation?

A substantial one, at three levels. Through the Medical Advisory Council, state health university vice-chancellors and elected state medical council members supply nineteen of the Commission’s twenty-two part-time members on rotation, and each autonomous board includes a member chosen from elected state council members. State medical councils continue to exist under state law: they maintain the State Registers and exercise first-instance disciplinary jurisdiction over practitioners for professional or ethical misconduct, acting under the Commission’s regulations and guidelines. States also conduct common counselling for state-level seats under Section 14. What states lost was the final word: their councils sit beneath a national appellate ladder and a central directions power.

Q: Who appoints the Chairperson and members of the National Medical Commission?

The Central Government appoints every member, but the senior appointments are filtered through a Search Committee constituted under Section 5. The Committee is chaired by the Cabinet Secretary and includes three experts with at least twenty-five years of experience in medical education, public health education and health research, one expert drawn from the state council nominees on the Commission, one person of long standing in management, law, economics or science and technology, and the Health Secretary as convenor. It recommends a panel of at least three names for each vacancy among the Chairperson, the three expert part-time members and the Secretary. The board Presidents and members are appointed through the same committee under Section 18.

Q: What happens to the registration of a doctor who was registered under the Medical Council of India?

Nothing adverse, and no fresh application is needed. The first proviso to sub-section (1) of Section 33 of the 2019 Act provides that a person registered in the Indian Medical Register maintained under the 1956 Act before the new Act came into force, and before the National Exit Test becomes operational, is deemed to be registered under the 2019 Act and enrolled in the National Register. Section 61 reinforces the position by keeping registrations, licences, permissions and recognitions granted under the repealed Act in force until their expiry. The register changed hands; the registrations crossed over by operation of law.

Q: Can a doctor appeal against a State Medical Council’s punishment under the NMC Act?

Yes, through a two-step ladder built into Section 30. Disciplinary action for professional or ethical misconduct is taken at first instance by the State Medical Council, acting under the regulations and guidelines framed under the 2019 Act and after giving the practitioner a hearing, a protection that extends to the imposition of a monetary penalty. A practitioner aggrieved by the state council’s action may appeal to the Ethics and Medical Registration Board, whose decision binds the state council unless a second appeal is taken to the National Medical Commission within sixty days of the communication of the Board’s decision. Appeals from the Commission on other matters lie to the Central Government under Section 9.

Q: Do foreign medical graduates have to take the National Exit Test?

Under the Act as enacted, yes, once the test exists. Sub-section (4) of Section 15 provides that any person with a foreign medical qualification shall have to qualify the National Exit Test to obtain a licence to practise and enrolment in the registers, and sub-section (2) of Section 33 bars enrolment of a foreign-qualified practitioner after the test becomes operational unless he qualifies it. Because no date has been appointed for the test to become operational, the previous screening route continues: foreign graduates qualify through the screening test conducted under the Screening Test Regulations of 2002, which Section 61 of the Act keeps in force until they are replaced, and the courts have applied them on that basis.

Q: What is the Medical Advisory Council and does it have any power over the Commission?

The Medical Advisory Council is the advisory body constituted by Section 11. It consists of the Commission’s Chairperson as its ex officio chair, all members of the Commission, one vice-chancellor of a health university for each state and Union territory, one member for each state and Union territory drawn from the elected members of its medical council, the Chairman of the University Grants Commission, the Director of the National Assessment and Accreditation Council, and four directors of the technology and management institutes nominated by the Central Government. Section 12 makes it the primary platform for states to put their views before the Commission and an adviser on standards and access. It has no power to bind or overrule the Commission.

Q: Can the Central Government remove the Chairperson of the National Medical Commission or take over the Commission?

Both, on stated grounds. Under Section 7 the government may remove the Chairperson or a member for insolvency, conviction of an offence involving moral turpitude, incapacity, declared unsoundness of mind, acquisition of a prejudicial financial or other interest, or abuse of position, with a hearing protected on the interest and abuse grounds. Under Section 55 it may supersede the whole Commission if the Commission is unable to discharge its functions or has persistently defaulted in complying with directions or in discharging them. Supersession follows a show-cause opportunity, lasts no more than six months at a time with one extension of up to six months, vacates every member’s office, and ends in reconstitution by fresh appointment.

