Introduction

For a long time, the notion of ‘health policy’ was associated purely with national concerns and remained outside the scope of the study of international relations (IR), whose focus was on economic and military engagements. Health rose to prominence in countries’ foreign policy and security agendas in the post-Cold War era. As the world globalised, health policy became linked with development, foreign policy, security, and trade. Today, health policy has become an important tool in multilateral political discourse, with organisations like the World Health Organization (WHO) playing a pivotal role in engagements that impact global governance.

Global health politics and global health diplomacy (GHD) work within an international system where policy is advanced through formal and informal negotiations between state and non-state actors that hold differential power. These interactions result in the formulation of health plans and governance frameworks, and the creation of platforms for collective action that shape the operationalisation of global health. Tensions emerge when powerful states possess disproportionate power in global health policymaking.^[1]

The COVID-19 pandemic brought global health politics to centre stage, amid stringent restrictions on mobility, limited supplies of essential medical and pharmaceutical countermeasures, and vaccine nationalism.^[a] The crisis catalysed the creation of a unique multilateral initiative i.e., the Access to COVID-19 Tools (ACT) Accelerator—to fast-track the development of essential diagnostics, therapeutics, and vaccines. However, frailties still exist within the multilateral sphere, which is reshaping diplomacy.^[2] The geopolitical rivalry between the United States (US) and China, WHO’s delay in declaring COVID-19 as a public health emergency of international concern (PHEIC), and vaccine nationalism raised concerns over the quality of global collective action and the very foundation that GHD is premised on: rights and responsibilities, and principles of justice, calling for an analysis of health politics from the perspective of international relations.^[3][4] Beginning in January 2025, the US’s cuts to global health aid, including the dismantling of the US Agency for International Aid (USAID), its withdrawal from WHO, and the proposed funding cuts to Gavi (the Vaccine Alliance), have impacted health activities, necessitating an overhaul of global health.^[5]

The rest of this paper utilises a literature survey on IR and GHD to examine the interlinkages between the disciplines of health and IR. It explores India’s strategic role in this domain.

The Emergence of Global Health Diplomacy

In the mid-19^th century, six pandemics—all attributed to cholera^[b]—triggered an increase in awareness of the importance of hygienic environmental conditions and human health, and stirred a so-called “sanitary awakening”,^[c] which would eventually shape modern public health.^[6] This period was characterised by policies that protected colonial military personnel from vector-borne diseases and  economic resources from trade disruptions due to infectious disease outbreaks.^[7] Thus, national interests comprising military and economic power became  associated with ‘high politics’, while health and development were considered  ‘low politics’ and kept outside national security and foreign policy agendas.^[8]

During the Cold War era, health was often used as an instrument of soft power to advance a state’s foreign policy objectives and foster goodwill.^[9] For instance, the US-USSR cooperation to eradicate smallpox enabled advancements in biomedical research, while simultaneously providing a space for the superpowers to vie for leadership on the global stage.^[10] Similarly, the US employed medical interventions such as the Medical Civic Action Programme (MEDCAPS) to garner support from the locals during the Vietnam War as part of its ‘winning hearts and minds’ strategy.^[11] The latter, however, raised concerns over the quality of healthcare being delivered and the politicisation of health concerns.^[12] Until the mid-1990s, the term ‘international health’ was used extensively, referring to the health status of developing economies, which comprised former colonies; the development of tropical diseases and the extent of military and commercial reach to former empires was of policy interest,^[13] reflecting a narrow understanding of ‘health’.^[14]

Towards the end of the Cold War and with the advent of globalisation, health was linked with foreign policy, and the two disciplines—health and IR—merged. Increased trade and commerce, and the ease of movement of people, provided faster avenues for the globalisation of health issues. New challenges, in the form of tobacco, spurious medicines, junk food, drug resistance, and altered disease-vector distribution patterns transcended geographic boundaries, and the distinction between domestic concerns and international ones blurred.

