Glorifying Virchow: Current Debate on Neoliberal Policies and Health Inequalities in India

Srinivas Goli; Shreya Singh; Shalem Balla

doi:10.53941/gssd.2026.100011

Abstract

This paper explores the theoretical and empirical links between neoliberal policies and health inequalities in the Indian context. The pathways through which inequality generates population health outcomes remain a major source of dispute within social epidemiology and health economics. Virchow’s philosophy, which undoubtedly galvanized thinking across the disciplines, emphasizes how political–economic ideologies and income inequality shape the distribution of health and social problems. In this paper, we argue that the focus on health inequality, while important, understates the role of neoliberal discourses and practices in making sense of contemporary debates on health inequality. Many quantitative studies have demonstrated that more neoliberal countries have poorer health than do fewer neoliberal countries, but we rarely find comprehensive documentation of evidence in the Indian context. Considering the fast-changing political and social environment and policy priorities post-1990s in general and post-2014, this paper examines the impact of a rising share of private healthcare delivery on health inequalities. Using inequality in the under-five mortality rate (U5MR) as a health outcome and per capita NSDP, per capita public health expenditure, the share of private health care spending and the poverty ratio as indicators of neoliberal policies, through robust econometric assessment, we find that economic growth without poverty reduction and public health care spending increase health inequalities. The fixed effects model plots depicting the interaction effects of PCPHE and time on health inequality suggest that public health spending consistently has a negative association with health inequality. However, the period impact of PCPHE on reducing health inequality has declined over time. Random effects model plots that show the interaction effects of the share of private health care utilisation and time consistently show a positive association with health inequality. Our findings also suggest that a positive association exists between the poverty ratio and health inequality. We conclude that integrating understandings of neoliberalism into theorising about health inequality enriches the political economic and political demographic perspective of health. India must implement “post-neoliberal” social and political economic policies to counter neoliberal models that emerged in the 1990s and rising social and health inequalities. Reducing poverty and ending austerity in public health spending are two key steps for reducing health inequalities.

