India’s Health Diplomacy as a Soft Power Tool towards Africa: Humanitarian and Geopolitical Analysis

Abstract

India and Africa have been sharing a multidimensional relationship of cooperation and friendship since the ancient civilizations. The COVID-19 pandemic has brought new possibilities and opportunities for India to leverage its soft power diplomacy towards Africa. The paper’s main focus is to analyze how India has made soft power part of its foreign policy and examine India’s relationship with the African continent through health diplomacy. A literature search was done in major databases, such as Web of Science, Medicine/PubMed, Scopus, OVID, and Google Scholar search engine to gather relevant information. Through humanitarian assistance and geopolitical influence, India had won the support and heart of Africans. Besides, India has become a global healthcare provider in the African continent through its global health diplomacy and vaccine diplomacy. India has achieved impressive gains through its soft power diplomacy and has become a compassionate and benevolent actor in the African continent.

Introduction

The world is entrapped in a pandemic cobweb due to the ongoing pandemic COVID-19, which has affected the population across the world. The outbreak of COVID-19 has not only distorted human life, but the economy as well, posing an unprecedented challenge to public health, travel and tourism, hospitality, sports, education, and entertainment, among others. The pandemic has also exposed the fragile and strained global public healthcare systems among several regions, including dramatically impacting the African continent. The health systems in many nations have been trying to keep up with the ongoing COVID-19 issue due to this unprecedented public health emergency. This virus has a high mutation rate, and its massive transmission infects people very quickly, spreading throughout the world. The novel coronavirus outbreak’s common source was ostensibly linked to Wuhan’s wholesale seafood and wet animals’ market. On 30 January 2020, the World Health Organization (WHO) declared the coronavirus pandemic as a Public Health Emergency of International Concern. On 11 March 2020, the WHO Director-General recognized it as a pandemic. As of 1 July 2021, 223 countries had reported 182,319,261 cases with 3,954,324 deaths and 167,936,532 recovered cases (WHO, 2021).

COVID-19 would have long-term effects on geopolitics and the socio-politico-economic conditions of different countries across the world. The geopolitical ramifications of COVID-19 worldwide are turning out to be an emerging reality. As the evolution and ramifications of COVID-19 remain a mystery, several conspiracy theories about China and the United States have surfaced worldwide. The outbreak of COVID-19 created a colossal challenge to the world, and the African continent is a glaring example of the same. Due to the remarkable population density, lack of healthcare facilities, and poor socio-economic conditions, Africa became the epicenter of COVID-19. The African countries are ill-equipped to deal with the problems posed by this rapidly spreading pernicious virus, which has wreaked havoc on health and the economy. Even before the pandemic, the African countries were overtly reliant on other countries for their basic requirements. Therefore, during the COVID-19 pandemic, India has been reaching out to the African nations in various ways to alleviate the suffering of people affected by the COVID-19 pandemic. Over several centuries, India has developed a strong bond of friendship and brotherly ties with the African countries. The foundation of the relations between India and Africa was laid by the magnificent lives and legacy of Gandhi and Mandela. As a long-time partner, India has been collaborating on a variety of developmental, capacity-building, and humanitarian assistance programmes with the African continent. (MEA, GOI, 2020). Did COVID-19 help India to leverage its soft power towards Africa? Is India’s soft power strategy successful in Africa?

The Indian soft power strategy through health diplomacy towards Africa has been viewed from two dimensions, humanitarian and geopolitical perspectives. Indeed, India has been using humanitarian assistance as a diplomatic instrument to build and strengthen India’s bilateral relations with the African countries. In Africa, India took a lead role in providing humanitarian assistance and intensifying its diplomatic relations. A changing geopolitical landscape during the pandemic presents an opportunity for stronger India–Africa collaboration. On the other hand, China’s involvement in the African continent has been growing exponentially. Against this background, the paper also focuses on how the Chinese involvement in the African continent creates challenges for India. The paper examines and analyzes the measures India has taken to counter China.

During the crisis of the COVID-19 pandemic, India employed an African-focused strategy to support the African nations. Health diplomacy is a form of soft power that is being used in the 21st century. India has been engaging in global health diplomacy to build strong diplomatic bonds with the African continent. Besides, the current pandemic has also given an opportunity for India to exercise its global health diplomacy as a soft power similar to a “Good Samaritan” for a humanitarian role. India is stepping up its health diplomacy towards Africa by providing COVID-19 vaccines and humanitarian assistance programs. In the context of the COVID-19 pandemic, India adopted health diplomacy as a soft power tool in its foreign policy and thereby is projected as one of the rising powers with tremendous soft power capabilities and potentialities. This article aims to analyze how India has made soft power diplomacy part of foreign policy. Secondly, the paper examines how India uses health diplomacy for humanitarian and geopolitical interests.

