India’s global ambitions come with global health duties both amidst the COVID-19 pandemic and in its aftermath
In the third year of the COVID-19 pandemic, India must assume a greater leadership role in the global health agenda. This will befit India’s status as the world’s seventh-largest economy and projections that India will overtake China as the world’s most populous nation as early as 2027.
Any future Indian leadership role must build on the past, as India has been underwriting global health security for several decades even before COVID-19. We share four examples. Firstly, India produces considerable human capital for health, such as 78,000 new doctors annually. While most of them stay to practice in India, a considerable number leave to work abroad. Indeed, Indians are the second most common nationality in the United Kingdom National Health Service, and the American Association of Physicians of Indian Origin counts 80,000 members of Indian origin working in the United States. Many of them are in the frontlines of the battle against COVID-19.
Secondly, India exports US$22 billion worth of medicines annually, ensuring affordable healthcare for millions of people across the world. Indian products account for 30 percent of the volume and 10 percent of the value of the US$100-billion generics market in the United States—the world’s largest. More importantly, India supplies half of the global demand for vaccines, which are public health’s “best buy”. The Indian manufacturing machine is playing an important role in producing COVID-19 vaccine doses for hundreds of millions of people, notably through the Serum Institute of India and Bharat Biotech. It is likely that Pfizer and Merck’s agreements with the Medicines Patent Pool for COVID-19 anti-viral pills (signed in November 2021) will include many Indian manufacturers as well.
Thirdly, health diplomacy is an emerging Indian foreign policy tool. Before COVID-19, India committed at least US$100 million to bilateral health projects in South Asia, Southeast Asia and Africa. Such projects, especially amongst Indian neighbours such as Afghanistan, Bangladesh and Nepal, serves both humanitarian and nation-building purposes. During COVID-19, India relied on health diplomacy to strengthen their presence and soft power in Africa, through donations or technical assistance. During a prolonged pandemic, such health diplomacy also serves to protect the health security of India and the world.
During COVID-19, India relied on health diplomacy to strengthen their presence and soft power in Africa, through donations or technical assistance.
And finally, India provides healthcare for 1.3 billion people at home, safeguarding the human security of an entire subcontinent. Improvements in population health, air pollution, gender empowerment and primary care are crucial to allow health to become a determinant—and not just a consequence—of India’s economic growth. Moreover, the world’s success in achieving the UN Sustainable Development Goals amidst a pandemic depends heavily on India’s ability to scale its policies and programmes for its billion-plus citizens. These examples demonstrate the crucial role that India plays in global health today.
Expanding India’s Leadership Role in Global Health
To take on a greater role in the global health arena, however, India must address its own issues, primary among which is the chronic under-investment in health. Currently, the country spends a mere 3.3% of its GDP on healthcare, significantly lower than the global average of 10 percent. Annually, 108 million Indians are pushed into poverty due to out-of-pocket health expenditure, which is three times higher than the world average. This is possibly worsened by the economic, social and health impact of COVID-19, although data is still being collected.
All this is entirely preventable. Healthcare is a political subject, and providing universal health coverage not only protects all citizens against diseases, but also increases the population’s resilience against COVID-19 and other possible pandemics. Therefore, India must spend more on health by mobilising additional resources from health-financing reform, which includes a reasonable mix of general taxation and social health insurance. This will improve population health, ensure societal equity and solidarity, accelerate India’s growth (partially through new job creation), and increase state legitimacy through competent public services.
India must spend more on health by mobilising additional resources from health-financing reform, which includes a reasonable mix of general taxation and social health insurance.