The pandemic potential of neglected tropical diseases in a globalised world demonstrated that interconnectedness had a significant impact on health everywhere, leading to the adoption of the term ‘global health’. The WHO’s Global Outbreak Alert and Response Network’s (GOARN) role in coordinating international efforts during the 2003 SARS outbreak also served as a pivot to where health was perceived as an all-pervasive threat to the world.^[15]

Owing to potential spillover effects of healthcare challenges, the stability of the entire world depended upon the disease burden of developing economies. Health was not only linked to economic productivity but to political stability as well, which enhanced its political profile and steered funding opportunities through institutional mechanisms.^[16] Accordingly, Western economies, through various initiatives, inserted health into developmental goals. The Millennium Development Goals (MDGs) were introduced, placing primacy on scaling up investments in the public health sector of developing countries,^[17] and in 2015, these goals were expanded to formulate the Sustainable Development Goals (SDGs). Fittingly, wealthy countries’ development assistance for health (DAH) for low- and middle-income countries (LMICs) rose from US$7.1 billion in 1990 to US$37.6 billion in 2016.^[18]

The emergence of contemporary health issues at the international level focused attention on the role of ‘global health diplomacy’ in achieving public health goals by delineating what actions must be taken, directing negotiations, and formalising institutional mechanisms to enable collective action. ‘Global health diplomacy’ is defined as “the multi-level and multi-actor negotiation processes that shape and manage the global policy environment for health in health and non-health fora.”^[d],[19] Table 1 outlines examples of GHD.

Table 1. Successes in GHD

Since the 2008 global financial crisis, the world has witnessed the rise of the Global South, necessitating the restructuring of governance mechanisms under multilateral organisations. Protectionism, vaccine nationalism, withdrawals from international negotiating bodies,^[e] geopolitical rivalries, economic coercion,^[f] conflicts in Europe and West Asia,^[g] and a multitude of threats emerging from transnational organised crime^[h] are challenging the stability of the current multilateral system.^[28]

In health, this crisis of the liberal order has resulted in questioning the transparency and legitimacy of WHO, and most recently, in the US ceasing its role in global health activities. Multilateralism is operating in ‘crisis mode’, necessitating a more comprehensive understanding of contemporary challenges to GHD and what can be done to mitigate them.^[29]

The Securitisation of Health

Global Health Security

Gro Harlem Brundtland, WHO Director-General in 1999, argued that "investing in global health is good politics,” and that globalisation necessitates international cooperation as “all of humankind today paddles in a single microbial sea.”^[30] This landmark speech brought attention to the idea of ‘global health’, making it a subject of national security agendas. At the same time, non-traditional security threats, such as HIV/AIDS, widespread tobacco use, and bioterrorism belied the notion that health was associated with ‘low politics’ by highlighting that health and quality of life were linked to human survival.^[31]

The link between security and health was premised on the notion that diseases had the potential to kill more soldiers than actual conflicts and wars, impacting a state’s military capacity.^[32] Towards the mid-2000s, infectious diseases were perceived as threats to peace and stability. WHO themed its 2007 World Health Report on global health security by defining it as “the activities required, both proactive and reactive, to minimise vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries.”^[33] The report identified “real-world” concerns that have the potential to cause security dangers. New and emerging biological risks that were related to broader activities including increased mobility of people, climate change, disruptive technologies, and terrorism were brought into the ambit of security studies. Initially, these biological threats were framed on the basis of potential damage to the Global North, and efforts were directed at promoting disease-specific interventions in developing economies to minimise transmission through international trade and travel.^[34]

Securitised responses are useful for health governance as they add a sense of urgency to a situation, encourage collective action, and induce policy responses.^[35] For instance, in the aftermath of the 2014-2016 West African Ebola outbreak and the 2016 Zika outbreak in the Americas,^[i] securitising discourses motivated investments in the research and development of therapies, and shifted focus on capacity-building and improving health systems in the Global South to ensure disease surveillance, prevention, and enhance emergency responsiveness.^[36] It is pertinent to note, however, that the securitisation of health issues tends to promote certain actors and privilege specific agendas over another.

