The Karnataka model: A unique PPP that delivers doctors to the grassroots

For decades, India’s rural public health infrastructure has suffered from an acute shortage of specialist doctors. Taluk hospitals, which are meant to serve as the first point of referral in the government system, have often functioned without anaesthetists, surgeons, or paediatricians. Patients requiring even moderately complex care have had to travel long distances, sometimes over 100 kilometres, at great cost, risk, and delay. In Gangavathi, pregnant women face childbirth with fear, praying that labour and delivery will present no complications. Those who did experience complications were transferred from the local taluk hospital to distant cities — and not all survived the long journey. It is no wonder, then, that many avoid seeking care from public healthcare facilities.  

To address this systemic void, the Government of Karnataka launched a bold experiment in 2017. In partnership with the National Board of Examinations in Medical Sciences (NBEMS) and the Association of National Board Accredited Institutions (ANBAI), the state began accrediting its district and taluk hospitals as training centres for the Diplomate of National Board (DNB) postgraduate medical programme.

The innovative programme had two key pillars: half of the DNB seats were reserved for in-service government doctors, enabling them to pursue specialist training while continuing their service in public hospitals, and the remaining 50 per cent were open-category DNB students who would serve a mandatory one-year bond in public hospitals after graduating.

Together, these measures created a steady pipeline of trained specialists for Karnataka’s public healthcare system—especially in rural and underserved regions. 

Soon, specialists began arriving at the local taluk and district hospitals: gynaecologists, anaesthetists, and paediatricians. The transformation was extraordinary. A child with pneumonia, once rushed to a hospital in a distant city, could now be treated in her hometown by a qualified paediatrician. A farmer with a hernia no longer needed to travel days for a basic operation. A woman in obstructed labour could now undergo a safe caesarean section in her taluk hospital because a trained gynaecologist and anaesthetist were finally on site. From barely 2,000 safe deliveries a year in Gangavathi, the numbers surged to nearly 5,000. Caesarean sections became routine. Complicated cases that once required high-risk transfers are now managed locally and safely. 

Gangavathi’s story is not an isolated success: it is one of 36 district and taluk hospitals across Karnataka that are part of this quiet revolution in rural healthcare. Importantly, Karnataka is among the first states in the country to use taluk hospitals as postgraduate (PG) training centres, paving the way for a sustainable supply of specialists in rural areas. 

Recognising the innovation and impact of this bold public–private partnership, the Indian Institute of Management – Bangalore undertook a year-long case study to understand its design, implementation, and outcomes. The results are striking. As of 2025, over 300 DNB specialists have completed their training, and more than 170 are currently serving in government hospitals across Karnataka under their bond obligations. Through the in-service route, 93 government doctors have already completed training in nine key specialities, including orthopaedics, paediatrics, general surgery, ophthalmology, and radiology. Many of them have now been posted in taluk hospitals for the very first time. In total, 369 DNB students are currently enrolled across 36 government-run hospitals (16 district hospitals and 20 taluk hospitals). The programme has succeeded not only in increasing the number of specialists but also in decentralising training and care delivery.

The strength of the Karnataka model lies in its unique tripartite collaboration: the Government of Karnataka provided infrastructure, administrative support and stipends; NBEMS ensured rigorous academic standards, transparent evaluations and national accreditation; and ANBAI, through its network of private hospitals, mentored faculty and trainees, offering these services entirely pro bono. Unlike typical schemes that rely on large capital outlays or external consultants, this initiative worked within existing systems. By leveraging the strengths of each partner, it embedded postgraduate medical education directly into the state’s public health framework. 

Numbers alone do not capture the transformation underway. As services improve, community trust rises, and more patients choose public hospitals. As utilisation increases, healthcare teams become more motivated, thus setting off a virtuous cycle of trust, access and improved outcomes.

While Karnataka’s success is remarkable, its significance lies in its replicability. Even in the most underserved regions, specialist care can be delivered through smart, system-level innovation. This is not a high-cost intervention. It is not reliant on cutting-edge technology or massive new infrastructure. It is a model built on policy reform, training and collaboration, all of which can be adapted by other states. Of course, challenges still remain, as retention of specialists in rural areas, integration with other public health priorities, and sustained mentorship are ongoing concerns. But Karnataka’s experience shows that with shared purpose and political will, these hurdles can be overcome.

(Alexander is the Founder and Patron of AHPI, ANBAI, CAHO and Vayah Vikas; Jawaid [IAS] is a former Additional Chief Secretary, Government of Karnataka)

(Disclaimer: The views expressed above are the author's own. They do not necessarily reflect the views of DH.)