Washington, DC – India has engineered one of the most dramatic economic and developmental transformations in modern history. Since 1991, when a bailout from the International Monetary Fund accelerated government efforts to liberalize the economy, India’s GDP has grown by an average of 6.6 percent per year.1 A quarter-century of growth has lifted hundreds of millions of Indians out of poverty and helped raise the nation’s health status.
India eliminated polio in 2014, a feat that many health experts did not think was possible. The mortality rate among under-fives decreased from 126 per 1,000 live births in 1990 to 49 per 1,000 in 2013,2 while the maternal mortality ratio (MMR) went down from 556 per 100,000 live births to 167 during the same period.3 Successful efforts have been made to stem population growth, a major public health goal since the dawn of independence in 1947. India’s total fertility rate (TFR) was 2.3 per woman in 2013,4 and 11 of India’s 20 states for which data are available had reached a TFR at or below the replacement rate of 2.1.5
India’s economic growth story is compelling and its health gains are significant, but they should not conceal the very great needs of many millions of its citizens. Inequality is the biggest social challenge facing India today, and the process of economic liberalization has widened the country’s wealth gap. Prime Minister Narendra Modi has acknowledged the challenges, describing India as a rich country with poor people.6 Confined to India’s vast rural hinterland and the slums that surround its urban centers, these neglected populations suffer ill health linked to poverty and poor access to quality services.
India’s health burden is complex and varied. While diseases of poverty endure—India has the world’s highest numbers of tuberculosis cases and neonatal deaths—citizens across the social spectrum are being struck down by first-world diseases and the crippling medical costs that come with them. The leading causes of death in India reflect the changing lifestyles that have accompanied the country’s march to lower-middle-income status: Ischemic heart disease, chronic obstructive pulmonary disease, and stroke are all among the nation’s top five killers.7
Successive Indian governments have failed to prioritize the health of their citizens. The public health system is chronically underfunded, and a visit to an average health center offers clear evidence of this neglect: Facilities are poorly equipped and staffed by overstretched, undermotivated medical personnel who leave patients waiting more in hope than in expectation of treatment.
While efforts have been made in recent years to pump resources into the system, particularly at the primary health care level, the legacy of decades of underinvestment, coupled with poor absorptive capacity at all tiers of government, will take a long time to overcome. Most patients have voted with their feet, turning to a sprawling but poorly regulated private health sector or putting their lives in the hands of informal health care providers.
India’s public health system is deficient, but there are many examples of excellence within it. India’s health workforce is large and talented and is the key to elevating India’s health status, provided its most capable personnel can be incentivized to stay in the country in sufficient numbers. India has medical researchers and scientists of world renown. Political leaders in some state governments have devoted significant attention and increased resources to improving health services.
A host of entrepreneurs across India have found unique solutions to health care problems and are finding ways to scale them up. Promising partnerships are being developed between nongovernmental organizations (NGOs) and Indian companies to fill critical health care gaps.
What India lacks is a functioning health system united by a shared health care vision that can bring these talents together and direct them toward a common purpose. India has access to plentiful capital and labor but is short of the technical knowhow needed to strengthen its health system, scale up innovation, and deliver consistent, high-quality, and properly regulated services across the public and private sectors. These are the areas where the United States can be a most helpful partner to India and, in the process, contribute to the strengthening of the bilateral relationship.
India is a strategic partner of critical importance to the United States. During the first of his two official visits to India as president, Barack Obama described the bilateral relationship as “one of the defining partnerships of the 21st century.”8 US-India trade reached $109 billion in 2016, the two countries have forged a close defense partnership, and the flow of people between the two countries is at record levels.9 Health engagement is an important component of the relationship, but most of it takes place outside official government channels, through business collaborations, university partnerships, and the work done by NGOs, philanthropic foundations, and entrepreneurs both at the national and subnational levels.
