Significant domestic health challenges for both, says CFR study.
By Sujeet Rajan
NEW YORK: India and China are expanding their health-related assistance to developing countries and contributing more actively to the development of international health rules and norms, as they become stronger donors, yet they account for 33 percent of the global disease burden and face problems in combating infectious disease, says a new study by the Council on Foreign Relations (CFR).
“China and India have unrealized potential in global health governance and need to be encouraged to do more,” writes Yanzhong Huang, a senior fellow for global health at the CFR in a paper titled ‘Enter the Dragon and the Elephant – China’s and India’s Participation in Global Health Governance’. “It is certainly critical to urge them to shoulder greater global health responsibilities, but it is equally important to accommodate their legitimate domestic development concerns while including them in the governance structure as equals.”
Huang, who is also an associate professor and director of the Center for Global Health Studies at the John C. Whitehead School of Diplomacy and International Relations at Seton Hall University, says the rising health challenges and the unsustainability of the existing global health financing model underscore the potential role of newly emerging economies whose share of the global gross domestic product rose from 17 percent in the 1960s to nearly 40 percent today.
Much of this growth belongs to Brazil, Russia, India, China, and South Africa (BRICS), which account for 20 percent of global GDP and 75 percent of foreign exchange reserves worldwide.
Among the emerging powers, China and India have long been critical to successfully addressing global health problems. Historically, infectious diseases that originated in either country have altered epidemiological patterns worldwide. The first known pandemic of cholera began in the Ganges River delta, and many major disease outbreaks, including the 1957 Asian flu, the 1968 Hong Kong flu, and the 2003 SARS epidemic, originated in China.
Both China and India have a long history of providing development assistance for health. China’s health aid can be traced back to the dispatch of medical teams to Algeria half a century ago, points out Huang. India also has dispensed significant resources, donating medicines, diagnostics, ambulances, and other supplies to neighboring countries, and significantly also to countries in Africa.
Growing economic strength in China and India has allowed each to expand its aid program. From 2007 to 2011, China committed $757.1 million in health assistance to Africa, and since 2009, India has committed at least $100 million to bilateral health projects in nearly twenty countries in Africa and South and Southeast Asia.
While both countries are major recipients of foreign aid, China and India are steadily moving away from net recipient status to net donor status. In 2003, India announced that it would continue to accept bilateral assistance from only five countries and the European Union. Between 1967 and 2010, net official development assistance received as a percentage of gross national income (GNI) in India dropped from 2.79 to 0.17, indicating that the shift to net donor status could arrive in a few years.
Similarly, in 2010, China received only $646 million. In 2011, the Global Fund announced that China would no longer be eligible to apply for funding. As a result, the funding China received from international health programs dropped precipitously to approximately $4 million. By the end of 2012, all bilateral programs aimed to support China’s health sector ceased to exist.
Health, development challenges in India, China
Despite robust growth, both countries face significant domestic health and development challenges, says Huang. Combined, they account for 33 percent of the global disease burden, measured by disability-adjusted life year. Both face acute problems in combating infectious disease.
In 2011, India had the world’s largest tuberculosis-infected population, with 1.21 million new cases, while China had 870,000 new cases. India also is home to the third-largest number of individuals with HIV/AIDS, after South Africa and Nigeria. In China, HIV prevalence remains low, but the epidemic is spreading rapidly among high-risk groups, such as sex workers and men who have sex with men, with the potential to move into the general population.
India and China also confront the looming threat of non-communicable diseases (NCDs). Currently, NCDs account for 53 percent of all deaths in India and could rise to 67 percent in 2020. The situation is even worse in China, where 85 percent of deaths are attributed to NCDs. Indeed, China recently surpassed India to become the diabetes capital of the world, and annual incidents of cancer in China have reached 2.6 million – 1.8 million people die of cancer annually. According to a WHO report, from 2005 to 2015, China is going to lose 0.93 percent of its GDP, and India 1.5 percent, as a result of heart disease, stroke, and diabetes.
