By Oommen C. Kurian
The following commentary is part of a series – “Agenda 2021: A Blueprint for U.S.-Europe-India Cooperation” – co-produced with the German Marshall Fund as part of the India Trilateral Forum initiative
The coronavirus pandemic has brought into focus weaknesses within national healthcare-delivery systems and amplified some of them. It has also highlighted the blind spots within multilateral institutions and global structures, reaffirming the validity of the call for reform of international organizations. The pandemic has also brought to the fore the intricate interdependencies that exist within the international health system.
China, the epicenter of the global outbreak, currently is the world’s largest supplier of active pharmaceutical ingredients. India is a leading exporter of generic drugs across the world—for example, it is estimated that it supplies up to 50 percent of the United States’ generic drug needs—yet it also depends on China for more than two-thirds of its bulk drug needs. Vulnerabilities caused by the pandemic have caused disruptions across global supply chains. As the global powers use the crisis as an opportunity to reassess their dependencies and plan for the future, one outcome has been that health policy has shifted to the heart of the discourse around national security and of global diplomacy.
India’s strong private sector in pharmaceutical manufacturing has been working closely with its counterparts in the United States, the United Kingdom, Belgium, Sweden, and other countries, to develop affordable vaccines and medicines to control the pandemic. The success of the global COVAX facility is heavily dependent on India’s vaccine manufacturing capacity—the interim distribution forecast released in February states that 240 million of the 337.2 million doses to be distributed in the first half of the year are to be produced by India’s Serum Institute. India also has largely bilateral research and development collaborations with many European and North American countries.
In addition, India is invested in the movement to reform global institutions, triggered in part by the pandemic’s challenges. For example, in order to build a new global partnership with reformed and effective multilateralism, it has offered recommendations to reform the World Health Organization (WHO), including with regard to funding, accountability, response capabilities, governance structures, and pandemic management.
Challenges to reform in such institutions stem from the embedded inequities in the global system and from differentiated strategic interests. There are times when clear conflicts in interests come into play, like when India and South Africa jointly called for the World Trade Organization (WTO) to suspend intellectual property rights related to the coronavirus until the world achieved herd immunity, so as to ensure that poorer countries can access and afford the vaccines, medicines, and other medical technologies to fight the pandemic.
These battles are playing out in a context where mass coronavirus vaccination is likely to be slow and limited by intellectual property, narrow national strategic considerations demonstrated by vaccine nationalism, prohibitive costs, and fiscal as well as other constraints. Experts have argued that a focus on financing universal health coverage should be a central theme in the reimagining global-health governance and policies. However, even among major UN agencies, there is consensus that the international architecture is not well equipped to address current health challenges, with no sustained revenue for common health goods.
Given this complex state of affairs, what a global health system should strive toward is a situation of pooled resilience against common threats like pandemics, where all partners gain from cooperation. That many poorer countries subsidize the health systems of richer ones is a fact—whether it is through export of skilled medical workforce or cheaper generic medicines, even as health-workforce shortages and lack of access to medicines remain domestic concerns. Formalizing such flows into cross-border investments that improve the status quo and offer a win-win to all parties should be promoted.
For example, U.S. investments in India to improve its pharmaceutical regulatory system would offer maximum returns given the enormous financial pressures that the pandemic has put on the U.S. healthcare system and the need to depend more on generic medications in the foreseeable future. Similarly, a possible collaboration between the United Kingdom and Nigeria and other major source countries for their health human power with direct investments to improve medical education infrastructure could be considered. Lessons can be learned from the massive expansion of medical education that India has undertaken in a public-private-partnership mode.
Rather than the current models of externalization of domestic regulation and calls for ethical recruitment—both having had very limited success in ensuring quality of drug production and equity in the supply of health workers—new strategies based on positive externalities will benefit all parties. In addition, serious thought is needed about innovative models of dual, multiple, and global citizenship to create a pool of “global health-keeping forces” along the lines of the UN peacekeeping forces, to be readily accessible to any crisis-hit country. This would be a precious resource when a pandemic hits different countries following different trajectories and peaking at different times.
In the recent past, because of strategic concerns and the need felt by global powers to make supply chains less dependent on China, many new initiatives like the Quad Plus or D-10 indicate a movement away from predominantly Western groupings and a fresh wave of inclusion. It is only natural that a major disruptive event like the coronavirus pandemic will guide their focus toward global health security, either directly or indirectly. The attention to ways of containing China’s ascendence in these initiatives may relegate global health concerns to only an instrumental role, with any possible gains being purely incidental.
Any real progress will need sustained momentum and real country-level action, which looks possible more through reform of established multilateral institutions and global structures like the WHO and the WTO than through their replacement with parallel structures with ambitious global health objectives. The emerging multilateral structures and issue-based coalitions can use their collective heft to catalyze the process of change within traditional global institutions around issues of global health, and to push them toward course correction when needed.
Oommen C. Kurian is senior fellow and head of the Health Initiative at the Observer Research Foundation, a leading Indian think tank. He studies India’s health sector reforms within the broad context of the Sustainable Development Goals, with a focus on financing and governance structures.