Poverty and Health in India: Trends, Challenges, and Progress

India’s relationship with poverty and health resembles a deeply intertwined story, where one cannot be understood without the other. Since 1947, the country has lifted hundreds of millions out of destitution and dramatically improved survival rates, yet a poor household in rural Bihar still faces a starkly different health reality from a middle-class family in Bengaluru. Tracing how this relationship has evolved, what the state has done about it, and where progress stalls, helps explain both the achievements and the unfinished agenda of public health policy.

The historical roots of poverty and ill-health 🔗

At independence, India inherited a colonial health system designed primarily for British administrators and urban elites, leaving the rural majority largely unattended. Life expectancy at birth was a mere 41 years in 1950, while the infant mortality rate hovered around 180 deaths per 1,000 live births. Endemic diseases like malaria, tuberculosis, smallpox, and cholera regularly devastated communities, and the partition added a layer of demographic trauma that public health infrastructure was simply not equipped to absorb.

The colonial economy had also left the country materially impoverished. Famines, low agricultural productivity, and minimal industrialisation meant that most Indians lived close to subsistence. Poverty did not just coexist with poor health; it produced it through malnutrition, unsafe water, overcrowded housing, and lack of access to even basic medical care. Understanding this starting point is essential to appreciate how far the country has travelled.

The Bhore Committee: a blueprint for a new nation 🔗

Even before independence, planners recognised that the health system needed a complete overhaul. The Health Survey and Development Committee, popularly known as the Bhore Committee, was set up in 1943 under Sir Joseph Bhore and submitted its landmark report in 1946. The committee proposed a three-tier healthcare structure built around primary health centres, each ideally serving 40,000 people in the short term and 20,000 in the long run, integrating preventive, promotive, and curative services.

The Bhore report was guided by principles of universality, equity, and comprehensiveness. Its idea that all citizens should access health services irrespective of ability to pay shaped India’s First Five-Year Plan (1951-56) and continues to echo in current frameworks like the National Health Mission. PHCs and Community Health Centres trace their lineage directly to this committee.

The Mudaliar Committee and successive reviews 🔗

By 1959, it was clear that the Bhore vision was running into financial and administrative obstacles. The Mudaliar Committee, chaired by Dr A. Lakshmanaswami Mudaliar, was appointed to evaluate progress after the first two Five-Year Plans. Its 1961 report concluded that primary health centres bore little resemblance to what Bhore had envisioned, citing understaffing, inadequate equipment, and poor supervision. The committee recommended strengthening district hospitals as referral institutions and consolidating existing PHCs before expanding new ones.

Later committees built on this foundation. The Chadah Committee (1963) integrated health and family planning workers, the Mukherjee Committee (1965) reorganised family planning staffing, and the Shrivastav Committee (1975) proposed community health workers, an idea that eventually evolved into today’s ASHA workers under the National Rural Health Mission.

The shifting economic landscape and its health consequences 🔗

For the first three decades after independence, India followed a planned economy with modest growth and gradual health gains. The economic liberalisation of 1991 was a turning point. GDP growth accelerated, the middle class expanded, and private hospitals proliferated, especially in metros. However, public investment in health did not keep pace with the demands of a growing population, and the private sector became the dominant provider of curative care.

The consequences for poor households were mixed. On one hand, new medicines, diagnostics, and specialist care became available. On the other, an increasingly privatised system meant that getting sick could push families into poverty. According to systematic reviews, around 50 million Indian households fall below the poverty line annually due to out-of-pocket health expenditure, a phenomenon known as catastrophic health expenditure.

The poverty-health feedback loop 🔗

Poverty causes ill-health, and ill-health deepens poverty. Poor households are more exposed to undernutrition, unsafe drinking water, indoor air pollution from biomass fuels, and crowded living conditions. When illness strikes, they have less savings to draw on, often lose daily wages, and may resort to distress sales of land or jewellery. Research published in Frontiers in Public Health found that the poorest rural households spend 23.4% of their consumption on health, compared to 17.4% among the richest, underscoring how the same medical bill is far more devastating at the bottom of the income ladder.

Major government initiatives shaping the present 🔗

Over the decades, India has launched an evolving set of programmes to break this poverty-health loop. The National Rural Health Mission of 2005 brought public health back to the centre of policy, expanded primary care infrastructure, and introduced ASHA workers as a frontline cadre. The 2017 National Health Policy set ambitious targets, including raising public health expenditure to 2.5% of GDP, reducing under-five mortality to 23 per 1,000, and increasing life expectancy at birth to 70 years by 2025.

Ayushman Bharat: the largest health assurance scheme in the world 🔗

Launched in September 2018, Ayushman Bharat has two main pillars. The first is the network of Ayushman Arogya Mandirs (formerly Health and Wellness Centres) delivering comprehensive primary care, including screening for non-communicable diseases. The second is Pradhan Mantri Jan Arogya Yojana (PM-JAY), which provides ₹5 lakh of annual hospitalisation coverage per family for around 12 crore vulnerable families.