Second, India must strengthen primary care delivery, instead of investing in expensive hospital-based secondary or tertiary care. Since the country is still largely rural, an appropriately sized network of rural primary care clinics must be built, staffed, financed and maintained. India’s highly qualified health service and the vibrant tech/IT industry must find synergies to re-imagine how primary care can be delivered to all Indians. Such re-imagination must consider the use of digital health, screening, testing and monitoring during home isolation in the age of COVID-19, all led by primary care. The result will be better health for one-fifth of humanity as well as the opportunity for India to export best practices, such as primary care integration with hospitals or electronic health records. In the same way Cuba exports doctors for diplomacy, dollars and soft power, India can export healthcare management and digital health, potentially to markets such as the African continent or in populous Brazil or Indonesia.
Third, India’s pharmaceutical manufacturing machine must move higher up the value chain, alongside the “Make in India” ethos. This can fit the tectonic changes caused by COVID-19, not necessarily only through the patented original research route. Manufacturing capacity must be increased to create economies of scale and further reduce prices. Additionally, factories must be flexible enough to quickly re-tool, to provide surge manufacturing capacity for crisis situations, e.g., to manufacture vaccines for new variants or seasonal variations. That India is crucial to the world is evident in the fact that the US FDA has an India Office, and in 2019, India’s pharmaceutical companies received fewer quality warnings than American ones. This commitment to quality is crucial for any expansion of India’s role in global health, especially when moving into the biosimilar market (higher-end generics projected to be US$27 billion in 2024), transferring technology to other emerging markets, or helping Big Pharma through contract manufacturing. However, caution must be exercised: A global systemically important role for India’s pharmaceuticals means operational fail-safes, diversified supply chains, and geographically dispersed factories become important.
Factories must be flexible enough to quickly re-tool, to provide surge manufacturing capacity for crisis situations, e.g., to manufacture vaccines for new variants or seasonal variations.
Finally, India’s leadership in global health can also be measured through its contributions to reforms in the international patent system. While intellectual property rights (IPRs) and competition are desirable public goods, they can lead to destructive zero-sum games, affecting lives, eroding public health, and channelling capital away from poor to rich countries in a neo-colonial fashion. COVID-19 presents a unique opportunity for such new rules to be anchored by Indian political, diplomatic and technical leadership. India must take a leadership role in rewriting some of the rules of the global IPR regime, given its experience, expertise and economic exposure. Innovation, competition and hard work should always be rewarded, but in ways that are fair and sustainable for the rest of the world. Strengthening the global IPR regime will help global public health and individual human beings, while also laying the foundation for science in other slower-moving species-level global health threats, such as climate change or anti-microbial resistance. India, along with South Africa, has sponsored a proposal for waiver of patent rights for COVID-related vaccines, drugs and technologies, to the World Trade Organisation (WTO). While the proposal is still being debated at WTO, this demonstrates India’s commitment to the promotion of global health equity.
India has global ambitions, and these come with global health duties both amidst the COVID-19 pandemic and in its aftermath. India must match its duties to its ambitions as a global superpower, and the world is relying on India to rise to the occasion.
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 Kaushalendra Kumar, Ashish Singh, Santosh Kumar, Faujdar Ram, Abhishek Singh, Usha Ram, Joel Negin and Paul R. Kowal, “Socio-Economic Differentials in Impoverishment Effects of Out-of-Pocket Health Expenditure in China and India: Evidence from WHO SAGE,” PLOS One 10, no. 9 (13 August 2015)
 Keith Aoki, “Neocolonialism, Anticommons Property, and Biopiracy in the (Not-so-Brave) New World Order of International Intellectual Property Protection,” Indiana Journal of Global Legal Studies 6, no. 1 (Fall 1998).
The views expressed above belong to the author(s).
The article is originally published at ORF Online.
Dr Khor Swee Kheng is a Senior Visiting Fellow at UNU-IIGH. Currently, he specialises in health systems & policies and global health, holding fellowships at Chatham House, the United Nations University (UNU-IIGH) and ISIS Malaysia.
Suggested citation: Khor Swee Kheng, K. SRINATH REDDY. "India, COVID-19 and the Global Health Agenda," United Nations University, UNU-IIGH, 2022-02-22, https://unu.edu/iigh/article/india-covid-19-and-global-health-agenda.