With the increasing crisis and challenges to human security, challenging the basic nature of life of people, governments and international institutions have started seeking methods to redefine international politics and foreign policy making. However, the challenges have been multifaceted, which has scarred every sphere of human life. The challenges to human rights and life unfolding daily in the Middle East, which is spreading fast in the entire region demands bold new initiatives. The concept of security has shifted, moving away from a macro focus solely on the security of nations and other large entities to also include a micro-level focus on the security of individuals and communities, in which securing the standard of health and protecting life has been one of the primary concerns. In the recent years, health has been adapted as a strategic foreign policy and diplomatic concern for many countries and regions of the world.1
However, such shift is not a new phenomenon. For example, the Red Cross doctrine of the 1860s clearly states the security of the people, and those elements of the doctrine were institutionalised in the UN Charter of the 1940s as the Universal Declaration of Human Rights and the Geneva Conventions.2 The Foreign Policy and Global Health Initiative, launched by the foreign ministers of Brazil, France, Indonesia, Norway, Senegal, South Africa and Thailand in 2006 and articulated in the Oslo Ministerial Declaration in 2007, is one of the most well-known efforts to integrate health issues into foreign policy, making health a determinant in diplomatic parlance. In the declaration it was stated:
We believe that health is one of the most important, yet still broadly neglected, long-term foreign policy issues of our time...We believe that health as a foreign policy issue needs a stronger strategic focus on the international agenda. We have therefore agreed to make ‘impact on health’ a point of departure and a defining lens that each of our countries will use to examine key elements of foreign policy and development strategies, and to engage in a dialogue on how to deal with policy options from this perspective.3
A definition for global health diplomacy has been much discussed and debated. Definitions range from normative, “an emerging field that addresses the dual goals of improving global health and bettering international relations”4, or “winning hearts and minds of people in poor countries by exporting medical care, expertise and personnel to help those who need it most”5 to a more technical, “multi–level, multi–actor negotiation processes that shape and manage the global policy environment for health”.6
In particular, Fidler and Nick Drager stated that it is the increasing frequency of crisis situations with profound health impacts and high economic costs which involves immunisation against major diseases along with providing proper food and drinkable water and health facilities to conflict and remote and less developed areas, along with meeting the challenge of countering diseases that travels beyond borders, such as polio, anthrax, SARS, HIV/AIDS and pandemic flu that have made health a key pillar of the foreign policy agenda. They argue that health problems that do not have the uncertainty of a potentially catastrophic event, such as non-communicable diseases, neglected tropical diseases, road traffic injuries, mental health, and maternal and child health do not pose any immediate danger to non-affected states and give no incentives for foreign policy action. Foreign policy attention is thus largely given to issues that reflect interdependence since governments seek collective action for self-protection. Fidler further observes with Lawrence Gostin that “the biosecurity threats present in our globalized world actually make self-help the most attractive and effective strategy for powerful states”.7 Andrew Price-Smith concurs with Fidler that interdependence between states resulting from the processes of globalization has pushed developed countries to become interested in the health situation in developing countries.8 Price-Smith explains health’s increased importance in foreign affairs as directly linked to the security implications of contemporary health threats. He draws particular attention to the effects of infectious diseases on destabilization of states and the ensuing terrorism, criminal activity and illicit trade which have harmful effects on the global scale.9 Large scale immigration, failure of state machineries and regional conflicts also pose a major challenge to health care. Health is on the radar of foreign policy because it has become integral to three global agendas:
- Security — driven by the fear of global pandemics or the intentional spread of pathogens and an increase in humanitarian conflicts, natural disasters, and emergencies;
- Economic — concerned not only with the economic effect of poor health on development or of pandemic outbreaks on the global market place but also the gain from the growing global market in health goods and services;
- Social justice — reinforcing health as a social value and human right, supporting the United Nations millennium development goals, advocating for access to medicines and primary health care, and calling for high income countries to invest in a broad range of global health initiatives.10
Intellectual property is one of the vital facets that face health practitioners and one of the main issues where health and foreign policy intersect. It is also the area where health concerns have been most successfully integrated into economic policymaking.