References

1.
Virchow, R. Mittheilungen über Die in Oberschlesien Herrschende Typhus-Epidemie; De Gruyter: Berlin, Germany, 1848.
2.
Thomson, S.; Cylus, J.; Evetovits, T. Can People Afford to Pay for Health Care? New Evidence on Financial Protection in Europe; World Health Organization. Regional Office for Europe: Copenhagen, Denmark, 2019.
3.
Smith, K.E.; Bambra, C.; Hill, S.E. (Eds.) Health Inequalities: Critical Perspectives; Oxford University Press: Oxford, UK, 2016.
4.
Kenworthy, N.J. Crowdfunding and global health disparities: An exploratory conceptual and empirical analysis. Glob. Health 2019, 15, 71. https://doi.org/10.1186/s12992-019-0519-1.
5.
Drèze, J.; Sen, A. An Uncertain Glory: India and Its Contradictions; Princeton University Press: Princeton, NJ, USA, 2013.
6.
Doyal, L.; Pennell, I. The Political Economy of Health; Pluto Press: London, UK, 1979.
7.
Peacock, M.; Bissell, P.; Owen, J. Dependency denied: Health inequalities in the neo-liberal era. Soc. Sci. Med. 2014, 118, 173–180. https://doi.org/10.1016/j.socscimed.2014.08.006.
8.
Rotarou, E.S.; Sakellariou, D. Neoliberal reforms in health systems and the construction of long-lasting inequalities in health care: A case study from Chile. Health Policy 2017, 121, 495–503. https://doi.org/10.1016/j.healthpol.2017.03.005.
9.
Gatwiri, K.; Amboko, J.; Okolla, D. The implications of neoliberalism on African economies, health outcomes and wellbeing: A conceptual argument. Soc. Theory Health 2020, 18, 86–101. https://doi.org/10.1057/s41285-019-00111-2.
10.
Baru, R.V.; Mohan, M. Globalisation and neoliberalism as structural drivers of health inequities. Health Res. Policy Syst. 2018, 16, 91. https://doi.org/10.1186/s12961-018-0365-2.
11.
Taylor, R.; Rieger, A. Medicine as social science: Rudolf Virchow on the typhus epidemic in Upper Silesia. Int. J. Health Serv. 1985, 15, 547–559. https://doi.org/10.2190/XX9V-ACD4-KUXD-C0E5.
12.
Kickbusch, I. The political determinants of health—10 years on. BMJ 2015, 350, h81. https://doi.org/10.1136/bmj.h81.
13.
Sakellariou, D.; Rotarou, E.S. The effects of neoliberal policies on access to healthcare for people with disabilities. Int. J. Equity Health 2017, 16, 199. https://doi.org/10.1186/s12939-017-0699-3.
14.
Schrecker, T. Neoliberalism and health: The linkages and the dangers. Sociol. Compass 2016, 10, 952–971. https://doi.org/10.1111/soc4.12408.
15.
Deaton, A.; Bury, L. The Great Escape: Health, Wealth, and the Origins of Inequality; Princeton University Press: Princeton, NJ, USA, 2013.
16.
Rao, K.S. Do We Care? India's Health System, 1st ed.; Oxford University Press: New Delhi, India, 2017.
17.
Tiwari, C.; Jain, N.; Goli, S.; et al. Political determinants of health: (Re)examining the role of governance in reducing maternal mortality. Health Econ. Policy Law 2023, 18, 248–273. https://doi.org/10.1017/S1744133123000026.
18.
Mackenbach, J.P. Political determinants of health. Eur. J. Public Health 2014, 24, 2. https://doi.org/10.1093/eurpub/ckt183.
19.
Schrecker, T.; Bambra, C. How Politics Makes Us Sick: Neoliberal Epidemics, 2nd ed.; Palgrave Macmillan: London, UK, 2020.
20.
Sparke, M. Globalisation and the politics of global health. In The Oxford Handbook of Global Health Politics; Oxford University Press: Oxford, UK, 2018; pp. 37–58.
21.
Primrose, D.; Chang, S.; Lee, M. (Eds.) The Routledge Handbook of the Political Economy of Health and Healthcare; Routledge: London, UK, 2021.
22.
Navarro, V. Neoliberalism, Globalization, and Inequalities: Consequences for Health and Quality of Life; Baywood Publishing: Amityville, NY, USA, 2007.
23.
Labonté, R.; Stuckler, D. The rise of neoliberalism: How bad economics imperils health and what to do about it. J. Epidemiol. Community Health 2011, 65, 198–200. https://doi.org/10.1136/jech.2009.102707.
24.
Wilkinson, R.; Pickett, K. The Spirit Level: Why Equality Is Better for Everyone; Penguin Books Limited: London, UK, 2010.
25.
Mudge, S.L. What is neo-liberalism? Socio-Econ. Rev. 2008, 6, 703–731. https://doi.org/10.1093/ser/mwn016.
26.
Viens, A.M. Neo-liberalism, austerity and the political determinants of health. Health Care Anal. 2019, 27, 147–152. https://doi.org/10.1007/s10728-019-00377-7.
27.
International Institute for Population Sciences (IIPS). National Family Health Survey (NFHS-1), 1992–93; IIPS: Mumbai, India, 1995.
28.
International Institute for Population Sciences (IIPS); ICF. National Family Health Survey (NFHS-4), 2015–16; IIPS: Mumbai, India, 2017.
29.
International Institute for Population Sciences (IIPS); ICF. National Family Health Survey (NFHS-5), 2019–21; IIPS: Mumbai, India, 2021.
30.
International Institute for Population Sciences (IIPS); ORC Macro International. National Family Health Survey (NFHS-2), 1998–99; IIPS: Mumbai, India, 2000.
31.
International Institute for Population Sciences (IIPS); ORC Macro International. National Family Health Survey (NFHS-3), 2005–06; IIPS: Mumbai, India, 2007.
32.
Coburn, D. Income inequality, social cohesion and the health status of populations: The role of neo-liberalism. Soc. Sci. Med. 2000, 51, 135–146. https://doi.org/10.1016/S0277-9536(99)00445-1.
33.
