Neglect of primary health care and education in India are reasons for its backwardness.

The Unbuilt Foundations

In 1946, a year before Independence, the Bhore Committee told the colonial government that a country's health could not be left to chance and sketched a network of primary health centres reaching every village. Two decades later the Kothari Commission (1964-66) asked that six per cent of national income be spent on education. Both blueprints were sound; both were honoured mostly in speeches. Seventy-five years on, India is the world's fourth- or fifth-largest economy by size, yet it ranks 130th of 193 countries on the UNDP Human Development Index (HDR 2025). The gap between the size of the economy and the condition of its people is where the story of backwardness begins. India's backwardness is, in large part, the price of neglecting the two foundations on which every advanced nation was built: a healthy body and a trained mind. The claim is largely true, but it must be tested against other causes and against the progress India has made.

To begin with, human capital is what turns a large population into a productive one. A child who is stunted in her first thousand days learns less in school and earns less as an adult; a child who sits through five years of school without learning to read carries that deficit into every job she takes. NFHS-5 (2019-21) found 35.5 per cent of Indian children under five stunted and 57 per cent of women anaemic. The ASER surveys have repeatedly found that roughly half of Class V children in rural India cannot read a Class II text. These are not merely social statistics; they are the hidden ceiling on India's productivity, explaining why a country with a vast workforce exports so few high-skill goods and why so much of its labour remains trapped in low-wage farming and informal work.

The neglect is visible first in spending. The National Health Policy (2017) set a target of public health expenditure at 2.5 per cent of GDP by 2025, a figure that the country is still working towards, while most developed countries spend several times that share. For decades the shortfall was paid for by families. National Health Accounts estimates show out-of-pocket spending falling from 64.2 per cent of total health expenditure in 2013-14 to 39.4 per cent in 2021-22, a real gain, yet one illness can still push a household below the poverty line. Primary care, the cheapest and most effective layer, has historically received the least, so that patients crowd district hospitals for ailments a well-run sub-centre could treat. The deaths of dozens of patients, many of them newborns, within days at a government hospital in Nanded in October 2023 showed what overloaded tertiary care looks like when the primary tier fails beneath it.

Education tells a parallel story of access without quality. The Right of Children to Free and Compulsory Education Act (2009) brought almost every child into a classroom, and UDISE+ 2024-25 records 24.69 crore students in 14.71 lakh schools. Yet the same data show the Gross Enrolment Ratio falling from 90.3 at the middle stage to 68.5 at the secondary stage, so that a third of adolescents leave before they gain employable skills. A recent NITI Aayog paper on education and skilling puts it plainly: years of schooling do not necessarily reflect actual learning. Teacher vacancies, single-teacher schools and rote examinations have produced certificates without capabilities, and a young workforce without capabilities is a demographic liability rather than a dividend.

The comparison with East Asia makes the cost vivid. Japan's Meiji government made elementary schooling compulsory in 1872, and South Korea, Taiwan and later China built universal literacy and basic health before or during their industrial take-off. Their factories could hire workers who could read instructions and stay healthy through a shift. Jean Drèze and Amartya Sen, in An Uncertain Glory (2013), showed how India grew fast after 1991 but fell behind even poorer Bangladesh on several social indicators, because it neglected the public provision of schooling and health. Growth that is not built on human capability runs out of road, while capability creates its own growth.

The neglect also deepens every other form of inequality. Poor health and poor schooling fall hardest on women, Dalits, Adivasis and rural families, who cannot buy their way into private hospitals and private schools. When the girl drops out after Class VIII to care for siblings, the nation loses a worker, a voter better able to hold government to account and a mother whose children would have been healthier. Low female labour force participation, persistent caste gaps in learning and the rural-urban divide in life expectancy are all traced back to the same two failures. Backwardness, in this sense, is not only economic; it is a backwardness of opportunity.

Yet an honest essay must recognise that neglect of health and education is not the only cause. Colonial rule drained India's wealth, as Dadabhai Naoroji argued, and left a deindustrialised country with a literacy rate of about 18 per cent in 1951. Slow land reform, a long period of controls that held back manufacturing, weak urban planning and a judiciary burdened with delays have each slowed development. Neglect is also partly an effect of backwardness: a poor state with a narrow tax base struggles to fund schools and clinics, and so the circle closes. The truer statement is that the neglect of primary health and education is the most decisive among several causes, because it is the one that keeps the others from being solved.

Moreover, the record is not one of neglect alone. Kerala and Tamil Nadu show what attention can achieve. Tamil Nadu's school noon meal, begun under K. Kamaraj and universalised in 1982, kept poor children in class and fed them, and Kerala's network of public schools and health centres gave it social indicators far ahead of its income. Nationally, the maternal mortality ratio fell from 130 in 2014-16 to 97 in 2018-20, and infant mortality declined from 39 in 2014 to 28 in 2020, according to the Press Information Bureau. Mission Indradhanush widened immunisation, and polio was eliminated, with the WHO certifying India polio-free in 2014. These gains prove that the neglect can be reversed when the state takes the task seriously.

Building upon this, India's recent reforms point the way. Ayushman Bharat's network of Ayushman Arogya Mandirs aims to bring screening for non-communicable diseases and free medicines close to home, while its insurance arm shields families from catastrophic hospital bills. The National Education Policy (2020) restates the six per cent goal and puts foundational literacy and numeracy first through the NIPUN Bharat mission, and states such as Uttar Pradesh and Odisha have recorded measurable gains in reading and arithmetic over the past decade, according to NITI Aayog. The task ahead is to raise public spending, fill vacancies of doctors and teachers, and judge schools and clinics by outcomes, not outlays.

When the Bhore Committee wrote its report, it imagined a doctor within reach of every village; when the Kothari Commission wrote its own, it imagined a school that taught every child to think. India has spent seven decades building roads, dams and factories, and it has much to show for them. But nations are finally made of people, and people are made in clinics and classrooms. If India is to become a developed country by 2047, the unbuilt foundations of 1946 and 1966 must at last be laid, for no economy can rise higher than the health and minds of the citizens who carry it.