US official development assistance to India is modest and has been in decline for several years, as India’s ascent to lower-middle-income status caused donors to review their relationships. This transition process is expected to accelerate. Under the Trump administration’s budget plans for Fiscal Year 2018, support for global health programs under the U.S. Agency for International Development (USAID) and the Department of State was to be cut from $35.5 million to $19.6 million and from $18.6 million to $10 million, respectively, compared with FY 2016 levels.10
These budget realities mean that the United States must extract the maximum possible value from its investments in India and focus on addressing mutually beneficial global health interests. Priorities should include:
- Safeguarding progress in tackling communicable diseases like HIV and polio that was possible, in part, through US investments and innovations.
- Supporting India’s ambitious plans to tackle its most deadly infectious disease, TB, which—unless contained—puts the health security of the United States in jeopardy due to the risk posed by multidrug-resistant strains and the fact that India is one of the top five countries from where domestic cases originate.11
- Strengthening programs that pilot and scale up innovations to address priority health issues for India, generating goodwill that ensures the United States continues to enjoy high-level access to senior health officials in the government of India (GoI).
- Maintaining disease surveillance assets and laboratories that can identify emerging diseases of concern to both countries, including pandemic influenza and the Zika virus, and that also provide a platform for the United States to study infectious disease and conduct medical trials.
- Deepening cooperation and technical assistance on drug regulation to ensure that Indian generic medicines distributed domestically and exported to the United States are safe for consumers.
The US government cannot achieve these goals alone. Therefore, it has a critical role to play in facilitating, expanding, and troubleshooting partnerships between the many nongovernmental US partners working in India’s health sector and their host-country counterparts. Enhanced health cooperation is an opportunity for both countries to strengthen their strategic relationship.
 Twenty-five-year average, 1991–2015. See World Bank, “GDP Growth (annual %), India,” http://data.worldbank.org/indicator/NY.GDP.MKTP.KD.ZG?end=2015&locations=IN&name_desc=false&start=1991&view=chart.
 Ministry of Health and Family Welfare, “Situational Analyses: Background to the National Health Policy,” March 2017, 1, http://www.mohfw.nic.in/showfile.php?lid=4276.
 Government of India, National Institution for Transforming India (NITI Aayog), “State Statistics (2011–2013),” http://niti.gov.in/state-statistics.
 Ministry of Health and Family Welfare, “Situational Analyses: Background to the National Health Policy,” March 2017, 2, http://www.mohfw.nic.in/showfile.php?lid=4276.
 Press Trust of India, “PM Narendra Modi calls for ‘long jump’ to push socio-economic transformation,” NDTV, April 17, 2017, http://www.ndtv.com/india-news/pm-narendra-modi-calls-for-long-jump-to-push-socio-economic-transformation-1682217.
 World Health Organization (WHO), “India: WHO Statistical Profile,” January 2015, http://www.who.int/gho/ countries/ind.pdf?ua=1.
 The White House Office of the Press Secretary, “Remarks by the President to the Joint Session of the Indian Parliament in New Delhi, India,” November 8, 2010, https://obamawhitehouse.archives.gov/the-press-office/2010/11/08/remarks-president-joint-session-indian-parliament-new-delhi-india.
 US Embassy Delhi, “Two Years in the Defining Relationship of the 21st Century,” January 20, 2017, https://in.usembassy.gov/wp-content/uploads/sites/71/2017/01/Two-YearUpdateWebsite.pdf.
 US Department of State, “Congressional Budget Justification Fiscal Year 2018, Department of State Foreign Operations, and Related Programs,” May 23, 2017, 221–27, https://www.state.gov/documents/organization/271013.pdf.
 In May 2015, an Indian woman visiting the United States sparked a health alert after she fell seriously ill with extensively drug-resistant TB (XDR-TB), prompting efforts across three states to trace everyone with whom she had come into contact. See Denise Grady, “Indian Woman Being Treated in US for Drug-Resistant Tuberculosis,” New York Times, June 9, 2015, https://www.nytimes.com/2015/06/10/health/indian-woman-being-treated-in-us-for-drug-resistant-tuberculosis.html.