The COVID-19 pandemic demonstrated how infectious disease was framed as a security threat by political actors and the WHO, which threatened the lives of the public and called for exceptional responses.^[37] While it has been argued that this approach was beneficial in curtailing morbidity and mortality rates, there is a lack of consensus on the outcomes of securitised responses that justify their use.^[38] The securitisation of health issues may also be used to promote autocratic rules and cause disruptions in other sectors, triggering economic and political instability.^[39] This demonstrates the state-centric nature of securitisation, where the social contact between the citizens and the public is sacrificed to protect the state.^[40] Applying the logic of security to health issues presents a risk since there are many issues that have the potential to become securitised, highlighting the ad-hoc manner of threat construction which relies upon intersubjective understandings of what entails a threat and thus holds potential for misuse.^[41]

Biosecurity  

The conventional notion of health security turned in the late 20^th century when it was identified that health issues could be regarded as biological threats in non-traditional ways. In 1975, the Biological Weapons Convention (BWC) came into effect, seeking to address disarmament in the post-war era.^[42] Biosecurity refers to the management of threats that emerge from biological pathogens introduced/released either through accidental or deliberate means.^[43] The former refers to the accidental release of pathogens during vaccine manufacturing or biomedical research. Biological threats that are deliberate—to create harm, panic, or terror—are referred to as ‘bioterrorism’. In the aftermath of 9/11, bioterror took the spotlight when letters containing anthrax spores were sent to US government officials and media houses, resulting in five deaths.^[44]

Bioterrorism discourse during this period resulted in tensions amongst policymakers along the lines of whether security measures should be focused from a national or an international perspective, whether resources should be directed towards intelligence networks and diplomacy to monitor the supply of raw materials and prevent the production of bioweapons, and whether bioterrorism should be visualised solely under defence strategies.^[45] For policymakers, the tension lay primarily at the ‘dual-use’ dilemma, where “the knowledge and technologies that result from life science research used for legitimate research and technology development may also be appropriated for illegitimate intentions and applications,”  and to create bioweapons.^[46] The biotechnology revolution has generated novel diagnostics, therapeutics, and vaccines to tackle various diseases.^[j]

Further, with the increasing convergence of bioinformatics, computer science, and artificial intelligence (AI), analysts have pointed out that great amounts of biological information are stored and can be acquired and manipulated by malicious actors. The exchange of biological information is crucial to collectively address public health emergencies and constitutes ‘bioinformational diplomacy’.^[47] Thus, there is a need for ‘cyberbiosecurity’ for three main reasons: biological information can be of immense value and may be subjected to state secrecy; clandestine acquisition of biological information for malevolent purposes can affect critical infrastructures; exchanging biological information can be regarded as a diplomatic effort to collectively combat global health threats.^[48]  

Collectively, the management of health threats is a challenge to global health diplomacy as it entails an inherent risk where securitised responses hold the potential to be misused while triggering necessary policy action, and emerging technologies like biotechnology raise the dual-use dilemma.

Global Health Politics

Stalled Negotiations over a Pandemic Treaty 

WHO’s delayed response in declaring the 2014 West African Ebola outbreak and the COVID-19 outbreak in 2020-21 as a PHEIC was reflective of frail multilateralism.^[49] It demonstrated weaknesses of the  International Health Regulations (IHR)—adopted in 2005 as the legally binding guidelines that enable WHO to declare a PHEIC—highlighting the need for increased responsibility and accountability measures in WHO’s response to health emergencies.^[50] Consequently, WHO member states negotiated a pandemic prevention, preparedness, and response framework (i.e., the Pandemic Treaty) under the aegis of an Intergovernmental Negotiating Body (INB).^[51] The most recent meeting concluded in April 2025, and the proposed amendments indicate that WHO will be the overseeing authority in the application of adequate measures for the protection of public health.^[52] This is premised primarily around reminding World Trade Organization (WTO) member states of their right to exert flexibilities around TRIPS (Trade-Related Aspects of Intellectual Property Rights), and the inclusion of a Pathogen Access and Benefit Sharing (PABS) mechanism.^[53]