The concept of “medical diplomacy” was introduced as early as 1978 by Peter Bourne, special assistant to the president for health issues during the Carter administration, USA. According to GHS Initiative in Health Diplomacy, UCSF (2008), “Health Diplomacy occupies the interface between international health assistance and international political relations. It may be defined as a political change agent that meets the dual goals of improving global health while helping repair failures in diplomacy, particularly in conflict areas and resource-poor countries.”11 More recently, the July 2011 BRICS (Brazil, Russia, India, China, and South Africa) health ministers meeting was held in Beijing with the theme of “Global Health — Access to Medicine”, where ministers pledged to work together to implement health reforms and share the successes and challenges of experiences.
“In the past” — said Robert Cooper, “it was enough for a nation to look after itself. Today it is no longer sufficient.”12 This is particularly true in the health arena. There is an increasing range of health issues that transcend national boundaries and require action on the global forces that determine the health of people. The broad political, social and economic implications of health issues have brought more diplomats into the health arena and more public health experts into the world of diplomacy.13
India and Health Diplomacy
Being a recent arena of diplomacy, Indian diplomats and foreign policy practitioners have started growing an understanding and developing India’s diplomatic initiatives in the health sector. Most of the global health initiatives originate in the United Nations and under the aegis of the World Health Organisation (WHO). Many countries have added a full-time health attaché to their diplomatic staff in recognition of the importance and complexity of global health deliberations; others, along with India, have added diplomats to the staff of international health departments. Their common challenge is to navigate a complex system in which issues in domestic and foreign policy intertwine the lines of power and constantly influence change, and where increasingly rapid decisions and skillful negotiations are required in the face of outbreaks of disease, security threats or other issues.
New global health problems include infectious diseases, non-communicable diseases (NCDs), bioterrorism and dual-use research, health-system strengthening, and critical social determinants of health, such as food security. These health threats have led to the emergence of new actors, processes, and institutions seeking to mitigate their effects.
Although progress has been made in disease prevention and control, as well as in health-system strengthening, more still needs to be done to continue the fight against HIV/AIDS, manage biosecurity issues and acute pandemics, and ensure effective and sustainable global health financing. Financing is a particular worry during times of austerity.14 With the dynamism brought into foreign policy decision making in India, health is turning into a major fulcrum which will be playing a major determinant in building relations between nations. India has started playing an integral role in global health assistance, making it an integral part of India’s foreign assistance program and its significance is growing exponentially over the years. Indian policymakers believe the scope of the country’s health assistance program will continue to expand and hopeful of exploring opportunities for country’s private health sector and civil society in health assistance initiatives. Health assistance can be traced through infrastructure, human resources, education and capacity building. Health assistance can typically be seen in the form of bilateral health assistance, Health IT and Pharma etc. Since 2009, India has committed at least US$100 million to bilateral health projects in nearly 20 countries in south Asia, southeast Asia and Africa. India’s Health IT could develop the Pan-Africa Telemedicine and Tele-Education Network, where hospitals and universities throughout Western Africa are being linked with counterparts in India to facilitate sharing best medical practices.15
The foreign policy and policymakers in India are committed to strengthening cooperation and sharing of experiences in public health sector. India uses foreign assistance as diplomatic tool for foreign trade and investment; and sustained cooperation to many developing and under-developed nations including Africa. India strongly believes in the concept of south-south cooperation and critical about western donor-aid concept. Indian foreign assistance typically includes technical cooperation, grants, and contributions to international organizations, soft loans, and Export-Import (EXIM) Bank lines of credit with subsidized interest rates.16
However, the role of India in healthcare should be explored for universal health coverage. India’s engagement in global health diplomacy needs to be formulated and implemented not only to generate revenue but also to have an increased global political engagement. India cannot wait for a pandemic to occur, like (SARS, CHAGAS, EBOLA and ZICA) to reexamine and develop a comprehensive foreign policy which strongly encompasses the principle of health security.