Methodology

A literature search was done in all major databases such as Scopus, Web of Science, OVID, PubMed/MEDLINE, and Google Scholar search engine to identify keywords such as “Soft power” OR “Foreign Policy” OR “Humanitarian” OR “Geopolitical” OR “Diplomacy” OR “Health” AND “India” AND/OR “Africa”. The other information sources included authentic websites and annual reports of government ministries of India and African countries. Some critical information was extracted from the news articles from the Economic Times, the Diplomat, Foreign Policy, and Indian Express and was included for this review. To ensure the quality of the news articles, two authors (BS and VKC) screened and reviewed the articles for their source and authenticity. After removing the duplicates, the relevant articles and sources were then finalized to be included in this review. The main findings were divided into various subthemes and are discussed in detail in the results section.

Results

Soft power: Theoretical foundation

The concept of power has been an important fulcrum in the realm of international relations. The theory of power was developed by Niccolò Machiavelli in The Prince (early 16th century) and Thomas Hobbes in Leviathan (mid-17th century). Machiavelli represents decentralized and strategic thinking about power. Machiavelli’s power illuminates power as a means, not a resource, and seeks strategic advantages, such as the military one between his prince and others. Hobbes represents the causal thinking about power as a hegemony. He had highlighted that power is centralized and focused on sovereignty. After World War II, scholars started taking an understandable interest in power. According to Max Weber, power is described as the possibility that an actor in a social relationship will carry out his will despite resistance. Every scholar differentiates the concept of power in one way or another. The main apostle of power is Robert Dahl (The theory of community power), and other notable authors are Peter Bachrach and Morton Baratz (Two faces of power, 1962), Steven Lukes (Power: A Radical View, 1974), Michel Foucault (power is everywhere because it comes from everywhere), Antony Giddens (power is exercised, created, influences, and limits by human agents), Hannah Arendt (power corresponds to the human ability not just to act, but to act in concert), and John Gaventa (theory of power and powerlessness).

One of the most eloquent proponents of soft power is American political scientist and neoliberal Joseph Nye Jr. According to him, power is the ability to influence others’ behavior to get the outcomes that one wants. Nye differentiates power into two forms: hard and soft power. Hard power is described as an ability to achieve one’s objective through coercive actions or threats, the so-called “carrots and sticks” of international politics. On the other hand, hard power is also known as command power, and it is the oldest form of power. The basic elements of hard power are tangible assets such as military power, economic strength, science and technology, natural resources, and geography. Soft or co-optive power can shape the preferences of others without using force, intimidation, or aggression (Nye, 2008: 95). Joseph Nye conceived and coined the term soft power in his book entitled Bound to Lead: The Changing Nature of American Power.

The basic elements of soft power are intangible assets such as political values, culture, ideology, attractive personality, international institutions, and policies. For soft power, legitimacy is crucial. According to Nye, a country’s soft power stems from three sources: culture, political values, and foreign policies. Culture is the set of practices that give a social meaning, and it has many manifestations. Culture is divided into three levels by Joseph Nye: universal, ethnic, and other cultures owned by people in specific social strata or small organizations. Governmental policies at domestic and international levels are some other potential sources of soft power. The foreign policy, likewise, has significant impacts on soft power. The governmental soft power diplomacy may either strengthen or weaken a country’s foreign policy. Whereas, on the other hand, foreign policy may contribute to a country’s soft power by providing credibility and moral authority. If a policy is based on far-sighted and deeply inclusive national interests, it is more acceptable and gives credibility to its humanitarian and geopolitical interests. Nye stated that it is necessary to use soft and hard powers to enrich integrated strategies, which is called smart power. In other words, smart power combines both the elements of hard and soft power and its combination allows legitimately leveraging maximum results.

Since 1990 the concept of soft power has gained attraction among academicians and politicians. Over a period of time, the concept of soft power attained larger scope. Kurlantzick (2007: 6) has defined soft power as “anything outside of the security and military realm, with not just common culture and public diplomacy, but even more coercive economic and political levers such as assistance and investment as well as involvement in multilateral organizations.” He mentioned that if a country has some considerable soft power potential, it will give legitimacy to foreign action, and others would be more willing to comply with its objectives. According to Wilson, “soft power is the capacity to persuade others to do what one wants” (Wilson, 2008: p. 114). He affirms that soft power is crucial for achieving goals and whereby the world becomes smarter. Geun Lee developed his theoretical framework of soft power as an extension of Nye’s. He incorporated Robert D Putman’s concept of two-level games and introduced his concept of soft power in the name of soft power synergy and soft power dilemma. Soft power, according to Lee, is described as the use of ideational or symbolic resources to shape one’s wishes and desires, resulting in behavioral changes in others.

