Enforcement of Constitutional Obligation to Provide Specialized Medical Facilities: Mandating Bone Marrow Transplant Services in Tamil Nadu Government Hospitals

1. Introduction

In Dr. S. Gurushankar v. The Chief Secretary to the Government of Tamil Nadu (Madras High Court, 09 April 2025), the Madurai Bench addressed two writ petitions under Article 226 of the Constitution of India. Petitioners Dr. S. Gurushankar (W.P.(MD) No.11886 of 2019) and A. Veronica Mary (W.P.(MD) No.19218 of 2024) sought judicial intervention to compel the State of Tamil Nadu to:

Frame uniform guidelines for medical and infrastructural standards in all government hospitals, with special emphasis on raising public health expenditure to 2.5% of GDP (per National Health Policy 2017) and implementing Supreme Court directions in Paschim Banga Khet Mazdoor Samity v. State of West Bengal, (1996) 4 SCC 37.
Establish and operationalize free Bone Marrow Transplantation (BMT) facilities—currently available only in Chennai government hospitals—at Madurai Government Rajaji Hospital and, by extension, other districts.

The respondents, represented by the Chief Secretary, Principal Secretary (Health & Family Welfare) and the Director of Medical Education, argued that such decisions were “policy matters” and hence non-justiciable, in addition to pointing to financial and infrastructural constraints.

2. Summary of the Judgment

The Court delivered a common order disposing of both petitions. Key holdings and directions include:

The State’s constitutional obligation under Articles 21 and 47 to provide adequate medical services cannot be evaded on grounds of financial or policy constraints.
Reliance on Paschim Banga Khet Mazdoor Samity v. State of W.B. (1996) 4 SCC 37 and subsequent Supreme Court precedents established that the High Court can direct positive action to fulfill fundamental rights.
The respondents must allocate the estimated funds (approx. ₹13.53 crores for civil structure, equipment and human resources) for establishing BMT facilities at Madurai Government Rajaji Hospital within three months of this order.
Once funds are allocated, the BMT unit must be fully operational within six months of fund allocation.
Petitioners are granted liberty to make a representation seeking the framing of comprehensive guidelines for medical and infrastructural standards across all Tamil Nadu government hospitals. The Health & Family Welfare Department must consider such representations and pass appropriate orders within three months.

The petitions were accordingly disposed of with no order as to costs.

3. Analysis

3.1 Precedents Cited

The Court’s willingness to traverse the boundary between “policy” and “justiciable right” was guided by a line of Supreme Court precedents:

Paschim Banga Khet Mazdoor Samity v. State of West Bengal, (1996) 4 SCC 37:
Established that the State’s constitutional obligation to provide essential services (including medical care) cannot be deferred for lack of funds. Analogized to the obligation to provide free legal aid, the Court held that time‐bound plans must be laid out and implemented.
Khatri v. State Of Bihar, (1981) 1 SCC 627:
Held that financial constraints cannot nullify fundamental constitutional obligations (in that case, free legal aid).
State Of Punjab v. Mohinder Singh Chawla, (1997) 2 SCC 83:
Reiterated that when specialized treatment is unavailable in government hospitals, the State must bear related hospitalization expenses—even if policy limits nominally exclude them—because the right to health is integral to Article 21.
State Of Punjab v. Ram Lubhaya Bagga, (1998) 4 SCC 117:
Emphasized that Article 47 makes public health a primary obligation of the State. Investment in healthcare infrastructure is indispensable to uphold the right to life.
C. Anand Raj v. State of Tamil Nadu (Madras High Court, W.P.(MD) No.22575 of 2024, 30 Jan 2025):
The same Bench rejected the government’s “policy‐decision” objection in the context of dialysis technicians, holding that the High Court may direct the creation of specialized posts to cure deficiencies that infringe fundamental rights.

3.2 Legal Reasoning

The Court’s reasoning unfolded along three pillars:

Constitutional Duty Over Policy Excuses: Articles 21 (right to life) and 47 (duty of the State to raise the level of nutrition and standard of living, and improvement of public health) place a non‐negotiable duty upon the government. Financial or administrative constraints cannot override this duty.
Justiciability of Healthcare Deficits: When essential medical services are systematically unavailable to large swathes of the population—especially the poorest—the Court may intervene under Article 226 to issue positive directives ensuring access.
Structured Implementation: The Court specified clear timelines and quantitative benchmarks (three months for fund allocation, six months for operationalization), thus converting a broad constitutional obligation into an enforceable plan.

3.3 Impact

This judgment has significant repercussions:

Judicial Oversight of Health Policy: It reaffirms that courts can compel executive action on healthcare infrastructure when fundamental rights are at stake, blurring the line between policy and enforceable duties.
Replicable Framework: The structured approach—allocating funds, setting up units within clear timetables—can serve as a template for other specialized treatments (e.g., organ transplants, oncology units) across India.
Empowerment of Underprivileged Patients: Rural and economically weaker sections in Southern Tamil Nadu will gain access to free BMT without travelling to Chennai, reducing both financial burden and treatment delays.
Prompt Guideline Development: By granting petitioners the right to represent for uniform standards, the Court has opened the door to comprehensive rules governing all government hospitals in Tamil Nadu, potentially raising overall healthcare quality.

4. Complex Concepts Simplified

Writ of Mandamus: A judicial order compelling a government authority to perform a mandatory duty it is legally obliged to carry out.
Article 226: Empowers High Courts to issue writs—including mandamus—to enforce fundamental rights or any other legal right.
Article 21: Guarantees the right to life and personal liberty, interpreted by courts to encompass the right to health.
Article 47: Obligates the State to improve public health and nutrition.
Bone Marrow Transplant (BMT): Also called stem cell transplant, a complex, multi‐disciplinary procedure replacing diseased bone marrow with healthy stem cells, crucial for treating leukemia, lymphoma, aplastic anemia, and genetic disorders.
Public Interest Litigation (PIL): A judicial mechanism allowing individuals or NGOs to seek court intervention for public causes, especially when fundamental rights of disadvantaged groups are affected.

5. Conclusion

The Madras High Court’s decision in Dr. S. Gurushankar v. Chief Secretary, Tamil Nadu recognizes healthcare not as a discretionary policy choice but as a constitutional imperative. By compelling the State to allocate funds and set up BMT facilities with definitive timelines, the Court has crystallized a new precedent: wherever essential medical treatments are systematically absent, courts can enforce positive obligations under Articles 21 and 47. This ruling will likely catalyze further judicial scrutiny of healthcare deficiencies and spur governments to pre‐emptively bolster medical infrastructure, ensuring equitable access to life‐saving therapies across India.