India’s National Health Policy (NHP) of 2017 marked a significant milestone in the nation’s ongoing efforts to reform its healthcare system. Building upon its predecessor, the NHP 2002, this policy aimed to address the evolving health landscape, characterized by a dual burden of communicable diseases and non-communicable diseases, persistent high out-of-pocket expenditures, and pervasive inequities in access to quality healthcare. It articulated a vision for achieving the highest possible level of health and well-being for all, at all ages, through a preventive and promotive healthcare orientation and universal access to quality healthcare services, without anyone facing financial hardship. The policy sought to shift the paradigm from a predominantly “sick care” approach to one that prioritizes wellness and prevention, alongside comprehensive primary, secondary, and tertiary care.
The formulation of NHP 2017 was necessitated by several critical factors: the unfinished agenda of the Millennium Development Goals, the advent of the Sustainable Development Goals (SDGs) with a strong emphasis on Universal Health Coverage (UHC), the growing burden of chronic diseases, and the realization that public health spending remained abysmally low, contributing to catastrophic health expenditures for millions. While the policy outlined ambitious goals and a strategic direction, its release immediately sparked extensive debates among public health experts, policymakers, healthcare providers, and civil society organizations. These debates revolved around its fundamental approach, the proposed funding mechanisms, the role envisioned for the private sector, and the concrete strategies for achieving its lofty objectives, particularly in a country as diverse and populous as India.
Debates on the National Health Policy 2017
The National Health Policy 2017, while broadly welcomed for its progressive intent and aspirational targets, became the subject of intense scrutiny and debate across various dimensions of healthcare governance, financing, and delivery. These discussions highlighted the fundamental challenges and ideological divergences in India’s journey towards achieving universal health coverage and equitable access.
Funding and Public Spending Targets
Perhaps the most significant and contentious debate centered on the policy’s commitment to increase public health expenditure to 2.5% of the Gross Domestic Product (GDP) by 2025. At the time of the policy’s formulation, India’s public spending on health hovered around a mere 1.15% of GDP, among the lowest globally. Proponents of the policy argued that the 2.5% target, though still modest compared to developed nations (where it often exceeds 8-10% of GDP) and even some developing countries (like Brazil at over 4%), represented a significant leap from the current levels and signaled a stronger political commitment to health. They emphasized that even reaching this target would translate into a substantial increase in absolute terms, enabling greater investment in infrastructure, human resources, and essential services.
However, a chorus of critics argued that the 2.5% target was far from adequate to achieve the stated goals of universal health coverage and substantial reduction in out-of-pocket expenditure (OOP). Public health experts pointed out that the High-Level Expert Group (HLEG) report on UHC for India (2011) had recommended a target of 2.5% of GDP by 2017 and 3% by 2022. The NHP 2017’s extended timeline to 2025 for a lower target was seen by many as a lack of true ambition or urgency. Critics also questioned the feasibility of achieving even this modest target, given India’s historical track record of under-allocation and under-utilization of health budgets. There were concerns about how this increased funding would be mobilized – whether through central government allocations, state contributions, or a combination, and whether it would genuinely translate into improved service delivery at the grassroots level. The debate also touched upon the proportion of funds allocated to primary healthcare (two-thirds of resources), which while lauded conceptually, posed questions about practical implementation and ensuring flow to the periphery.
Role of the Private Sector and Public-Private Partnerships (PPPs)
Another highly contentious aspect of NHP 2017 was its explicit acknowledgement and strategic engagement with the private sector. The policy stated that the private sector is a “strategic partner” and encouraged public-private partnerships (PPPs) for improving health service delivery, particularly in underserved areas and for specialized services. It also endorsed strategic purchasing from private providers, where the government would pay for services rendered to its citizens by private entities.