In the contemporary world, the relevance of soft power is increasing day by day. As Nye has explained in his work Soft Power: The Means to Success in World Politics in the contemporary world, the traditional hard power is not enough to achieve geopolitical, geo-economic, and geostrategic goals. The traditional approach viewed the state as one of the unique actors in the international arena. However, in this globalized world with multilateralism, the other players (non-state actors) gradually emerge and play a crucial role in international relations. According to Nye, the use of hard power in modern times is costly, whereas, on the other hand, soft power is free, does not require substantial resources, and has limited repercussions in case of its failure. Soft power is relevant in three domains. Firstly, in democracy, even in the face of uncertainty, a democratic state will uphold its soft power. The democratic states will not prefer war; rather, they try to use peaceful means and goals. Therefore, democratic countries prefer to use soft power rather than hard power. Secondly, the economically powerful states exert their influence and change the other states’ behaviors through economic assistance, as the economic resources can produce soft power as well as hard power. Thirdly, soft power will help to foster peaceful relations in an international community. As a result, if a country can form international rules representing its interest and values, its actions would seem more valid in other countries’ eyes. Indeed, soft power will help in this situation in an interdependent and globalized world rather than hard power.

Soft power and health diplomacy

With the effects of rapid globalization, international priorities and practices have been changed dramatically. In the ever-changing world order, particularly during the global health emergency, health issues have risen to the forefront. The emerging use of global health diplomacy is based on the world’s growing interconnectedness and the factors which used to influence health issues and concerns. The concept of global health diplomacy (GHD) is characterized by considerable diversity. Kickbusch et al. (2007: 230–232) had defined GHD as multi-level, multi-actor negotiation processes that shape and manage the global policy environment for health. More precisely, Fauci (2007) has defined health diplomacy as “winning the hearts and minds of people in poor countries by exporting medical care, expertise and personnel to help those who need it most”. The GHD can be described as a political change agent that aims to improve global health while also assisting in repairing diplomatic failures, especially in conflict zones and resource-poor countries. Fidler (2001) states that GHD aims to capture “Policy shaping processes in which state, non-state, and other institutional actors negotiate responses to health issues or use health principles or framework in policy shaping and negotiations techniques, to achieve other political, economic, or social goals.” This definition acknowledges the dual nature of the relationship between health and foreign policy and the importance of negotiation in achieving objectives within each policy sphere.

The key objectives of health diplomacy are: (a) enhanced health protection and public health; (b) improved relations between states and a commitment by a wide range of actors to work together to improve health; and (c) achievement of fair outcomes that support the goals of poverty reduction and equity. Four factors have contributed to the ascent of global health diplomacy. Firstly, because of the importance of soft power, nation-states are important instruments for improving bilateral and multilateral relations. Secondly, the realm of health diplomacy is expanding, and many new actors, including WHO, have been shaping the global policy environment in the sphere of health and its social and geopolitical determinants. Thirdly, globalization had accelerated the rise of cooperation between developed and developing countries and heightened the need for GHD, leading to binding and non-binding agreements. Fourthly, the health diplomat’s role in making agreements and negotiations is relevant.

Health diplomacy can be in the form of disease identification, prevention, and responding to health issues and through global health diplomacy providing medical assistance and humanitarian aid during an emergency. Health diplomacy not only offers reciprocal benefits, it rather binds the societies, also giving cooperating countries a forum for leveraging their soft powers to promote their multidimensional interests. In contemporary societies, health challenges have been growing exponentially and can no longer be resolved with hard power alone. The effective use of soft power provides the platform for political negotiations and solutions. International responses to H5N1 (2007), H191 (2009), Ebola (2014), and the COVID-19 pandemic are just a few examples of recent health diplomacy success stories. Despite having divergent goals and motivations, the international community could come together to combat such common challenges. Currently, several countries across the globe have been using health diplomacy as a foreign policy tool, enhancing their influences and promoting multidimensional interests.

Several scholars have already noted the link between health diplomacy and soft power. The analysis of Lee (2010: 3) shows that health diplomacy is used as an opinion-shaping instrument. For instance, Brazil used health diplomacy as a soft power instrument through its national tobacco control program. According to Kickbusch (2011: 342), the term soft power is often used to elaborate health programs that serve as a tool to improve political reputation. Specifically, states use health programs to improve their international position to demonstrate their commitment to ethical issues.

Another relevant example is China exerting its soft power through its growing aid relations with Africa. Cuba, a small developing country, has been using health diplomacy since the 1960s to enhance its international status and gain prestige within the international community (Feinsilver, 2010: 85–104). Recently, many countries, including India, have started playing an integral role in global health assistance, making it an integral part of foreign assistance programs, and its significance is growing exponentially over the years.