The scale is significant. By December 2025, over 42 crore Ayushman cards had been issued and more than 1.78 lakh Arogya Mandirs were operational. In October 2024, the scheme was extended to all senior citizens aged 70 and above, regardless of income, through the Vay Vandana Card. The Economic Survey 2024-25 estimated savings of over ₹1.25 lakh crore in out-of-pocket expenditure attributable to the scheme.

However, independent evaluations are more cautious. A study from Chhattisgarh found that after four years of implementation, PM-JAY enrolment was not associated with increased utilisation of inpatient care or meaningful protection against catastrophic expenditure, with many beneficiaries in private hospitals still incurring large bills. The lesson is that coverage on paper does not automatically translate into financial protection on the ground.

Other programmes addressing the social determinants 🔗

Health does not happen only in clinics. Programmes like the Swachh Bharat Mission for sanitation, the Pradhan Mantri Ujjwala Yojana for clean cooking fuel, Jal Jeevan Mission for piped water, POSHAN Abhiyaan for nutrition, and the Mid-Day Meal Scheme tackle the upstream causes of illness. Together with conditional cash transfers like Janani Suraksha Yojana for institutional deliveries, they form an ecosystem aimed at the social determinants of poor health.

Achievements worth celebrating 🔗

The cumulative impact of these policies is visible across multiple indicators. Life expectancy at birth rose from 41 years in 1950 to around 72 years by 2024, narrowing the gap with developed countries. Infant mortality fell sharply, from over 180 per 1,000 live births at independence to around 26 in 2024. Maternal mortality has dropped to under 100 per 100,000 live births in several states. Full immunisation coverage for the April-October 2025 period stood at 98.6%, and tuberculosis treatment success climbed to 90% in 2025.

On the poverty side, multidimensional poverty has fallen substantially. NITI Aayog’s national multidimensional poverty index, which incorporates health, education, and standard of living, suggests that around 16% of Indians are now multidimensionally poor, down from much higher levels a decade ago. Diseases that once defined India’s mortality profile, like smallpox and polio, have been eradicated, and HIV is increasingly under control through the National AIDS Control Programme.

Persisting challenges 🔗

Yet the achievements come with significant caveats. The first and most stubborn is low public health spending. India’s government health expenditure stood at about 1.9% of GDP in FY 2024-25, still below the National Health Policy target of 2.5% and well below the WHO-recommended benchmark of around 5%. This underfunding shows up in dilapidated district hospitals, vacant specialist posts, and erratic drug supplies.

Out-of-pocket expenditure and inequality 🔗

While out-of-pocket expenditure has declined from over 62% of total health spending a decade ago to around 47% in 2021-22, it remains far higher than in most middle-income peers. Households continue to bear the brunt of medication costs, especially for chronic illnesses like diabetes, cardiovascular disease, and cancer. The burden is not evenly distributed: rural populations, scheduled castes and tribes, and informal sector workers face the steepest disadvantages, both in accessing care and in financing it.

The rural-urban and inter-state divide 🔗

India is really many health systems coexisting. Kerala records infant mortality close to high-income country levels, while several northern and central states still report rates two to three times the national average. Specialist doctors and tertiary hospitals cluster in metro cities, forcing rural patients to travel long distances and incur additional travel and accommodation costs. The shortage of trained health workers in remote areas continues to undermine the promise of universal coverage.

The rise of non-communicable diseases 🔗

India is undergoing an epidemiological transition. Even as infectious diseases decline, cardiovascular disease, diabetes, cancers, and mental health conditions are rising rapidly, often hitting poorer populations harder because of delayed diagnosis and treatment. These conditions require long-term care, expensive medication, and continuous follow-up, which existing schemes are only beginning to address.

The road ahead 🔗

Looking forward, the central question is whether India can convert its impressive headline numbers into durable, equitable health gains. That will require sustained increases in public spending, stronger regulation of the private sector, better human resource policies, and continued attention to the social determinants of health. Digital initiatives like the Ayushman Bharat Digital Mission and the integration of telemedicine into primary care offer real opportunities, particularly for remote areas, provided they do not leave behind those without smartphones or digital literacy.

The story so far is one of remarkable transformation tempered by uneven progress. The Bhore Committee’s vision of universal, equitable, comprehensive care remains the right north star, even if the journey is still incomplete.

What do you think? If you had to choose one priority to break the cycle of poverty and ill-health in India, would you put more money into primary care or into expanding insurance coverage? And how should policymakers balance the urgency of reducing out-of-pocket expenditure with the longer-term goal of strengthening public hospitals and the health workforce?

References

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