This stance ignited fierce debate, with critics expressing deep apprehension about the potential “privatization” of healthcare in India. They argued that relying heavily on the private sector, driven by profit motives, could further exacerbate inequities, compromise quality for cost, and undermine the already fragile public health system. Concerns were raised about the lack of robust regulatory mechanisms to govern the private sector, which could lead to exploitation, exorbitant charges, and unethical practices. Civil society organizations and advocates for universal healthcare stressed that health is a public good and a right, not a commodity, and therefore, the primary responsibility for healthcare provision must remain with the state. They pointed to the global experience where market-driven healthcare systems often fail to serve the poor and vulnerable effectively.
Conversely, proponents of greater private sector involvement highlighted its significant presence in India’s healthcare landscape, accounting for a large proportion of outpatient visits and inpatient admissions. They argued that given the sheer scale of healthcare needs and the limitations of public infrastructure and resources, leveraging the private sector’s capacity, efficiency, and reach was pragmatic and necessary. They emphasized that strategic partnerships and purchasing could improve access, reduce wait times, and bring innovation, provided there were adequate regulatory oversight and robust quality assurance mechanisms. The debate here was not just about if the private sector should be involved, but how – whether as a complementary partner under strict government control and for specific services, or as a fundamental pillar of a market-based system.
Achieving Universal Health Coverage (UHC) and Financial Protection
The NHP 2017 reiterated the commitment to “progressive achievement” of UHC. It aimed to reduce out-of-pocket expenditure (OOP) from 62% to 30-35% and increase the proportion of government health expenditure from the current 1.15% to 2.5% of GDP. The policy also emphasized financial risk protection through schemes like health insurance, particularly for secondary and tertiary care.
Critics contended that the term “progressive achievement” lacked a concrete timeline and a clear roadmap for UHC. They argued that without a specific deadline and a robust, tax-funded system, achieving true UHC, where no one is denied healthcare due to inability to pay, would remain elusive. The reliance on health insurance schemes, even government-funded ones, was seen by some as potentially fragmented and not truly universal, as it might primarily cover hospital-based care and neglect comprehensive primary healthcare services, which are critical for preventing many conditions. There was a strong call for a move towards a predominantly tax-funded system akin to the National Health Service (NHS) in the UK or similar models in European countries, which directly provide services rather than merely financing insurance premiums.
Supporters, however, argued that given India’s vast population and diverse socio-economic conditions, a phased approach to UHC was more realistic and sustainable. They pointed out that the policy’s emphasis on strengthening comprehensive primary healthcare, including preventive and promotive aspects, was a foundational step towards UHC. The subsequent launch of Ayushman Bharat (Pradhan Mantri Jan Arogya Yojana - PMJAY) in 2018, which provides health insurance cover to the poorest 40% of the population, further shaped this debate. While PMJAY aimed to address financial protection for a large segment, it simultaneously reignited discussions about whether an insurance-based model can truly achieve UHC without significantly bolstering the public health infrastructure and moving towards a direct provision of services.
Emphasis on Primary Healthcare vs. Secondary/Tertiary Care
The NHP 2017 strongly advocated for a focus on comprehensive primary healthcare (CPHC), stating that two-thirds of the health budget should be allocated to this level of care. This was a welcome shift from previous policies that often prioritized hospital-centric, curative care. The policy envisioned health and wellness centers (HWCs) as the bedrock of CPHC, offering a wider range of services including maternal and child health, non-communicable disease screening, mental health, and geriatric care.
While the emphasis on primary healthcare was largely applauded by public health professionals as a cost-effective and equitable approach to improving population health, some debates emerged regarding the balance. Concerns were raised that an overemphasis on primary care might inadvertently lead to neglect of crucial secondary and tertiary care facilities, which are essential for managing complex diseases, emergencies, and specialized treatments. Critics also questioned the practical feasibility of effectively transforming existing sub-centers and primary health centers into comprehensive HWCs without significant investment in infrastructure, human resources, and technology. The operational challenges of integrating vertical disease programs into a horizontal CPHC framework also became a point of discussion. However, the policy’s supporters stressed that a robust primary healthcare system acts as the gatekeeper, preventing unnecessary referrals to higher centers and ensuring that appropriate care is delivered at the most cost-effective level.