Ostry, J.D.; Loungani, P.; Furceri, D. Neoliberalism: Oversold? Instead of delivering growth, some neoliberal policies have increased inequality, in turn jeopardizing durable expansion. Financ. Dev. 2016, 53, 38–42.
34.
Kentikelenis, A.; Rochford, C. Power asymmetries in global governance for health: A conceptual framework for analyzing the political-economic determinants of health inequities. Glob. Health 2019, 15, 70. https://doi.org/10.1186/s12992-019-0516-4.
35.
Ministry of Statistics and Programme Implementation (MoSPI). Social Consumption in India: Health, 60th Round, 2004; MoSPI: New Delhi, India, 2005.
36.
Ministry of Statistics and Programme Implementation (MoSPI). Social Consumption in India: Health, 71st Round, 2014; MoSPI: New Delhi, India, 2015.
37.
Ministry of Statistics and Programme Implementation (MoSPI). Social Consumption in India: Health, 75th Round, 2017–18; MoSPI: New Delhi, India, 2019.
38.
Office of the Registrar General & Census Commissioner, India. Census of India (1991). 1991. Available online: http://censusindia.gov.in/census.website/data/census-tables (accessed on 14 January 2026).
39.
Office of the Registrar General & Census Commissioner, India. Census of India (2001). 2001. Available online: http://censusindia.gov.in/census.website/data/census-tables (accessed on 14 January 2026).
40.
Office of the Registrar General & Census Commissioner, India. Census of India (2011). 2011. Available online: http://censusindia.gov.in/census.website/data/census-tables (accessed on 14 January 2026).
41.
World Health Organization. Global Health Expenditure Database. 2022. Available online: https://apps.who.int/nha/database (accessed on 14 January 2026).
42.
O'Donnell, O.; Van Doorslaer, E.; Wagstaff, A.; Lindelow, M. Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their Implementation; The World Bank: Washington, DC, USA, 2007. https://doi.org/10.1596/978-0-8213-6933-3.
43.
Deaton, A. Health, Inequality, and Economic Development. J. Econ. Lit. 2003, 41, 113–158. https://doi.org/10.1257/002205103321544710.
44.
Preston, S.H. The changing relation between mortality and level of economic development. Popul. Stud. 1975, 29, 231–248. https://doi.org/10.1080/00324728.1975.10410201.
45.
Ministry of Health and Family Welfare, Government of India. National Health Policy, 2017. Available online: https://mohfw.gov.in/sites/default/files/9147562941489753121.pdf (accessed on 14 January 2026).
46.
Wilkinson, R.G. Income Inequality, Social Cohesion, and Health: Clarifying the Theory—A Reply to Muntaner and Lynch. Int. J. Health Serv. Plan. Adm. Eval. 1999, 29, 525–543. https://doi.org/10.2190/3QXP-4N6T-N0QG-ECXP.
47.
Goli, S.; Arokiasamy, P. Trends in health and health inequalities among major states of India: Assessing progress through convergence models. Health Econ. Policy Law 2014, 9, 143–168. https://doi.org/10.1017/S1744133113000042.
48.
Goli, S.; Moradhvaj; Pradhan, J.; et al. The unending burden of high out-of-pocket expenditure on institutional deliveries in India. Public Health 2021, 193, 43–47. https://doi.org/10.1016/j.puhe.2021.01.029.
49.
Ministry of Law and Justice, GOI. The Maternity Benefit (Amendment) Act, 2017—No. 6 of 2017. The Gazette of India, 28 March 2017. Available online: https://labour.gov.in/sites/default/files/maternity_benefit_amendment_act2017_.pdf (accessed on 14 January 2026).
50.
Goli, S.; Moradhvaj; Rammohan, A.; et al. High spending on maternity care in India: What are the factors explaining it? PLoS ONE 2016, 11, e0156437. https://doi.org/10.1371/journal.pone.0156437.
51.
Srivastava, R.; Padhi, B. Collapse in Wage/Salary Income Growth in India, 2011–12 to 2017–18; Center for Employment Studies Working Paper Series; Institute for Human Development: New Delhi, India, 2020.
52.
Ministry of Finance, GOI. Budget at a Glance: Expenditures, Union Budget. 2020. Available online: https://www.indiabudget.gov.in/budget2020-21/doc/Budget_at_Glance/budget_at_a_glance.pdf (accessed on 14 January 2026).
53.
Mooney, G. Neoliberalism is bad for our health. Int. J. Health Serv. 2012, 42, 383–401. https://doi.org/10.2190/HS.42.3.b.
54.
Arestis, P.; Sawyer, M.C. (Eds.) Economic Policies for a Post-Neoliberal World; Springer International Publishing AG: Cham, Switzerland, 2021.
55.
Coburn, D.; Coburn, E.S. Health and Health Inequalities in a Neo-Liberal Global World. In The Economics of Health Equity; McIntyre, D., Mooney, G., Eds.; Cambridge University Press: Cambridge, UK, 2007; pp. 13–35.
56.
Kashwan, P.; MacLean, L.M.; García-López, G.A. Rethinking power and institutions in the shadows of neoliberalism. World Dev. 2019, 120, 133–146. https://doi.org/10.1016/j.worlddev.2018.05.026.
57.
Moon, S. Power in global governance: An expanded typology from global health. Glob. Health 2019, 15, 74. https://doi.org/10.1186/s12992-019-0515-5.
58.
Lynch, J. Reframing inequality? The health inequalities turn as a dangerous frame shift. J. Public Health 2017, 39, 653–660. https://doi.org/10.1093/pubmed/fdw140.
59.
Hartmann, C. Postneoliberal public health care reforms: Neoliberalism, social medicine, and persistent health inequalities in Latin America. Am. J. Public Health 2016, 106, 2145–2151. https://doi.org/10.2105/AJPH.2016.303470.

Scilight Press

Author Information

Abstract

Keywords

References

About Scilight

Journals

Publishing Policies

Contact Us