Soft power in India’s foreign policy

India had been using soft power diplomacy even before Nye’s concept of soft power in 1990. During the last two decades, India made a dramatic change in its foreign policy from hard power to soft power. It is worth mentioning here that India uses its soft power diplomacy mainly for image building rather than as an instrument to exert influence. India had transformed its soft power into a concrete state policy through its glorious history, culture, political values, civilizational uniqueness, and foreign policy. The three important factors such as history, geography, and capability, have decisively influenced Indian foreign policy. As a democratic country, India has maintained unity in diversity, strengthening the concept of a federal, plural, and secular state, and leverages its soft power potential. It has been upholding the value and political utility of its democracy in its foreign relations, especially while dealing with other countries. Historically, India has been a country with profound soft power potential as it encapsulates the Gandhian ideas (nonviolence or ahimsa, a legacy of the freedom movement) and the Nehruvian concept of non-alignment movement, which is well-acknowledged globally.

Nehru’s non-alignment, the Indira Doctrine, and the Gujral Doctrine were three important phases of the Indian foreign policy since independence, wherein the hard power remained as an important part and parcel of the same. Unequivocally, Nehru and Indira Gandhi had used much more hard power strategies than the soft power approaches. Sardar Vallabhai Patel, B. R. Ambedkar, Veer Savarkar, and Syama Prasad Mookerjee were some other prominent leaders who believed in hard power (Jagannathan, 2019). India’s soft power is captivated by the principle of the Gujral doctrine. This doctrine gives more emphasis to peaceful economic relations with neighboring countries. Since the enunciation of the Gujral doctrine, the Indian government has made several policies and projects to extend the utilization of soft power tools.

In 2014, the Narendra Modi government started using soft power as the main instrument in its foreign policy. Under Prime Minister Modi, India has been using its soft-power potential to enhance its reputation abroad. From 2014 onwards, PM Modi has been using a nuanced combination of three powers, hard power, soft power, and smart power. PM Modi’s soft power is linked to the concept of old Indian ideals such as Vasudhaiva Kutumbakam, in which explicitly the “world is one family.” Soft power and dissemination of the same are visible through policies like the “Neighbourhood First” policy, the “Act East” policy, and the “Connect Central Asia” policy, among others.

The Government of India (GOI) had initiated the campaign for national brands such as Made in India, Swachh Bharath Abhiyan, and Incredible India to promote India’s image in the global community. The GOI has made several initiatives, such as forming a public diplomacy division under the Ministry of External Affairs (MEA), Ministry of Overseas Indian Affairs, to strengthen the links between the diaspora and play a particularly important role in soft power diplomacy. The role of the Indian diaspora has been increased tremendously. The diaspora has become a catalyst in expanding the healthcare sectors in India and their host countries. Although the Indian diaspora has played a catalyst role in strengthening India’s relations with their host countries, their role in health diplomacy is visible overtly or covertly. Concomitantly, Sharma (2013) has argued that the Indian diaspora could play an important role in the expansion and growth of the pharmaceutical industries.

Tharoor (2011: 330–343) has argued that India has become a major power in the world because of its soft power. Tharoor contends that not just through trade, politics, economy, or army, rather the Indian culture has the potential to make our country truly an influential leader in the 21st century. Through soft power diplomacy, India gives active support to the other countries which is convincing and persuading for its intangible standing. The COVID-19 crisis has given India an opportunity to project its soft power and leverage its image and reputation as a neutral, trusted, and credible development partner.

Pandemic and infrastructure paralysis

COVID-19, also known as coronavirus, is a pernicious virus that has created a global public health crisis in the world never witnessed before. The world has been entrapped in a pandemic cobweb due to the ongoing pandemic COVID-19 that created major challenges to the world economy by impacting almost all countries. The first outbreak of coronavirus infection occurred in December 2019 in Wuhan (China), when a cluster of unusual respiratory cases with pneumonia was identified. This heralded the threshold of a novel coronavirus called Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses ( Lai et.al., 2020). On 11 February, the Director-General of the World Health Organization, during the media briefing, announced the name of this disease as COVID-19.

The outbreak of COVID-19 had distorted human life and the economy, presenting an unprecedented challenge to public health and various other industries such as travel, tourism, hospitality, sports, education, and entertainment. According to Antonio Guterres, the Secretary-General of the UN,

the pandemic has exposed long-term fragilities, inequalities, and injustices as the world experienced its worst recession in eight decades with increasing severe poverty and the danger of famine, the social and economic effect of a pandemic is huge and growing.

According to the Global Health Security Index (GHSI) 2019, national health security has been fundamentally fragile across the globe. No country is completely prepared for epidemics/pandemics. Moreover, every country has been facing significant gaps in healthcare facilities to address the current health crisis. Particularly, COVID-19 ostensibly exposed the weaknesses and vulnerabilities of health systems in developed and developing countries.