Human Resources for Health (HRH)
The policy acknowledged the critical shortages, maldistribution, and skill gaps in India’s human resources for health. It proposed various strategies, including creating new cadres of healthcare professionals, skill enhancement, and improving medical education. It also discussed exploring options for integrating AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy) practitioners into the mainstream health workforce.
These proposals sparked considerable debate. The idea of introducing new cadres, such as mid-level health providers, faced resistance from established medical associations who raised concerns about quality of care and dilution of medical standards. There were also debates about the feasibility of attracting and retaining healthcare professionals, particularly doctors, in rural and underserved areas, given the existing challenges of infrastructure, remuneration, and professional growth. The integration of AYUSH practitioners, while seen as a pragmatic approach to address HRH shortages, also triggered debates about their scope of practice, scientific validity, and potential impact on patient safety. The policy’s general nature on HRH, without a detailed action plan or clear financial commitments for training and deployment, left many questions unanswered regarding its implementation.
Governance, Regulation, and Information Systems
The NHP 2017 highlighted the need for strengthening governance and regulatory frameworks, including regulation of the private sector, drugs, medical devices, and health technology assessment. It also emphasized the importance of robust health information systems for evidence-based policy making and monitoring.
Debates here centered on the historical weakness of regulatory bodies in India, their susceptibility to capture, and the challenges of enforcement in a vast and fragmented healthcare landscape. Critics questioned how the policy intended to genuinely empower regulatory bodies and ensure their independence. Furthermore, while the policy stressed the importance of data, the actual mechanisms for building a unified, interoperable national health information system and ensuring data privacy were not fully elaborated, leading to concerns about implementation gaps. The lack of a strong legal framework for patients’ rights and accountability of providers also remained a subject of discussion.
Addressing Social Determinants of Health
The NHP 2017 acknowledged the crucial role of social, economic, environmental, and behavioral determinants in influencing health outcomes. It called for inter-sectoral action to address these broader determinants.
While this recognition was welcomed, some critics argued that the policy lacked concrete strategies, mechanisms, or financial allocations to truly foster effective inter-sectoral coordination. They contended that simply acknowledging social determinants without outlining specific pathways for health ministries to influence policies in other sectors (e.g., sanitation, education, nutrition, urban planning) would render this aspect largely rhetorical. The deep-rooted inequities in Indian society require far more than just health sector interventions, demanding a whole-of-government approach that the policy did not fully articulate or empower.
The National Health Policy 2017 represented a significant step forward for India’s healthcare vision, attempting to lay down a comprehensive framework for addressing the multifaceted health challenges of a rapidly developing nation. It signaled a clear shift towards a preventive and promotive health orientation, acknowledging the critical need to increase public health spending and move towards universal health coverage. The policy’s emphasis on strengthening comprehensive primary healthcare, recognizing the importance of digital health, and envisioning a greater role for evidence-based decision-making were particularly laudable aspects, providing a vital directional compass for future reforms.
However, the extensive debates surrounding the NHP 2017 underscored the persistent fault lines and unresolved tensions within India’s healthcare system. The core of these discussions revolved around the adequacy of the proposed financial commitment, the extent and nature of private sector involvement, and the practical roadmap for achieving true universal health coverage that minimizes catastrophic out-of-pocket expenses. Many of the policy’s aspirations, while noble, were seen as lacking concrete implementation strategies, especially concerning the transformation of human resources, the strengthening of regulatory bodies, and effective inter-sectoral coordination. These ongoing discussions highlight that while the NHP 2017 provided a much-needed policy statement, the real challenge, and the continued subject of debate, lies in translating its progressive intent into tangible improvements in the health and well-being of all Indian citizens, particularly the most vulnerable.