Global health is witnessing momentous changes in the way it will be governed in the future, and not just at the World Health Organization (WHO). The current crisis is an opportunity for countries like India to recast its health diplomacy and fork out a new vision for India’s role in world health.
WHO, the indisputable centre of global health, has suffered what could be a serious set-back, with its largest donor, the US, freezing funds, pending investigations into the role of the UN’s only technical agency in the early days of the ongoing pandemic and its allegedly “China-centric” focus.
Currently, the WHO is the war room that coordinates research and development, and issues technical guidance to more than 190 countries on how its member-states must fight COVID-19. The situation is hardly conducive for facing sudden financial uncertainty even as the organisation serves up crucial technical assistance on everything from surveillance, to patient management, to mental health for frontline healthcare workers, to risk communication and community engagement, in addition to launching an international clinical trial to find treatment options, and even helping kids read indoors.
A number of countries have offered to step in, to help the WHO continue its important firefighting work of leading the response even as the pandemic has reached more than 2.2 million cases and left more than 150,000 people dead over the last four months. As commentators have pointed out, the US contributes 16% of the WHO budget – of which 4% accounts for assessed contributions (like “subscription fees”), perhaps not as significant as the 12% that come in the form of voluntary contributions, primarily towards polio eradication and emergency work. Early analyses by WHO indicate that essential health programmes including polio eradication and trauma management, and WHO’s emergencies work in certain countries will be affected by the potential suspension of American funding.
Much has been said about the growing Chinese influence at the UN and how that it is expected to grow within the WHO. Multilateral organisations have been arenas where geopolitics flourish and reconfigure. The unfortunate timing of the pandemic will not stop opportunistic political games or trade wars from playing out. There is a vacuum to be filled, products to sold, and lives to be saved.
Anyone who has tracked the US attack against multilateralism is now familiar with its playbook. In fact, some observers have stated that American discomfort with multilateral institutions, including the WTO, predates the current Trump administration and goes well into the Obama years at the White House.
Given how high prices of medicines became an inevitable rallying point in the US, the Trump administration was progressively inching towards working with other member-states on matters of drug pricing, for example. So in some sense, the American decision to freeze funding to WHO, is on one hand, not surprising given its previous politics, and yet on the other, somewhat perplexing given its timing.
The pandemic will definitively recast global health in health security terms. There will be a decisive tilt to make borders more secure, despite the lack of evidence on the efficacy of travel restrictions during health emergencies. There are ongoing efforts to curb export restrictions at the WTO. This will be a tussle between stronger multilateralism and short-term populist politics dictated by domestic calculations. There are apprehensions that an increased role for China could mean coding authoritarian tendencies and non-transparency into global governance of health.
But this, in part, could be a fallacious, simplistic narrative. The reality is in fact much more complex and nuanced. The European Union, a key player, on how these global international development complexes are run, will not simply move aside to accommodate stronger interests. The game is on.
So where and how does India feature in all of this? Irrespective of China’s future role at WHO, here is what India can and must do.
Adopting “whole of government approach” to health
Like others, India must step in and support WHO, and multilateralism in health. India owes it, not only to Indians, but to people worldwide. India’s recent statement of support to WHO is welcome, but this should be followed up by concrete, defining efforts.
We must take this opportunity to chart out a comprehensive health policy that takes into account how this pandemic has implications for trade, economics and of course, health. This is not about today or the next five years, but a vision for all future governments. Health should be front and centre, to secure both economic growth and the demographic dividend.
WHO has repeatedly called for a “whole of government approach”. We need a cross-disciplinary expert group defining such a health policy. The government must take the lead in constituting and bringing together expertise that takes a range of factors into account. The government needs to have a plan, and share if it already has one, on a coherent strategy to engage with multilateral institutions across different sectors post-COVID19. In Geneva-speak, diplomats call it “policy coherence”, where health interests are treated and addressed in a coherent manner across different sectors.
Globally, one hopes that this pandemic would usher in the return of expertise. India must embrace science, expertise and blend a truly inter-disciplinary approach to global health which fuses diplomacy, external affairs, health, trade, urban planning, and finance, among others, to improve well-being. Pandemics and countries, cannot be effectively addressed by a small ring of inward-looking politicians, disregarding expert advice, as both the US and UK, have belatedly recognised.
Given its position as the pharmacy of the world, India must continue to honour its supply chain commitments under the difficult circumstances of a country-wide lockdown that has affected production. Already, its access to some APIs was disrupted early in the year, when Chinese suppliers were affected – other countries will work on their supply chains to reduce dependence on countries like India and China.
Further, by increasing its commitment to the health goals for its population, India will single-handedly help global health, like no other country can. Why? India has some of the highest burdens of disease both infectious and non-communicable diseases, in addition to having dismal health indicators. Strengthening health systems and ensuring primary health care will address some of these challenges.
India has persistently lacked sufficient and effective investment in healthcare through the decades (currently at 3.5% of the GDP) continuing till today – as illustrated at this hour, by our weak health systems unable to cope with the double burden of not only COVID-19 but also traditional challenges such as Tuberculosis.