The outbreak of COVID-19 created a health crisis in the African continent. Even before the pandemic, Africa had been dealing with endemic diseases like malaria, tuberculosis, cholera, and, more recently, emerging diseases like Lassa fever and HIV/AIDS. In response to the pandemic, about 42 African countries imposed full or partial lockdowns (UNECA, 2020). Catastrophic spread of COVID-19 and high mortality in Africa have taken place given the fragile healthcare systems. The high prevalence of respiratory diseases and diabetes in densely packed urban areas is likely to aggravate the continent’s vulnerability and virus lethality. The COVID-19 pandemic has highlighted the fragile health systems of the African continent in general and especially in sub-Saharan Africa. As per the report by the Washington Post (19 April 2020), the continent’s healthcare services are insufficient with inadequate infrastructure, resources, healthcare staff, and overdependence on traditional health workers. As of 18 April 2020, 41 countries had less than 2000 ventilators, and about 10 countries had no ventilators at all (Bearak & Paquette, 2020 April 18).

During the peak of COVID-19, most of the countries in Africa were not in a position to trace, test, and treat the COVID-19 patients, given poor healthcare infrastructures. This argument can be substantiated by taking into account the testing laboratories for testing the COVID-19 patients. South Africa and Senegal have the National Institute for Communicable Diseases and the Pasteur Institute of Dakar, respectively (Mishra, 2020b). Later on, the WHO had assisted several African countries in establishing COVID-19 research laboratories, thereby increasing the number to 44 (WHO Regional Office for Africa, 2020).

Against the above-cited backdrop, most of the African countries have been depending on China and India for medicines and personal protective equipment such as facemasks, face shields, gowns, and goggles. The African countries are excessively reliant on other countries, particularly for pharmaceutical products. About 94% of pharmaceuticals products are imported from several regions and countries such as the EU (51%), India (19%), Switzerland (8%), China (5%), USA (4%), UK(3%), and others (9%) (UNECA, 2020). In Africa, the number of COVID-19 cases has increased exponentially. As of 12 August 2021, the confirmed cases and deaths recorded to the amount of 7,111,780 and 179,801 respectively. South Africa seems to be hit hardest with a substantial number of confirmed cases and deaths amounting to 2,554,240 and deaths 75,774 respectively. (BBC News. (2021, August 11).

As a developing country and the second most populated country, the Indian health sector has also faced several challenges due to inadequate infrastructures and health staff (medical and paramedical). According to the WHO guidelines, the minimum doctor-to-patient ratio is 1:1000. However, India has only 1.1 hospital beds and 0.7 doctors are available per 1,000 people ( The Economic Time 2020). The Indian health sector is inadequate and unprepared to contain and combat COVID-19 due to the shortage of physicians, hospital beds, equipment etc. The GOI has provided a special fund to manufacture essential medical equipment like testing kits and ventilators. The rural areas are not well equipped with medical clinics, supplies, medicines, adequate beds, clean toilets, labour rooms, and imaging centers. About five rounds of lockdowns have been imposed along with the closing of the borders, shops, malls, and schools and prohibition of public gatherings. As of 25 August 2021, India seems to have been hit hardest by the pandemic in Asia, with cases and deaths amounts to 32,512,366 and 435,788 respectively (Worldometers Coronavirus, 2021).

As a pharmaceutical hub, India is one of the players in the global pharmaceuticals industry. India’s pharmaceutical industry is ahead of many nations and has developed its potential to be one of the leading players in the pharmaceutical world due to its relentless focus for nearly six decades. The Indian pharmaceutical industry is one of the important industries, given its size. During 2019–20, the pharmaceutical industry had a value of US$ 37 bn and contributed 1.5% and 3% directly and indirectly respectively to the Indian GDP (Sahay, 2020). India is known as the pharmacy of the world for multiple reasons. More than 3000 pharmaceutical companies have been operating in the country, with more than 10,500 manufacturing facilities (Srividhya, 2020). These pharmaceutical companies have been dominating the international market due to cost-effectiveness. Given these strengths, India is one of the world’s leading producers of low-cost generic drugs and vaccines, contributing about 20% of global demand by volume and 62% of global vaccine demand (Cyril, 2021). India has been exporting quality generic drugs globally, including the highly regulated markets such as the US, Europe, and Japan, and the less regulated markets such as Africa, Latin America, and Association of Southeast Asian Nations (ASEAN) countries (Export-Import Bank of India, 2018). India is the world’s third-largest producer of drugs by volume and the 14th largest producer by value (Sharma, 2020). Indian pharmaceutical companies have been supplying over 80% of the antiretroviral medicines used to treat AIDS across the globe (The Economic Times, 2016, June 9). In 1969, Indian pharmaceutical companies held only a 5% share of the global market, while the global pharma held about 95%. The situation has now changed. By 2020, the Indian pharma contributes nearly 85% whereas the global pharma contributes only 15% of the global demands (Sahay, 2020). Currently, the Indian pharma industry has been one of the most successful industries globally, not only meeting the domestic demands but, to a large extent, also addressing the global demands.