Q: How long is the term of the Chairperson and members of the National Medical Commission?

Short, and not renewable. Under Section 6 the Chairperson and the part-time members, other than the rotating state nominees, hold office for a term not exceeding four years and are not eligible for any extension or re-appointment, and every holder ceases to hold office on attaining seventy years of age. The ten members drawn from state and Union territory nominees in the advisory council and the nine drawn from state medical council nominees serve two-year terms, as do the part-time members of the autonomous boards. Ex officio members serve while they hold the office that seats them. A departing Chairperson or member also faces a two-year bar on employment with a private medical institution whose matters they handled.

Q: Did the NMC Act change the NEET examination?

It changed the test’s statutory basis and reach more than its conduct. The National Eligibility-cum-Entrance Test had entered the 1956 Act by amendment in 2016; Section 14 of the 2019 Act re-enacted it as a uniform test for undergraduate and postgraduate super-speciality admission in institutions governed by the Act, and a proviso extended the undergraduate test to institutions governed by any other law, which brought the All India Institutes of Medical Sciences and the Jawaharlal Institute at Puducherry into the common entrance. The Commission conducts the test through a designated authority, in practice the National Testing Agency for the undergraduate test, and Section 14 also writes the common counselling structure into the Act, the Centre counselling for All India seats and the states for state-level seats.

Q: Can the National Medical Commission stop a medical college from admitting students?

The power sits with the Medical Assessment and Rating Board rather than with the Commission directly, and stoppage of admissions is one item in a graduated set of measures under clause (d) of sub-section (1) of Section 26. Against a medical institution that fails to maintain the minimum standards specified by the education boards, the Board may issue a warning, impose a monetary penalty, reduce the intake of students, direct stoppage of admission, or recommend to the Commission the withdrawal of recognition of the institution’s qualifications. The Board also controls the entry gate: no new college, new postgraduate course or increase in seats may proceed without its prior permission under Section 28, and its permission decisions carry appeals to the Commission and then to the Central Government.

Q: What qualifications must the Chairperson of the National Medical Commission have?

Sub-section (2) of Section 4 requires the Chairperson to be a medical professional of outstanding ability, proven administrative capacity and integrity, possessing a postgraduate degree in any discipline of medical sciences from a university, with experience of not less than twenty years in the field of medical sciences, of which at least ten years must have been as a leader in the area of medical education. The Act explains that a leader means the head of a department or the head of an organisation. The same pattern of seniority thresholds runs through the boards: their Presidents and members must hold a postgraduate degree in medical sciences with at least fifteen years of experience, seven of them as a leader, subject to exceptions the Act makes for the assessment board’s management member and the ethics board’s ethics member.

Q: Does the National Medical Commission regulate Ayurveda and homoeopathy colleges?

No. The Commission’s field is modern scientific medicine, which Section 2 defines to include surgery and obstetrics and to exclude veterinary medicine and surgery; the Indian systems of medicine and homoeopathy sit outside it. Parliament applied the same template to them separately, enacting the National Commission for Indian System of Medicine Act 2020 for Ayurveda, Unani, Siddha and Sowa-Rigpa and the National Commission for Homoeopathy Act 2020, each repealing its predecessor council statute and erecting a nominated commission with autonomous boards. The connection the 2019 Act itself builds is deliberative: Section 50 requires joint sittings of the Commission with the central councils for the other systems at least once a year to enhance the interface between the systems of medicine.

Q: What is the National Medical Register and how is it different from a State Register?

The National Register is the all-India register of licensed medical practitioners maintained by the Ethics and Medical Registration Board under Section 31. It contains the name, address and all recognised qualifications of every licensed practitioner, may be kept in electronic form, is a public document within the meaning of Section 74 of the Indian Evidence Act 1872, and is published on the Board’s website. A State Register is the register of practitioners maintained by the medical council of a state or Union territory. The two are not alternatives but one system in two tiers: state councils maintain and update their registers in the specified electronic format, supply them to the Board, and the Board must ensure electronic synchronisation so that a change in one register is reflected in the other.