During a pandemic, access to vaccines, diagnostics, and therapeutics is critical to developing economies, and the development of pharmaceuticals rests primarily with high-income countries.^[54] Genetic material, such as pathogen samples, is  essential to the development of diagnostics and medical countermeasures. The sharing of genetic resources is premised on viral sovereignty,^[k] as specified in the Convention on Biological Diversity (CBD) and the Nagoya Protocol.^[55] These international instruments outline that access to genetic resources, including pathogens, requires permission from the country of origin and is a ”transaction where countries provide pathogen samples to potential users in exchange for medical countermeasures.”^[56]

During a 2007 H5N1 outbreak, Indonesia invoked ‘viral sovereignty’, refusing to share H5N1 samples, arguing that countries with limited resources provide vital biological information and samples to WHO-affiliated laboratories, but pharmaceutical companies from developed countries obtain these samples without permission. As a result, vaccines, diagnostics, and therapeutics are manufactured in developed countries and emerging economies struggle to access them.^[57] The application of Access and Benefit Sharing (ABS) in international environmental law did not result in equitable outcomes, calling for the need to devise alternative strategies.^[58] Thus, discussions around PABS have been met with scepticism owing to its potential to hinder equitable access to health resources.

Lastly, the Pandemic Treaty strives to include a ‘One Health’ approach to addressing threats with pandemic potential, ease of transfer of technology and data, equitable distribution of vaccines and countermeasures, and resilient supply chains.^[59] There are concerns that the Pandemic Treaty could give rise to nationalistic tendencies. COVID-19 raised concerns over the hierarchical landscape of global health and unequal power relations.^[60] A number of countries are also engaged in bilateral agreements with vaccine manufacturers and in vaccine diplomacy with geopolitical considerations as opposed to adherence to fair and equitable distribution of vaccines, contributing to a resurgence of vaccine nationalism.^[61]

COVAX^[l] – a partnership amongst Gavi, The Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations (CEPI), WHO, and UNICEF—was formed to ensure equitable access to COVID-19 vaccines. However, the framework was similar to a donation-based system and its release happened when national policies prioritised domestic populations.^[62] High-income countries unilaterally pre-ordered 70 percent of the vaccine supply, with Canada ordering vaccines in the excess of five times its need.^[63] COVAX was thus reflective of the inability of developing nations to self-procure.^[64] Reports showed that by early 2022, less than 10 percent of the population in low-income countries (LICs) were vaccinated compared to over 80 percent in wealthy nations.^[65] It is also reflective of the lack of infrastructural storage capacities in LMICs.^[66]

At the time of writing, the final draft of the Pandemic Treaty is ready to be presented for adoption at the World Health Assembly, which is set to take place in May 2025. Despite the INB negotiations going ahead without the US, negotiations over the critical PABS have not yet taken place, indicating that the document will not be ready for signatures by heads of state in the near future.^[67]

The Changing Global Health Landscape  

The US in January 2025, under President Trump, took steps to withdraw from WHO, citing the lack of transparency and accountability in determining the origin of COVID-19. Further, the US has suspended activities under the President’s Emergency Plan for AIDS Relief (PEPFAR)—a landmark initiative for global HIV/AIDS care—and began the process of dismantling USAID.^[68] Although it will take one year for the WHO withdrawal to come into effect and it is likely that it will require congressional approval, the potential impacts are massive.

For instance, data-sharing of the US Centers for Disease Control and Prevention (CDC) with WHO over infectious diseases has ceased, leaving an international organisation that ensures global health security without a prominent information partner. According to UNAIDS (The Joint United Nations Programme on HIV/AIDS), PEPFAR has saved more than 26 million lives and estimates that the loss of PEPFAR funding will result in an additional 6.3 million deaths by 2035.^[69] Eighty percent of USAID projects, primarily addressing tuberculosis (TB), malaria, and vaccine research, that save over 3 million lives annually, have been eliminated. In addition, the administration in January 2025, reinstated the Global Gag Rule, a mandate that prohibits US-funded organisations from providing services related to abortion.^[70] The reinstatement of this policy impacts women’s sexual and reproductive health, undermining progress in issues like the reduction of maternal mortality and unintended pregnancies, and the prevention of sexually transmitted diseases (STDs). 