Other public health challenges are notable. Tobacco use is currently the world’s leading preventable cause of death, and China and India are two of the most affected countries; smoking kills approximately 1.2 million people in China and 900,000 in India every year, 20 percent and 15 percent, respectively, of global smoking-related deaths.
Poverty and malnutrition also present obstacles, particularly in India, where New Delhi’s record is dismal. In a recent speech, Prime Minister Manmohan Singh called India’s 42 percent malnourishment rate “a national shame,” saying India could not hope for a healthy future with such a high percentage of underweight children. Public hygiene standards remain low in the country as well; it is estimated that Indian households account for 59 percent of people worldwide who practice open defecation.
These challenges highlight a fundamental lack of capacity in both countries to provide adequate care for their populations and control potential disease outbreaks, analyses Huang.
According to the World Health Organization, 48 percent of health spending in China is out-of-pocket payment; in India this figure is nearly 70 percent. Poor capacity in turn reduces the incentives to earmark significantly more resources to tackle health challenges in other, poorer states. Despite growing pressures to become full global health donors, China and India continue to focus attention on their domestic development challenges, he argues.
Huang says that although India is at the forefront of promoting generic drugs as an alternative to expensive brand-name medicines, such activity is driven by profit seeking. At the same time, a vast number of Indians still have no access to essential medicines. Despite India’s significant contribution to the global supply of affordable medicines, nearly half of the country’s 2.39 million HIV-infected people do not have access to antiretroviral treatment, says the study.
Furthermore, in the realm of health-system capacity building, both China and India remain conscious of national ownership over their respective projects. India believes in its own ability to handle domestic health programs and does not want to be dependent on international agencies. It has, for example, increasingly taken control over the anti-polio campaign. The government is expected to finance up to 79 percent of the campaign’s costs between 2011 and 2013. For China, there is an even more glaring collision between a state-centric approach and one that incorporates other actors (e.g., NGOs and intergovernmental organizations) in multi-stakeholder arrangements.
Due to the lack of improvement in people’s health and ongoing reliance on international donors, neither China nor India has provided other states a sustainable model for addressing health-care needs, says Huang. A reverse course can now be observed in both countries, where leaders have come to realize that economic growth does not trickle down. Over time, the Indian government became convinced that in order to compete internationally, it would have to ensure the health of its workforce. Equally important, since the mid-2000s, the delivery of public goods and services has become an electoral issue. Federal spending on health has increased dramatically since 2006.
In 2011, the Indian prime minister announced that health would be among the top priorities of the twelfth Five-Year Plan (covering 2012–2017), which includes a commitment to increase health spending to 2.5 percent of GDP by 2017 from the current level of 1.4 percent. The government also recently rolled out its “drugs for all” plan, which aims to provide 52 percent of the population with free drugs by April 2017 and will extend price controls to 348 “essential” drugs, including treatments for cancer and HIV.
Potential for Indo-Sino ties in health cooperation
According to Huang, there is tremendous potential for Indo-Sino ties in global health. For instance, it would be in their interests to work together to support Pakistan’s polio eradication efforts and core response capacity building in Southeast Asian countries, such as Myanmar. They might also consider establishing a working group to explore how to better coordinate their positions, or forge a partnership to promote an “Asian voice” in global health agenda setting and rule making. In the meantime, they could work closely with other emerging states to investigate ways to collaborate with civil society and the private sector to pursue deeper cooperation over impending global health concerns, access to effective anticancer drugs, for example, he says.
Huang says China could learn from India in how to nurture a strong private sector that is amenable to innovative technologies and solutions for health-care delivery. Many of India’s frugal innovations can be scaled up for China.
China could share its experience building a robust disease surveillance and response network to help India deal with its daunting infectious disease challenges.
Huang says if the United States intends to maintain its global health leadership status in the next decade without overcommitting its resources, it will have to actively engage China and India on global health governance.
“It is certainly critical to urge them to shoulder greater global health responsibilities, but it is equally important to accommodate their legitimate domestic development concerns while including them in the governance structure as equals,” says Huang, advocating a larger say for China and India in the global health agenda.