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Concept Paper

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The Indian Medical Service: A National Imperative for Healthcare That Reaches Every Citizen

Submitted:

30 October 2026

Posted:

02 November 2026

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Abstract
India’s healthcare challenge is no longer simply to build institutions, but to ensure that clinical expertise reaches every citizen reliably. As a physician, I see the consequences when accurate diagnosis is separated from timely treatment by workforce shortages, fragmented referrals and unclear institutional responsibility. This editorial examines whether an Indian Medical Service (IMS) could address a gap that existing administrative structures do not consistently bridge: sustained, clinically informed coordination across district, State and national health systems. Such a service must complement, not displace, State medical services and multidisciplinary public-health cadres, while respecting constitutional responsibilities. Its legitimacy would depend on transparent recruitment, rigorous administrative training and independently measured improvements in specialist access, diagnostic turnaround, referral completion, continuity of care and financial protection. An IMS should not be established for professional prestige or bureaucratic expansion. It merits consideration only if it demonstrably converts medical capacity into genuinely accessible, equitable and accountable care.
Keywords: 
Indian Medical Service
;  
healthcare governance
;  
universal health coverage
;  
clinical leadership
;  
health equity
;  
health systems strengthening
;  
healthcare accountability
;  
integrated healthcare delivery
Subject: 
Public Health and Healthcare  -   Health Policy and Services