Financing Global Health  

Analyses of health spending between 1990 and 2021 found that globally, US$9.2 trillion was spent on health.^[71] In 2019, an estimated US$43.1 billion in development assistance in health (DAH) was provided. The COVID-19 pandemic led to increases in 2020 and 2021; US$1.8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, while US$37.8 billion was provided for COVID-19 responses. A range of health stakeholders are responsible for funding including governments, private foundations, individuals, and the corporate sector.^[72] The ongoing Russia-Ukraine and Israel-Hamas conflicts have policy implications for WHO member state contributions to global health financing. The wars themselves have consequences on health—directly through military and civilian casualties and indirectly through displacement. They also cause disruptions in food supply, and access to medical supplies and water and sanitation services.^[73] Geopolitically, the wars have diverted political, military, economic, and diplomatic resources away from global health efforts, such as funds for adaptation to climate-change-induced health threats. It remains to be seen to what extent countries like Germany, which has been at the forefront of global health funding, and China, with its bilateral engagements and Health Silk Road project, will contribute to global health financing in light of the recent changes.

Uniquely, philanthropic organisations play an important role in shaping the global health agenda. Health has received considerable attention with at least 20 percent of development assistance to health coming from philanthropies or NGOs since 2000.^[74] They take part in global governance alongside states and other non-state actors. Global health politics researchers posit that donors are capable of “influencing, shaping, or determining” the political agenda of recipients.^[75] While the intersection of philanthropies in global health reflects a multilateral system where there is greater collaboration between the private sector and civil society with national governments, and the transfer of policy ideas across international borders, it is not inherently apolitical. Donors’ decisions on which issues tend to receive focus, and the nature of support are influenced by political considerations.^[76]

Furthermore, emphasis on pharmaceutical interventions has steered focus away from the social determinants of health and interdisciplinary approaches, which play a role in preventing disease outbreaks. The Chan Zuckerberg Initiative is a new donor and is likely to donate to health, but is registered as a limited liability corporation and not a foundation, indicating that it will be able to refrain from publicly disclosing its funding sources and funding decisions.^[77] Collectively, philanthropies represent a lacuna within global health politics where non-state actors that do not derive legitimacy from the public are able to exert a high degree of influence over global health but operate outside of the realm of oversight and accountability frameworks.^[78] Gaining public trust could be alleviated by demonstrating verifiable results of these funding exercises.

The COVID-19 pandemic ushered in an innovative funding mechanism to address potential pandemics. The Pandemic Fund is a newly formed financial mechanism that aims to provide long-term financial resources to support the pandemic preparedness and response (PPR) framework of LMICs, supported by the G20, various philanthropies and with the World Bank as the trustee.^[79] Concerns rest with a lack of a bottom-up approach to addressing the technical needs of implementation in specific LMICs, the need for prioritising African and Asian domestic manufacturers, and the lack of inclusion of LMICs in decision-making.^[80] There is concern over whether the Pandemic Fund will lead to equitable financing for pandemic preparedness in the LMICs. Studies suggest that the fund may exacerbate existing challenges, which poses the question of whether alternative mechanisms are needed to augment the Pandemic Fund.^[81]

This indicates that global health will have to continue to navigate evolving geopolitical conditions, leaving multilateralism and global solidarity to be the only solutions in addressing new and emerging threats.

India’s Health Diplomacy Efforts: An Overview

Prior to India’s independence, local governments were vested with the responsibility to govern health.^[82] This period was marked by limited resources and an ‘ephemeral’ approach to health, where health became the focal point for only the duration of an epidemic and rarely thereafter.^[83] Western medicine was viewed as an “element of imperialism”.^[84] The Bhore Committee,^[m] which carried out a detailed survey of India’s health landscape, served as a source of systematic data on the health of the population.^[85] It proved to be vital in guiding independent India towards public health reforms. During its deliberations, however, India was struck by the Bengal Famine (1943-44) during which an estimated 2.1 million people died. The calamity triggered a consciousness amongst the nationalists who said that “they would care for the welfare of ‘their’ people better than the colonial leadership.”^[86]