The COVID-19 crisis has provided an opportunity for the Indian pharmaceutical industry to play an even bigger role in global healthcare. Since the coronavirus pandemic outbreak, the country has been at the forefront of providing medicines and generic drugs to other countries. India had provided hydroxychloroquine (HCQ) and paracetamol to 120 countries, and the same was sent to Brazil, the US, and Israel, among others (The Economic Times, 2020). India has spent US$ 16 mn on pharmaceuticals, test kits, and other medical supplies for approximately 90 countries (Pant & Tirkey, 2021). India has developed two COVID-19 vaccines such as Covaxin & Covishield by Bharat Biotech and Serum Institute respectively. India has already provided vaccines to more than 100 countries, including neighbouring countries such as Nepal, Bhutan, Bangladesh, Afghanistan, the Maldives, Latin America, and African countries. (Roy & Shah, 2021).

In the post-outbreak of COVID-19, India faced a shortage of active pharmaceutical ingredients (APIs); our manufacturers were heavily dependent on China. About 70% of APIs were from China, the world’s largest producer and exporter of APIs by volume (Economic Times, 2020b). In the current situation, the Indian government had taken significant measures to reduce the over-dependency on the Chinese market. Besides, the Indian government made many concerted efforts to bolster the pharmaceutical industry. The Modi government’s announcement of Ayushman Bharat (Health Insurance Programme) recently boosted India’s pharmaceutical industry. Prime Minister Modi unveiled the world’s largest health program, known as Pradhan Mantri Arogya Yojana (PM-JAY), on 23 September 2019, part of the Ayushman Bharat (Press Information Bureau, 2021). PM-JAY is the world’s largest health insurance, fully financed by the GOI, providing medical services available to 40% of Indian citizens, including 100 million families at risk of secondary and tertiary care hospitalization in public and private hospitals in the country (Priya and Maiya, 2021). The GOI recently proposed an incentive package of 15,000 crores to introduce the Production Linked Incentive (PLI) scheme wherein manufacturing and exports of pharmaceutical drugs were promoted (Press Information Bureau, 2021: 46–52). In November 2019, the GOI had approved the extension/renewal of the current pharmaceuticals purchasing policy (PPP) (PBI, GOI, 20 November, 2021). The GOI had also launched “Pharma Vision 2020,” a plan to make the country a global pioneer in end-to-end drug manufacturing (Global Business Reports, 2019).

India’s African policy

India and Africa have been sharing multidimensional relationships of cooperation and friendship that date back to ancient civilizations. Humanitarian assistance is the core of Indian moral and cultural ideals, and thereby even the general public supports the GOI’s relief efforts/missions. India provides humanitarian assistance and disaster relief measures to African countries. The African littorals and island nations are prone to natural calamities such as cyclones, floods, tsunami, earthquakes, and droughts. During the Ebola crisis (2014) and the floods (2017), India provided direct humanitarian assistance to Sierra Leone. India has provided humanitarian assistance and disaster reliefs to the Horn of Africa countries such as Kenya, Somalia, and Djibouti that were afflicted by severe famines and droughts in September 2011 through the World Food Programme ( Mishra, 2020a). India became the first country to offer help to the southeast African countries, which were devastated by Cyclone Idai. The cyclone caused massive human and material losses in Mozambique, Zimbabwe, Malawi, South Africa, and Madagascar. India’s Navy rescued hundreds of people, many of them from Buzi Island, which was remote from the mainland (Indian Navy, 2019). On 24 January 2020, the Indian Navy launched Operation Vanilla to provide humanitarian assistance and disaster relief to the affected population of Madagascar after the devastation caused by Cyclone Diane. On 1 February Indian authorities delivered disaster relief materials to Madagascar, including stores, clothing, tents, food, blankets, and medicines (Mishra, 2020a).

The outbreak of COVID-19 has provided an opportunity to demonstrate solidarity with the African countries through its health diplomacy. India has provided a consignment of 1000 metric tonnes of rice and 1,00,000 hydroxychloroquine tablets to Madagascar to deal with the humanitarian crisis triggered by severe drought (Hindustan Times, 2021). On 24 October 2020, the GOI provided 270 tonnes of food aid to Sudan, South Sudan, Djibouti, and Eritrea to relieve the misery of people impacted by the pandemic. The 155 tonnes of wheat flour and 65 tonnes of sugar were transported on the Indian Naval Ship AIRAVAT (MEA, GOI, 2020).

India had provided humanitarian assistance to Africa through the different development cooperation mechanisms. The first measure was the lines of credit (LOCs), under the Department of Economic Affairs (Ministry of Finance) until 2003–2004. However, the GOI had stopped the direct signing of credit agreements with the recipient African countries. The same was disbursed through the Export-Import Bank of India or EXIM Bank. The second mechanism is India’s Technical and Economic Cooperation Programme (ITEC) under the Ministry of External Affairs, GOI.