Editorial/Concept Paper

A nation’s healthcare system must be judged not by the distinction of its institutions, but by the reliability with which its people receive medical care. To a patient, healthcare is not an administrative structure or a budgetary allocation. It is a competent doctor who is available, a diagnosis reached without avoidable delay, a medicine that can be obtained and a referral that leads to treatment. India has developed remarkable centres of medical excellence. Its greater national obligation is to make competent healthcare dependable across the full breadth of the country. The proposed Indian Medical Service (IMS) merits serious consideration in precisely this context: not as another administrative entitlement, but as a means of converting medical capacity into accessible, accountable and continuous care.[1,2]
As a physician, I recognise a distinction that healthcare administration must never overlook: establishing a diagnosis is not the same as ensuring that a patient receives treatment. A laboratory result that reaches no responsible clinician, an emergency referral that secures no receiving facility, or a specialist recommendation that cannot be implemented represents a breakdown in care despite the availability of medical knowledge. Such failures expose the consequences of separating clinical requirements from institutional responsibility. International evidence demonstrates that expanding access without improving quality cannot fulfil the promise of universal health coverage. The case for an IMS must therefore begin with the patient who remains inadequately served despite the existence of healthcare infrastructure.[2,3]
India’s achievements in medical education, public-health programmes, infrastructure and financial protection deserve recognition. Nevertheless, the National Health Accounts estimates for 2022–23, released in May 2026, show that out-of-pocket expenditure still represented 43.4% of total health expenditure, despite declining from 64.2% in 2013–14. Government health expenditure accounted for 1.43% of GDP under the reported historical series, against the National Health Policy’s aspiration of 2.5%. These figures reflect genuine progress alongside continuing financial vulnerability. The WHO’s India Health System Review also documents substantial differences in healthcare access, affordability and institutional capacity across States. National achievement cannot be assessed solely through aggregate expansion when the circumstances of individual citizens remain so unequal.[4,5]
Workforce distribution exposes the same difficulty. Parliamentary budget analysis published in 2026 reported that approximately 68% of sanctioned specialist positions in rural community health centres were vacant in 2023. The consequences are clinical, not merely statistical. A vacant obstetric post, an unavailable physician or an absent surgical specialist can interrupt an otherwise functional pathway of care. Increasing the number of medical graduates is important, but training, deployment, retention and institutional support must operate together. National health policy and international workforce guidance recognise that effective healthcare depends upon the availability of appropriately skilled personnel where their services are required.[6,7,8]
The proposal for an Indian Medical Service has an established administrative history. In January 2018, the Government of India confirmed that States and Union Territories had been consulted regarding the proposed creation of an All India Medical Service. In February 2023, Parliament was informed that a proposal for an Indian Medical Health Service had been returned for further consultation with stakeholders, including State Governments. These records neither establish that a service has been approved nor demonstrate its effectiveness. They do, however, establish a legitimate basis for examining its purpose, constitutional design and potential contribution to healthcare delivery.[9,10]
The constitutional foundation demands particular care. Article 312 permits the creation of an All-India Service through a specified parliamentary process, while public health, hospitals and dispensaries fall within the State List under the Seventh Schedule. An IMS must therefore be developed through cooperative arrangements that respect State responsibilities. India’s diversity makes this essential. Differences in geographical access, disease burden, workforce requirements and institutional performance cannot be resolved through an inflexible national template. The NITI Aayog State Health Index for 2019–20 illustrates the importance of State-specific performance assessment. National standards should support locally appropriate implementation, not replace it.[11,12]
The principal question is what an IMS could accomplish beyond existing arrangements. State medical services provide essential clinical personnel and administration; public-health cadres strengthen population-health management; and national institutions establish policies, standards and technical support. The Public Health Management Cadre initiative already recognises the need for multidisciplinary leadership. An IMS would be justified only if it supplied an additional capability: a jointly governed, professionally trained medical leadership cadre able to work across district, State and national institutions, connect clinical priorities with resource allocation, facilitate agreed inter-State deployment and maintain continuity in health-system planning. Its distinctive contribution would have to be sustained coordination across institutional boundaries, not duplication of existing authority.[13]
Such a service must be designed around clinical accountability rather than professional seniority. Its officers should combine substantial medical experience with structured training in public health, epidemiology, health economics, hospital management, medical ethics and quality improvement. They should work alongside nurses, laboratory scientists, pharmacists, allied health professionals, health economists and experienced administrators. The purpose would not be to place physicians above other professionals, but to ensure that decisions governing clinical services are informed by an understanding of their consequences for patients.
India does not require an Indian Medical Service merely to place doctors within administration. It requires a system in which medical understanding informs administrative decisions, responsibility follows the patient across institutions, and healthcare quality is judged by what reaches the citizen rather than what exists on paper. An IMS would have value only to the extent that it could make this principle operational.
I would place the district hospital at the centre of that responsibility. A district hospital must not function as an isolated institution between primary care and tertiary medicine. It should be the dependable clinical anchor of an integrated network, supported by functioning laboratories, emergency transport, specialist services, referral coordination and appropriate follow-up. The WHO–UNICEF operational framework for primary healthcare emphasises integrated, people-centred services. For an IMS, the practical task would be to help ensure that a patient referred from one facility is received by another, that essential clinical information accompanies the referral, and that responsibility for continuing care remains identifiable.[14]
The same obligation extends to chronic illness. Cancer, diabetes, cardiovascular disease, chronic respiratory disorders and mental illness require sustained clinical pathways rather than disconnected episodes of treatment. Screening is of limited value without diagnostic confirmation; diagnosis is insufficient without treatment; and treatment is incomplete without appropriate monitoring. Financial protection is equally essential. The WHO–World Bank monitoring framework places service coverage and financial hardship at the centre of universal health coverage. An IMS must be evaluated against these patient-centred requirements, not against administrative activity alone.[15]
There is, however, a substantial objection that must be confronted. Another service does not necessarily mean better services. A new cadre could increase administrative expenditure, create overlapping jurisdictions and weaken established institutions unless its mandate were carefully restricted. The alternative of strengthening existing State services and Public Health Management Cadres deserves equal examination. The case for an IMS must rest on a demonstrable institutional advantage, supported by transparent recruitment, agreed responsibilities, realistic financing, independent oversight and protection from unnecessary bureaucratic interference.
Its implementation should consequently be cautious and evidence-led. Defined functions could be tested through phased, State-agreed arrangements and evaluated against comparable improvements undertaken through existing services. The relevant outcomes would include specialist availability, emergency response, referral completion, diagnostic turnaround times, continuity of essential medicines, patient safety, avoidable delays and household expenditure. Administrative costs and unintended effects must be measured alongside benefits. A service that cannot demonstrate improvement in these outcomes would have no sufficient justification for expansion.
For a physician, these considerations ultimately return to an elementary professional obligation. A patient with sepsis cannot wait for administrative ambiguity to be resolved. A pregnant woman requiring emergency intervention cannot benefit from a specialist post that exists only in a staffing register. A patient with suspected malignancy cannot be reassured by the availability of sophisticated diagnostics if no coordinated pathway brings diagnosis and treatment together. The clinical consequences of institutional failure are borne by people, not by organisational charts.
India’s healthcare ambition must therefore extend beyond increasing the number of institutions and professionals. It must ensure that medical knowledge, public investment and administrative responsibility converge at the point where a citizen requires care. An Indian Medical Service is one possible means of pursuing that objective. It deserves rigorous, non-partisan consideration, but neither its name nor its national status can substitute for evidence of effectiveness.
I believe the final test should be unambiguous. If an IMS cannot shorten the distance between illness and competent care, reduce avoidable interruptions in treatment or strengthen accountability for clinical outcomes, its creation would serve little public purpose. If a carefully constituted and independently evaluated service can achieve these results more effectively than existing arrangements, it would merit consideration on the strength of that evidence. The Indian Medical Service should be judged by one standard alone: not the authority it confers upon doctors, but the quality of care it enables the nation to deliver to every citizen.
India’s medical excellence must not remain an achievement concentrated in institutions. It must become a dependable assurance available to its people.
  • Author Contributions: B.B. is the sole author and is responsible for the editorial’s intellectual direction, conceptual argument, critical appraisal of the supporting evidence, final scholarly interpretation and approval of the submitted manuscript. The author accepts full responsibility for its content and integrity.
  • Funding: No external funding, financial sponsorship or institutional grant was received for the preparation of this editorial.
  • Acknowledgments: None.
  • Originality and Publication Ethics: This editorial presents an independent, evidence-informed examination of the proposed Indian Medical Service in the exclusive interests of healthcare delivery, institutional accountability and equitable public access. It is intended as a non-partisan scholarly contribution and does not constitute an endorsement or criticism of any political party, government or administrative authority. The author accepts responsibility for the integrity of the manuscript, the appropriate attribution of published evidence and the accuracy of its scholarly representations.
  • Competing Interests: The author declares no financial or non-financial competing interests relevant to the subject matter of this editorial.
  • Ethics Approval: Not applicable. This editorial is based exclusively on published literature, publicly available policy documents and independent professional analysis. No original research involving human participants, identifiable patient information or experimental animals was undertaken.
  • Consent to Participate: Not applicable.
  • Consent for Publication: Not applicable. The manuscript contains no identifiable personal information or individual patient data requiring consent for publication.
  • Availability of Data and Materials: No original datasets were generated or analysed. All factual and documentary evidence is derived from publicly accessible scholarly publications, official reports and government records identified in the reference list.
  • Author’s Independence Statement: The opinions and policy considerations expressed in this editorial represent the author’s independent professional perspective as a physician and researcher. They do not purport to represent the official position of any medical institution, governmental body, professional association or political organisation. The sole objective is to advance evidence-informed discussion of accessible, equitable and clinically accountable healthcare for the people of India.
Copyright Statement
© 2026 Birupaksha Biswas. All rights reserved in the submitted manuscript, subject to the terms of any publishing licence or copyright agreement subsequently executed with the publisher. The author asserts the right to be identified as the creator of this editorial and to receive appropriate attribution for its original intellectual contribution, arguments and interpretations. The rights of all cited third-party works remain with their respective copyright holders. Any subsequent reproduction, distribution or adaptation shall be governed by applicable copyright law and the licensing terms under which the article is published.

