The health leadership opportunity for India

United States (US) President Donald Trump’s executive order on the inaugural day of his second term, withdrawing the US from the World Health Organization (WHO), was not unexpected. But the proposed speed at which this will be implemented, without the normal one-year transition period, is alarming. The US is, by far, the single-largest contributor to WHO, paying nearly a fifth of WHO’s expenses. In comparison, India’s contribution is only a tenth of the US contribution, much of it going to traditional medicine and digital health. Beyond the financial implications, curtailing the flow of trained US experts, who are critical to many of WHO’s programmes, will harm global health.

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American expertise has been at the forefront of many global initiatives, including smallpox and polio eradication efforts, childhood immunisation, newborn and maternal survival, and pandemic preparedness, and this will be difficult to replace quickly. Since the US typically pays in arrears, WHO could be hard-pressed to pay its salaries and expenses in the short-term, which would create extreme chaos at a time when global health challenges like drug-resistant infections and pandemic threats, compounded by the human-induced climate crisis, are on the rise.

Even the most ardent supporters of the WHO would agree that the organisation needs serious reform. WHO today is archaic and highly bureaucratic. Its location in Geneva vastly increases WHO’s operating expenses, and is more advantageous to the Swiss and other Europeans than it is to global health. WHO is a membership-driven organisation. That means that the head of WHO is elected by the health ministers of all 194 member-States, unlike the heads of other UN agencies who are typically appointed by the UN Secretary General. This leaves WHO exposed to politics and agendas that are unrelated to health. Although there are many competent WHO staff, the organisation also carries a significant amount of deadweight, and the quality of its output has been declining in recent years. Moreover, since most of its funding comes not just from designated contributions from member countries based on their size and income level but also from specific project-level funding, WHO staff naturally tend to focus on the priorities of those who pay for these projects.

WHO is clearly in need of reform, and one can expect that the WHO leadership will be more receptive to new ideas when the organisation is under threat than it has been in the past. With the withdrawal of the US, the situation presents an opportunity for India to take leadership by engaging broadly and deeply with WHO, for three reasons.

First, it can frame the agenda for reforming WHO. The opportunity to show leadership on the world stage in a consequential UN organisation would help make India’s case for broader responsibilities within the UN system, including on the Security Council.

Second, engaging with WHO on multiple fronts, including on vaccines, improvements in child survival, digital health, and pharmaceutical manufacturing — something that India has done well — gives the country the opportunity to enhance its soft power and influence in many parts of Africa and some in Asia that depend on WHO to guide their national health priorities and operations. Many expect China to fill these roles, but for reasons of shared language, historical links through immigration and trade, and relationships of trust, India is far better positioned to fill the gap.

Third, Indian engagement at WHO would benefit the health of our citizens, who now make up the largest population in the world. The experience and expertise we could gain from being part of a global enterprise could only enhance the quality of public health leadership within the country. A prime example is the current director-general of the Indian Council for Medical Research, who spent decades at WHO leading work on child survival before returning to India with that global experience and skillset.

India’s initial contributions can be in kind. Sending experts on secondment to WHO to fill key gaps left by the US withdrawal could be done relatively quickly and inexpensively. In addition, to claim senior leadership roles, India will have to increase its through voluntary contributions, but the cost is a small fraction of the tremendous benefits to be gained. These benefits would extend to the opportunity for a more robust innovation and research ecosystem within the country for biomedical sciences and public health. As borders in high-income countries close, India could well be a more attractive educational and training destination in these fields.

The US withdrawal provides an opening for India to lead on health, an important issue of concern to the world’s population. Whether and how we take that opportunity or leave it to other countries remains to be seen.

Ramanan Laxminarayan is a senior research scholar at Princeton University and president of the One Health Trust. The views expressed are personal