India’s independence, concomitant with the establishment of WHO, raised awareness of the notion that health was to be regarded as a fundamental responsibility of the state, and it was slowly incorporated into India’s foreign policy.^[87] In the Cold War era, India’s foreign policy was founded on its colonial struggles and was characterised by non-alignment, protectionism, an aversion to inelastic international alliances, and a preference towards diplomacy over coercion.^[88] This realist foreign policy enabled India to prioritise its relations with Great Powers and form self-strengthening alliances. This represented India’s identity for a significant period of its post-independence foreign policy outlook. Decolonisation triggered increased developmental assistance and international aid towards post-colonial states, in particular India, as it was an idyllic state for developmental activities owing to its political stability.^[89] WHO formed an ideal platform for the exchange of ideas and policies on health.^[90] This comprised expansive engagements with the US-dominated WHO, strengthening India’s medical education, medical infrastructure and technologies.^[91]

In the midst of the Cold War rivalry, India also maintained ties with the Soviet Union, and it ultimately led to the development of India’s pharmaceutical sector.^[92] By the 1990s, India’s balance of payments crisis and the collapse of the Soviet Union forced it to engage more actively on the global stage, particularly with the US, and adopt strategic autonomy as its foreign policy strategy.^[93] This phase marked the transition of India from an aid recipient to an aid donor, where in June 2003, India ceased accepting developmental aid from donors, barring a few nations, and opted for aid through multilateral organisations instead.^[94]

India’s health diplomacy efforts were initially directed towards its immediate neighbourhood. Technical cooperation in health and humanitarian assistance, for example, was delivered to Bhutan beginning in the 1990s.^[95] DAH was provided to Nepal, Myanmar, Maldives and Afghanistan.^[96] The Indian Technical Education Cooperation (ITEC) set up under the Ministry of External Affairs enabled the exchange of materials, facilitated technical cooperation, and training of personnel to South Asian neighbours.^[97] Further, the India Development Initiative (IDI) was established under the Ministry of Finance to assist other developing countries, introducing India as an emerging leader in South-South cooperation.^[98] Diplomatic efforts were carried out through Quick Impact Projects, bilateral cooperative arrangements, and through triangular cooperation.^[99]  Recent contributions to disaster relief management and (re)building of medical infrastructure in India’s South Asian neighbours—Afghanistan, Sri Lanka, and Maldives—is premised on India’s adherence to ‘Vasudhaiva Kutumbakam’, the philosophy that the world is one family, necessitating global cooperation and interconnectedness to address challenges.^[100]

India’s health diplomacy efforts have gained geostrategic advantages over the years. For instance, Africa has been a long-time recipient of India’s health diplomacy endeavours for humanitarian purposes. With the advent of China’s Health Silk Road and other initiatives, India has upped the ante in its engagements in multilateral diplomacy, as seen in India’s GHD efforts since independence (see Table 2).^[101]

Since 2014, discourse over India’s foreign policy has gained traction, enabling a closer analysis of India’s approach to global health. India is active in leveraging its expertise in health through multilateral institutions, bilateral cooperation efforts, and triangular partnerships. These diplomatic efforts are reflective of India’s need to ensure the security and stability of its immediate neighbourhood, particularly in the health sector. In addition, India’s soft power diplomacy during this period has been characterised as one of image-building instead of influence projection.^[102] India’s diplomatic efforts indicate what ‘global health’ means to the nation; health formed an integral aspect of India’s foreign policy agenda premised on its own experiences. The formation of WHO, its enabling activities, and the development assistance that followed, empowered India to cater to its own domestic needs. However, India’s identity remains firmly premised upon a shared negativity with the Global South—colonialism—which symbolises “a collective experience of domination, discrimination, exploitation, and suffering” and signifies India’s adherence to strategic autonomy.^[103] Accordingly, India draws upon its colonial past and development challenges to form a foreign policy that seeks to accommodate the differences of states as well as engage with them strategically. India stands firm towards the reform of multilateral institutions such as the World Bank and the International Monetary Fund, inequities in trade-related aspects, and is firmly against unequal and unfair power structures.^[104] India’s engagement with the world through health diplomacy is reflective of how it views the current world order, which is designed to maintain western hegemony.