Strengthening capacities for health diplomacy
India has been a somewhat silent player in Geneva over the last few years as far as health is concerned – India’s trade mission in Geneva is larger. Yes, India has lent support and referenced the right language in its statements on key matters. But observers and experts believe, there is a perception that India can do much more in taking a strong stand, and lead initiatives in building coalitions and working on resolutions – as it has done in the past.
Apart from initiatives such as the one on digital health and on the workaround traditional medicines, one is left looking for “Indian action” on the more pertinent issues of the day. In the current context, it assumes urgency, given the havoc this pandemic can cause.
“We are not putting our finger on the right issues”, rues a global health expert familiar with India’s engagement here.
For India to play a crucial, defining role as a prominent leader of the global south, first and foremost, it must strengthen its capacities for health diplomacy. From the limited vantage point of Geneva, one gets an impression, that a bulk of our resources has been dedicated to fighting Pakistan at the UN Human Rights Council.
Notwithstanding overwhelming emphasis on traditional security concerns, resources and capacities must be steered towards thinking about health priorities in a new way given new realities. Asian geopolitical compulsions aside, India will not be able to address health if it continues to view everything through the China-Pakistan prism, one observer said.
Evaluate allies in light of new realities
Experts here, familiar with workings of developing countries are of the view, that India must consider allying with China on health issues. “Relative to China, India will be a smaller player in global health. But by picking the right allies now, especially in health, India can help define the changing configuration in institutions like WHO”, a source said on the condition of anonymity.
One even suggested that this could be India’s “Dr Kotnis moment” with China, referring to the young Maharashtrian Doctor Dwarkanath Shantaram Kotnis sent to China in 1938 during the Sino-Japanese War to treat wounded Chinese soldiers. (Dr Kotnis in his tragically short life became a friend of China and remains an enduring feature of Indo-Sino relations, decades after his death in 1942.)
Notwithstanding paradigm shifts in global health security and geopolitics, Indian diplomats should be given the freedom and the latitude to make decisions. Deep centralisation of powers and decision-making that we see today, is simply not accommodating of creative approaches to diplomacy in the complex environment that we now inhabit.
India needs to build on its negotiating capital and make good on past losses. Diplomats have to be given the confidence that they will be supported. Streamlined functioning between country missions and New Delhi has to be established to enable this. Further, the size of Indian missions is relatively smaller, to those of the US and even China. Despite, limited resources, a prioritisation can help allocate resources most efficiently. For an aspiring superpower, we have to empower our diplomats.
At a minimum, our foreign offices should not be spending a disproportionate amount of their time and resources putting up shows to display India’s soft power at the expense of serious multilateral diplomacy work.
India’s upper hand
By virtue of being home to a billion and more, and a diverse population, India continues to throw up great innovation and skill, in tackling health challenges at a staggering scale. India has shown it can do it, from as recent as the Kerala model to successfully deal with COVID19, its efforts to address substandard and falsified drugs, to as far back as the eradication of Polio.
Director-general Tedros Adhanom Ghebreyesus, said recently, that he wants the WHO to partner with India on dealing with the infodemic that surrounds this pandemic. According to WHO, infodemic is an over-abundance of information – some accurate and some not – that makes it hard for people to find trustworthy sources and reliable guidance when they need it. While we have our own challenges of misinformation and fake news interfering in the delivery of public health goals, including contributing to Islamophobia in the time of the pandemic, India must help counter the infodemic globally.
In the past, WHO has also been appreciative of Indian proposals like Ayushman Bharat, despite its overwhelming focus on tertiary care. But that should not be surprising because it is in line with the overall direction adopted by WHO on universal health coverage, and not universal health care, as civil society groups have consistently pointed out.
Dr Tedros has also praised India for its efforts to combat the pandemic, despite having one of the world’s harshest and ill-planned lockdown, that has affected millions of inter-state migrants and unleashed hunger amongst the poorest. It is possible that this may be another one of WHO’s strategies to gain cooperation – as it did with China, fuelling allegations – to have a big member-state by its side, concerned as it is about the potentially devastating impact the pandemic can have in a country with a weak health system.
A prisoner of the superpower image
Strategic geopolitical considerations will continue to dictate global health – quid pro quo is the reality in multilateralism. To play a meaningful role in global health, India has to rise to the demands at home.
A source I spoke with for this article, believed that India was a prisoner of its image in the West. If India indeed aspires to be a superpower, then it must step up with bold strategies and big plans on how it imagines a post-COVID international health order with south-south cooperation as the cornerstone in the “new” system. For example, India must revitalise its contribution and leadership in the BRICS coalition.
If India resists lining up with China on health issues, it will simply play into the hands of American interests, some fear. Can India stand up to the US for drugs it needs, – as one commentator pointed out. India must realise that American influence, even in global health, will wane to a certain extent.
“If we play to the gallery, we will lose out,” the source cautioned. We have too many lives and needs at stake.
Priti Patnaik is a Geneva-based independent journalist and researcher reporting on global health and international trade. She tweets at @pretpat and for Geneva Health Files tracking international health policy. She has worked as a consultant to the World Health Organization in the past.