The African continent has remained the primary recipient of LOCs. The EXIM Bank has financed more than 68% of projects. The African countries have also remained at the forefront of receiving LOCs to construct and upgrade their healthcare infrastructures. The GOI has financed about 211 projects worth US$12.85bn in the form of LOCs (Eighth Report, 2021). However, during the last two decades, only six LOCs in health-related sectors worth US$141.64m have been provided to the African countries. These projects were mainly mandated to improve access to potable water in Sierra Leone, Cambodia, Mozambique, and Niger. It is said that these projects helped reduce water-borne diseases. In 2015, India had approved the LOCs worth US$18m and the previous LOCs of US$50m for the completion of 650 primary health clinics in Zambia. In August 2017, India had provided LOCs worth US$24.5m to improve and reconstruct Senegal’s healthcare system. Besides, India had extended aid of US$59,181 to help the Senegalese Ministry of Health to provide prosthetic limbs to 200 physically challenged people. In the same year, India had provided LOCs worth US$ 71.4m to improve Côte d’Ivoire’s four hospitals. Seychelles has received Indian aid worth US$ 8 mn for the implementation of the Integrated Health Information System. Besides, Zambia and Guinea had received US$ 50 m and US$35m respectively for the construction of prefabricated health posts and improvement of the health system.

Discussion

India’s health diplomacy towards Africa: Pre- and post-pandemic scenario

With the outbreak of COVID-19, vaccines and other health-protective equipment have emerged as the major challenges in general and for developing countries in particular, including the African countries. India has emerged as one of the top vaccine producers and one of the major players actively engaged in pursuing health diplomacy. Given its geopolitical, geo-economic, and geostrategic saliences, African countries have been figuring prominently in Indian foreign policy and its GHD as well. India’s health cooperation and partnership with African countries focused on achieving Universal Health Coverage by improving the primary healthcare facilities. The government, private sectors, and other stakeholders on the part of India have been engaged in the African continent’s healthcare sectors to provide affordable access to quality healthcare facilities. There have also been several large-scale collaborations between the two regions.

Major diseases have affected the lives of African people, obstructing growth and well-being. In its efforts to eradicate diseases, India’s engagements in the African medical sector are significant. India’s engagement with African countries in the health sector has been growing rapidly in the following areas: (a) setting up manufacturing units and healthcare infrastructure in African countries, (b) exporting high-quality, low-cost Indian pharmaceuticals, and (c) providing medical care for all Africans through medical tourism in Indian hospitals.

India has deployed its health diplomacy towards the African countries through various programmes such as Focus Africa Programme, Team-9 Initiative, and Pan Africa e-Network (PAeN). Under the Focus Africa Programme (2002), lifesaving drugs and pharmaceutical products have been exported to Ethiopia, Ghana, Kenya, Mauritius, Nigeria, South Africa, and Tanzania Team-9 (2004) initiatives had focused on the Western region to provide education and training opportunities to transfer the technologies in pharmaceuticals and healthcare. On 26 February 2009, India’s Ministry of External Affairs had PAeN as part of its aid for Africa program. Through PAeN, India has been aiming to share its expertise in tele-education, telemedicine, and ICT services to minimize the challenges of the healthcare sector. At the same time, it also focuses on developing healthcare capacity through continuing medical education lectures in super-specialty courses as per the African Union requirements. As part of the pilot study, Ethiopia Black Lion and Nkempte hospitals have been connected with the Care Hospital (Hyderabad) in July 2007. Following an e-Network, Indian medical institutions were connected with 53 African countries’ medical institutions to improve the healthcare system (James and Apurva, 2019: 31–33). Under this scheme, any doctor from any remote location of Africa can send their patients’ medical records to any super-specialty hospital for live diagnosis and advice. It is said that about 12 Indian super-specialty centers have been connected to 49 patient-end hospitals (out of a total of 53). Currently, many African countries have been seeking telemedicine consultation from Indian super-specialty hospitals. Egypt, Mauritius, the Republic of Congo, Nigeria, Senegal are some of the countries where India has established telemedicine centers along with the five African regional super-specialty hospitals.

Additionally, under the PAeN, the GOI had given an opportunity for African students, physicians, nurses, and paramedical workers to access Indian education and medical expertise (NATHEALTH). Also, India has been pursuing its health diplomacy through various short-term capacity-building programs like the Indian Technical and Economic Cooperation Programme (ITEC). Under the ITEC, the GOI has initiated several health-related programs such as specialized training in healthcare innovations, healthcare infrastructure management and clinical equipment, public healthcare administrative services, telemedicine, medical informatics, and training curriculum in management of cardiac imaging and medicine equipment operations, among others.