India’s Engagement with Global Health Diplomacy

Health Security

In terms of security, a concern is India’s lack of a unified national health security framework that considers biosecurity risks.^[105] As states cement biosecurity frameworks into the national security agenda, there is a need to balance bioinformational diplomacy with secrecy to manage the risk of cyberbiosecurity threats from rogue states and non-state actors. This requires dedicated legislation to manage public health emergencies, such as through a Public Health Emergency Management Act^[n] (PHEMA). The legislations that directed India’s response to the COVID-19 pandemic have become outdated. For instance, surveillance measures require integration across different sectors, i.e., serological, genomic, and epidemiological data sources and also requires increased linkage with the private healthcare sector, which contributes to more than 60 percent of India’s healthcare needs.

With the increasing impact of climate change and anthropogenic activities on health, India needs to adopt practical steps to operationalise One Health from a multidisciplinary perspective, accounting for experts in public health, veterinary sciences, social science, and environmental science. Supply chain shocks, delays in technology transfer, and challenges in obtaining emergency regulatory approval necessitate a dedicated public-private partnership (PPP) network with its own funding mechanism to mitigate health threats through the timely supply of medical countermeasures. International cooperation, in particular through regional partnerships such as Quad BioExplore and US-India TRUST initiatives, can contribute to global health security.

Health and Trade

India’s diplomatic efforts centred on health are reflective of its strengths and its domestic demands. For instance, in the case of pharmaceuticals, India exports affordable drugs whilst ensuring that generics are available to its population. During COVID-19, India’s own vaccine diplomacy initiatives were challenged by national export bans owing to its need to cater to its domestic population, constraining supply under COVAX.^[106] Similarly, as a champion of the Global South, India and South Africa jointly filed for a TRIPS waiver to ease countries from certain provisions of the TRIPS agreement.^[107] In the midst of the COVID-19 pandemic, TRIPS became a barrier to access to vaccines and medicines particularly for the Global South. The waiver was widely opposed by the Global North, making the acquisition of affordable vaccines and therapeutics a challenge to large populations.^[108] Ultimately, when the TRIPS waiver was enforced, it was opined that it had no impact on access to vaccines since the demand for vaccines had diminished by then.

India placed GHD at the forefront of its foreign policy by distributing medicines and vaccines, and by providing essential healthcare services to over 150 countries during the pandemic.^[109] India’s Patents Act (1970) and the Patent Rules (2003) enabled the nation to act as a pioneer in exporting high-quality, affordable medicines, notably against cancer, TB, and HIV/AIDS.^[110] Landmark judgements including the granting of compulsory licensing of Bayer’s Nexavar to the Indian generic, Natco Pharma rejection of Gilead’s hepatitis C drug patent application by Indian courts, and the recent rejection of Johnson and Johnson’s evergreening attempt of an anti-TB drug are examples of India’s focus on ensuring equitable healthcare.^[111]

Although India’s prioritisation of public health safeguards has been commendable, political pressure through unilateral mechanisms, such as during the recent Free Trade Agreement (FTAs) between India and the UK, and the India-European Free Trade Association, threaten these endeavours.^[112] Moreover, the modification of India’s Patent Rules in 2024 is likely to threaten the production of affordable generics and its distribution to the Global South, signifying the impact of political pressure on health diplomacy efforts, and marking this as a cause for concern.^[113]

India in Global Health Politics

India played a role in the WHO FCTC negotiations and was a coordinator for Southeast Asian countries.^[114] A number of vector-borne diseases are endemic to India, such as dengue fever and malaria, and zoonotic viruses that cause infection in humans, such as Nipah.  The national healthcare sector has developed robust vector-containment protocols and adopted ‘One Health’ strategies to control public health outbreaks.^[115] Tailoring preventative health measures to vulnerable communities has promoted awareness of the spread of Nipah virus infections, demonstrating how elevating health issues garners attention and proactive mitigation policies.^[116]