There is a need to build capacity for global health diplomacy by training public health professionals and diplomats respectively. Two types of imbalance need to be addressed as a priority: imbalances that can emerge between foreign policy and public health experts, and imbalances that exist in the negotiating power and capacity between developed and developing countries. The linking of health and foreign policy has revealed substantive tensions between the two fields. At their most fundamental level, public health and foreign policy communities differ in their ideologies, functions, audiences and obligations, as well as approaches to solving problems.17Yet despite these differences, health issues have featured in foreign policy circles with increasing frequency.
Economically, sustaining health prominently in foreign policy is becoming more difficult because the international economic context and domestic fiscal crises adversely affect governments, societies, international organizations and non-state actors. In many ways, the life-blood of the rise of health within foreign policy has been the massively increased funding for global health, which went from $5.59 billion in 1990 to $21.79 billion in 2007.18 In epidemiological terms, foreign policy action will become harder because, as noted above, political and economic capital for existing efforts (e.g. HIV/AIDS) – widely recognized as inadequate – will be more scarce, forcing tough decisions about how to prioritize available political commitment and economic resources.19 Especially for a country like India, which is geo-strategically located in a neighbourhood, which has polio on the rise, affected by massive natural calamities on a yearly basis, suffering from malnutrition and lack of proper governance in tackling such major health challenges.
There is a large reservoir of highly trained experts and scientists in knowledge based industries, such as, information technology, science, research and development etc. They can play an important part in developing India as a Research & Development centre. The overseas Indians have distinguished themselves in the field of medicine and healthcare in the countries of their residence. They can play an important role in secondary and tertiary healthcare in India. The Diaspora can also help in promoting India as healthcare destination. They can effectively contribute in the expansion and growth of pharmaceutical industry.20 The faster Indian foreign policy institutions adapt using as an integral element in their decision making apparatus, it would not only register as an altruistic behaviour of the state machinery, but a strategic move to bring regional and sub regional integration, along with creating a global forum to having an integrative mechanism to be responsive not only during times of exigency but to be apt in adapting with the changing global health necessities. While upholding the international standards of health, and maintaining the solemn path of sticking to serving to the maximum number of masses in need of being provided health security, one can take the assistance of “policy entrepreneurs” within governments which function not only in the sphere of being public health officials, but as health ambassadors for the country, which would provide a definitive direction for having a national health policy that would be strengthened by the nation’s foreign policy approach.
1 Fidler, D., (2005), Health and foreign policy: a conceptual overview. London: The Nuffield Trust; Fidler, D., 2006. Health as foreign policy: harnessing globalization for health. Health Promotion International, 21(Supplement 1): 51-58; Kickbusch, I., 2008. Moving Global Health Governance Forward. In: K. Buse, W. Hein and N. Drager, eds. Making Sense of Global Health Governance: A Policy Perspective. Basingstoke: Palgrave Macmillan, 320-339.
2 Paula Gutlove and Gordon Thompson, (2003), “Human Security: Expanding the Scope of Public Health,” in Medicine, Conflict & Survival, 19, pp. 17-34.
