Do countries with high GDP growth become healthy over time? Or is it the other way around? Can countries create wealth in the long term if their population is not healthy or educated?
For a very long time, the prevailing wisdom among economists was that wealth produced health: Grow GDP, and better health would naturally follow. If countries were sick, it was because they were poor. Growth, therefore, was the cure.
That changed in 1993, with the publication of the World Development Report 1993 ,WDR 1993), by the World Bank and its deceptively simple idea. The report, through extensive research and examples concluded that health is not merely a consequence of development — it is one of its preconditions. Investing in health was not social spending to be afforded after prosperity arrived; it was among the most powerful ways and a necessary condition to create prosperity in the first place.
This was not a philosophical claim, but an empirical one. The report showed that some of the highest-return investments available to governments were not factories or flyovers, but vaccines, sanitation, clean drinking water, maternal care, and basic nutrition. These interventions addressed the largest burdens of disease at the lowest cost. They kept children alive, adults productive, and families out of poverty.
WDR 1993‘s findings were anything but intuitive, and motivated the world’s richest individual at that time to give away most of his wealth to improve global health. This is what Bill Gates said:
“My personal commitment to improving global health started when I learned about health inequities. I remember reading the 1993 World Development Report. Every page screamed out that human life was not being as valued in the world at large as it should be. My wife Melinda and I were stunned to learn that 11 million children die every year from preventable causes. That is when we decided to make improving health the focus of our philanthropy.”
Many observations from WDR 1993 remain relevant today.
First, what kills and disables people matters more than how advanced our hospitals are. The WDR emphasized targeting the biggest causes of premature death and illness with cost-effective interventions — immunization, tuberculosis control, oral rehydration, antenatal care — rather than prioritizing expensive tertiary care for a few. While India has made some progress on these fronts, we lag behind even neighbors like Nepal, Bangladesh and Sri Lanka. Our population in Bihar, Uttar Pradesh, Jharkhand and Madhya Pradesh, has health indicators that resemble the poorest countries in the world, not of any modern nation.
Second, public money must focus on public goods. Markets are ill-suited to deliver prevention. No private system naturally ensures potable water in every home, sewerage networks, mosquito control to prevent dengue or malaria, national hypertension screening, or universal vaccination. These require collective action and sustained public financing. The report did not oppose private health care; it insisted that governments guarantee a core package of essential health services for all.
Third, health investment is economic strategy, not charity. Poor health among the poorest imposes economy-wide costs — lost productivity, fragile human capital, and higher long-term dependency. Reducing avoidable illness was framed not as redistribution, but as efficiency. Poor health destroys human capital silently. Investments in education and work experience can be wiped out by a heart attack or stroke in mid-life — events we now see far too often among young colleagues. These losses are not just personal tragedies; they are macroeconomic drags on growth.
Ultimately, health care costs remain the single largest reason households fall into poverty in countries like India that have failed to invest adequately in health. What is the point of lifting families out of poverty through elaborate government schemes if a single hospitalization can push them right back in? (And yes, questions about Ayushman Bharat deserve serious discussion — but that is a column for another day.)
For countries that absorbed this lesson, the results were dramatic. Nations such as Costa Rica and Sri Lanka achieved health outcomes comparable to far richer nations with only modest incomes. China slashed infant mortality well before its economic boom of the 1980s, and at a time when it was much poorer than India. The early investment in their people continues to pay off for the Chinese. Other fast growing economies like South Korea, Singapore, Malaysia, Thailand and Vietnam also invested early in basic health and education, and created the foundation on which growth could later stand.
What happens when economic growth runs ahead of population health? Russia, after decades of rapid industrial expansion, entered the 1970s with a hidden weakness: deteriorating adult health. Male life expectancy peaked at around 64 years in the mid-1960s, then began an extraordinary decline, reaching 57 years by 1994. Alcohol-related deaths, cardiovascular disease, unsafe workplaces, and weak primary care quietly hollowed out the working-age population. The economic consequences — lost productivity, demographic contraction, and fragile long-term growth — were severe.
Brazil experienced its own “economic miracle” between 1968 and 1973, growing at 7–10 percent annually. Yet child mortality remained above 100 deaths per 1,000 live births, and malnutrition was widespread. When external shocks hit in the 1980s, growth collapsed. Poor health and extreme inequality magnified the downturn, and durable progress only resumed after the expansion of universal primary health care in the 1990s.
GDP growth without population health is not development — it is a temporary illusion.
India’s engagement with this lesson has been muddled. There remains a persistent belief — often voiced even by my friends in the corporate sector who sincerely want a Viksit Bharat — that India is too poor to afford strong public investments in health, education, or basic services like safe drinking water in every home. This belief is simply wrong. History shows that countries become healthier first and richer later, not the other way around.
Thirty years after it was published, the World Development Report the lesson is poorly understood. We can continue to chase GDP and hope that health follows. Or we can learn what was already evident in 1993: That the most important infrastructure a nation builds is the health and capability of its people — and that without it, GDP growth will always be fragile, unequal, and incomplete.
Ramanan Laxminarayan is president, One Health Trust. The views expressed are personal