India’s humanitarian assistance, supply of generic medicines and vaccines to Africa have been characterised as soft power to further strengthen the bilateral relations between the two regions, and to circumvent China’s extensive engagement in the region under the Health Silk Road.^[117] Additionally, India, through BRICS, G20, and bilateral arrangements has targeted improving SDG-3 (Good Health and Well-being) in LMICs in Africa, Latin America, and Asia (Table 2). Targeted programmes include reducing maternal mortality rates, improving child healthcare services, increased training programmes to medical professionals, and  improving access to medicines and telemedicine services.^[118]

Médecins Sans Frontières (MSF), an international humanitarian organisation, launched a social media campaign with the slogan, ‘Europe! Hands Off Our Medicine,’ in protest of the European Commission’s intent to negotiate with India’s generic medicine production.^[119] The proposed agreement had plans to limit the access of millions of people to affordable generics to combat diseases such as TB. The campaign played a role in dissuading Europe’s negotiations with India on what could have pulled the plug on vital generic medicines reaching millions of people in need.

Health diplomacy requires a consideration of national contexts to determine which policies are appropriate to suit a nation state, and to account for the domestic populations. Booming biotechnology and pharmaceutical industries have ample opportunity to contribute to India’s production of vaccines, therapeutics, and diagnostics. Extensive experience and knowledge in vector-borne diseases and emerging zoonotic diseases place India at a position where it has much to contribute globally, especially with climate change-induced irregularities changing the distribution and incidence patterns of these diseases. India’s federal polity and health being a matter under state and central purview enables states to take part in paradiplomacy where unique expertise in health efforts can be shared with other nations and address SDG-3 (good health and well-being).^[120]

GHD will enable a more nuanced understanding of complex issues and provide strategies to tackle health issues from a global health standpoint. For instance, certain vector-borne diseases pose a greater burden to some states and health efforts have advanced to cater to these needs. These efforts would prove to be a useful soft power tool, particularly in negotiations regarding TRIPS and IP waivers which the EU and North America have been firmly against. Platforms that can facilitate the exchange of ideas to promote health activities would contribute to achieving global health goals. Countries such as the US have established government departments^[o] dedicated to promoting health diplomacy efforts, recognising the complexities involved in GHD.^[121] Given the increasing importance of GHD and India’s strategic role in global health leadership, creating a specialised department for health security and diplomacy could enhance India's targeted endeavours in this area.

Table 2. India’s Key GHD Efforts 

The Way Forward

This paper aimed to provide readers with an overarching perspective of global health and health diplomacy since its inception and the challenges that lay ahead. Global health threats continue to form at the intersection of conflict, economic downturns, climate change, advancement of AI, and technological innovations, necessitating collective action and issue-based strategies under multilateral settings. While the ongoing conflicts in Europe and West Asia have placed a litmus test on the developed world’s contribution to health, issues persist, as evidenced by the recent mpox outbreak in Africa, and the continent’s limited supply of diagnostics and vaccines to address the PHEIC.^[139]

India must continue to maintain its standing in GHD efforts by calibrating its expertise and championing the cause of the developing world. The balancing act carried out by WHO as both a technical body and a political one was exemplified during the COVID-19 pandemic. While it remains the sole organisation that brings states together to deliberate technical aspects of health issues, it relies on political will to enable sovereign states to cooperate. India has expressed the need for reforms within WHO, including defined and clear-cut parameters for the declaration of a PHEIC, and enhanced accountability and transparency in its funding mechanisms.^[140] This serves as a critical juncture where IR scholarship requires integration with global health to ensure the carrying out of GHD outcomes. Analysts can incorporate understandings of the disciplines of IR and global health to further efforts in global health diplomacy.

Endnotes

• Healthcare
• India
• development assistance for health
• global health diplomacy
• global health policy
• global health politics
• global health security
• health diplomacy
• international health
• international health policy
• millennium development goals

The views expressed above belong to the author(s). ORF research and analyses now available on Telegram! Click here to access our curated content — blogs, longforms and interviews.

PREV NEXT