3 Amorim, C., Douste-Blazy, P., Wirayuda, H., Støre, J.G., Gadio, C.T., Dlamini-Zuma, N., and Pibulsonggram, N., (2007), Oslo Ministerial Declaration—global health: a pressing foreign policy issue of our time. The Lancet, 369 (9570): 1373-1378
4 Adams, V. (2008), Global health diplomacy. Medical Anthropology, 27(4), pp. 315-323
5 Fauci, A. (2007). The expanding global health agenda: A welcome development. National Medicine, 13, 1169-1171
6 Kickbusch, I., et al. (2008), Global health diplomacy: The need for new perspectives, strategic approaches and skills in global health. Geneva: World Health Organization, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636243/
7 World Health Organisation, (2009), Global Health and Foreign Policy: Strategic Opportunities and Challenges. Background Paper for the Secretary-General’s Report on Global Health and Foreign Policy. Geneva: WHO
8 Gostin, L. and Fidler, D., (2006), Biosecurity under the Rule of Law. Case Western Reserve Journal of International Law, 38: 437-478; Price-Smith, A., 2009. Contagion and chaos: disease, ecology, and national security in the era of globalization. Cambridge, Mass.: The MIT Press.
9 Price-Smith, A., (2002), The health of nations: infectious disease, environmental change, and their effects on national security and development. Cambridge, Mass.: The MIT Press
10 Ilona Kickbusch, “Global health diplomacy: how foreign policy can influence health”, The British Medical Journal, 2011;342:d3154 doi: 10.1136/bmj.d3154, http://graduateinstitute.ch/files/live/sites/iheid/files/sites/globalhealth/shared/1894/Publications/global%20health%20diplomacy_how%20foreign%20policy%20can %20influence%20health_bmj.d3154.full.pdf
11 UCSF Global Health Sciences, “GHS Initiative in Health Diplomacy.”, http://globalhealthsciences.ucsf.edu/programs/Diplomacy.aspx
12 Cooper R., (2003), The breaking of nations. Order and chaos in the 21st century. New York: Atlantic Monthly Press;
13 Ilona Kickbusch, Gaudenz Silberschmidt, and Paulo Buss, (2007), “Global health diplomacy: the need for new perspectives, strategic approaches and skills in global health”, Bulletin of the WHO; 85(3): 230–232
14 Yanzhong Huang, (2013), “Enter the Dragon and the Elephant: China’s and India’s Participation in Global Health Governance”, Council on Foreign Relations: International Institutions and Global Governance Program, Working Paper, (2013), pp. 3-4, https://assets.documentcloud.org/documents/682681/enter-the-dragon-and-the-elephant.pdf
15 Raghavendra Madhu and Srikanth Reddy, (2014) “An Opportune time for India to play the Global Health Diplomacy Card”, Global Policy, September 22, http://www.globalpolicyjournal.com/blog/22/09/2014/opportune-time-india-play-global-health-diplomacy-card
16 Raghavendra Madhu and Srikanth Reddy, (2014), “An Opportune time for India to play the Global Health Diplomacy Card”, Global Policy, http://www.globalpolicyjournal.com/blog/22/09/2014/opportune-time-india-play-global-health-diplomacy-card
17 Feldbaum, H., Patel, P., Sondorp, E., and Lee, K., (2006), Global health and national security: the need for critical engagement. Medicine, conflict, and survival, 22 (3): 192-198.
18 Institute for Health Metrics and Evaluation, Financing Global Health: Development Assistance and Country Spending in Uncertainty (Seattle: Institute for Health Metrics and Evaluation, 2010), p. 15
19 David P. Fidler, “Assessing the Foreign Policy and Global Health Initiative: The Meaning of the Oslo Process”, Briefing Paper, Chatham House, (2011), GH BP 2011/01, p. 14, https://www.chathamhouse.org/sites/files/chathamhouse/0611bp_fidler.pdf
20 J. C. Sharma, (2013), “India’s Foreign Policy, National Security & Development”, Distinguished Lectures, Ministry of External Affairs, http://www.mea.gov.in/foreign-policy.htm
(Dr. Shantesh Kumar Singh is currently working as a Postdoctoral Fellow at the International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia and he also holds a regular faculty position in the Department of Political Science at Shaheed Bhagat Singh College, University of Delhi, Delhi, India.)
(This article is carried in the print edition of September-October 2017 issue of India Foundation Journal.)