References

  1. Patel, V.; Kalita, A.; Furtado, K.M.; et al. The Lancet Commission on a citizen-centred health system for India. Lancet 2026, 407(10526), 388–468. [Google Scholar] [CrossRef] [PubMed]
  2. Kruk, M.E.; Gage, A.D.; Arsenault, C.; et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob. Health 2018, 6(11), e1252. [Google Scholar] [CrossRef] [PubMed]
  3. Kruk, M.E.; Gage, A.D.; Joseph, N.T.; Danaei, G.; García-Saisó, S.; Salomon, J.A. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet 2018, 392(10160), 2203–2212. [Google Scholar] [CrossRef] [PubMed]
  4. Ministry of Health and Family Welfare; Government of India. National Health Accounts Estimates for India 2022–23. Press Information Bureau, 27 May 2026. Available online: https://www.pib.gov.in/PressReleasePage.aspx?PRID=2265816.
  5. Selvaraj, S.; Karan, A.K.; Srivastava, S.; Bhan, N.; Mukhopadhyay, I. India Health System Review; World Health Organization, Regional Office for South-East Asia: New Delhi, 2022; Available online: https://apo.who.int/publications/i/item/india-health-system-review.
  6. PRS Legislative Research. Demand for Grants 2026–27 Analysis: Health and Family Welfare. New Delhi, 2026. Available online: https://prsindia.org/budgets/parliament/demand-for-grants-2026-27-analysis-health-and-family-welfare.
  7. Ministry of Health and Family Welfare; Government of India. National Health Policy 2017. New Delhi, 2017. Available online: https://www.pib.gov.in/newsite/PrintRelease.aspx?lang=2&reg=48&relid=159376.
  8. World Health Organization. Working for Health 2022–2030 Action Plan; WHO: Geneva, 2022; Available online: https://www.who.int/publications/i/item/9789240063341.
  9. Ministry of Personnel; Public Grievances and Pensions; Government of India. Introduction of Indian Medical Civil Service. Rajya Sabha written reply. 4 January 2018. Available online: https://www.pib.gov.in/PressReleasePage.aspx?PRID=1515447.
  10. Lok Sabha; Parliament of India. Unstarred Question No. 1025: Cadre of Indian Medical Service. 8 February 2023. Available online: https://sansad.in/getFile/loksabhaquestions/annex/1711/AU1025.pdf?source=pqals.
  11. Government of India. The Constitution of India. Article 312: All-India Services; Seventh Schedule, List II, Entry 6: Public Health and Sanitation, Hospitals and Dispensaries. Ministry of Law and Justice. Available online: https://www.indiacode.nic.in/bitstream/123456789/16124/1/the_constitution_of_india.pdf.
  12. Aayog, N.I.T.I. Healthy States, Progressive India: Health Index Round IV (2019–20). Government of India, 2021. Available online: https://www.niti.gov.in/node/366.
  13. Ministry of Health and Family Welfare; Government of India. Booklet for Public Health Management Cadre: Guidance for Implementation. New Delhi, 2022. Available online: https://nhsrcindia.org/public-health-management-cadre-booklet.
  14. World Health Organization; UNICEF. Operational Framework for Primary Health Care: Transforming Vision into Action; WHO: Geneva, 2020; Available online: https://www.who.int/publications/i/item/9789240017832.
  15. World Health Organization and World Bank. Tracking Universal Health Coverage: 2025 Global Monitoring Report; WHO: Geneva, 2025; Available online: https://www.who.int/publications/i/item/9789240117808.
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