HIV/AIDS has remained one of the major public health concerns and one of the critical causes of untimely deaths in several African countries. Therefore, such diseases and conditions have been prioritized and framed in the agenda of Indian health diplomacy while engaging with African countries. When some African countries such as Sierra Leone, Liberia, and the Republic of Guinea were seriously affected by the crises of AIDS and malaria, India offered immediate financial assistance worth US$500,000. Also, India contributed US$10m to the UN Secretary-General’s Ebola Response Multi-Partner Trust Fund and US$2m for the procurement of protective gear to combat Ebola (Beri–, 2011: 3–9). Apart from the above-cited steps, India had also provided medicines and medical equipment to improve the public healthcare system in African countries. In June 2016, India provided 1 tonne of medicines as a grant in aid over the next three years to help it achieve the health targets outlined in its “Harambee Prosperity Plan.” In the same year, Kenya also received about 30 ambulances, tele-cobalt cancer therapy machines, essential Alkaptonuria (AKU) medicines, and line of credit to establish a 100-bed cancer hospital (MEA, GOI, 2016).

India has been pursuing predominantly bilaterally oriented health diplomacy towards the African countries. The Indian pharmaceutical manufacturers have been expanding their strong footholds in the African continent by gaining access to the new markets. On the other hand, the African countries have gained access to much-needed medicines and other healthcare facilities. India has been exporting the branded and generic pharmaceutical products to African countries at much lower prices. Indian companies are mostly investing capitals in countries such as Egypt, Ethiopia, Kenya,Mauritius, Mozambique, Nigeria, South Africa, Tanzania etc. Some companies have even started showing their results in terms of improving the healthcare facilities and accessibilities; for example, Cipla has providing drugs accessibility and affordability of antivirals for the treatment of HIV/AIDS since 2011 in many countries such as Cameroon, Kenya, Lesotho, and Zambia. Ranbaxy Laboratories had introduced Synriam in 2012 as an effective and easy malaria treatment across the entire African continent. The IPCA laboratories have been exporting branded and generic formulations as well as Antiphospholipid Antibody Syndrome (APLs) to 30 countries.Lupin Ltd and J. Chemical and Pharmaceuticals Ltd have been the major generic pharmaceuticals players in South Africa (James and Bhatnagar, 2019: 27–29).

Indian private hospitals have also been engaged in strengthening the African healthcare sector. Since 2003, Apollo Hospitals has been providing consulting services in Ghana and Nigeria. Apollo has also established a 100-bed multi-specialty hospital in Ghana. Currently, medical doctors from 24 African countries have been trained at the Apollo Hospitals. On 13 December 2014, the first-ever eye care camp for Ethiopians was organized by the Indian Embassy in Addis Ababa. Since 2000, Apollo has been providing treatment to 60,000 foreign patients worldwide. India is known for its cost-effective medical treatment and high standards in orthopedics, nephrology, oncology, cardiology, and neuro-surgery. The medical tourists have been coming for medical treatments mainly from Yemen (2.25%); Sudan (1.51%); Kenya (1.12%); Nigeria (1.11%); Tanzania (0.90%); South Africa (0.04%) Ministry of Tourism, GOI. (2021).

In the present scenario against the outbreak of the COVID-19 pandemic, India has played an important role in addressing the demand for pharmaceuticals, diagnostics, and now for vaccines to demonstrate India’s global health diplomacy. In response to the COVID-19 pandemic, India has provided aid to many African countries in general but has given serious attention to the COVID-19 affected countries. India has launched a capacity-building program for healthcare workers of African countries. India has deployed rapid response teams of doctors to assist African countries such as Mauritius and Comoros to combat the COVID-19 pandemic (MEA GOI, 2020). It has been argued that the deployment of medical personnel is perhaps the most visible aspect of India’s health diplomacy strategy, which was further broadened by supplying the COVID-19 essentials. Besides, India has also provided medical equipment and telemedicine support with top Indian institutions such as the All India Institute of Medical Sciences (AIIMS), Raipur and engaged the local African institutions to train the frontline healthcare workers to combat and control the ongoing health crisis. The Ministry of External Affairs (GOI) had organized an e-ITEC course, “COVID-19 pandemic: prevention and management guidelines for healthcare professionals” for the frontline healthcare workers of the African countries. For mapping COVID-19 in rural areas, technical assistance in terms of ArogyaSetu and the E-Gram Swaraj apps have been shared with African countries. India’s defense forces have also played an instrumental role in enhancing health cooperation with African countries. The Indian Naval ship INS Kesari has provided COVID-19 related relief materials to Mauritius, Seychelles, Madagascar, and Comoros as part of the Mission Sagar Initiative (Siddiqui, 2020). The Indian Navy medical teams visited local hospitals in these countries, trained personnel, and assisted in COVID-19 management techniques ( Banerjee, 2020).

India provided medicines to 25 African countries through medical diplomacy and vaccine diplomacy, such as hydroxychloroquine, paracetamol, anti-diabetic, anti-cancer, anti-asthmatic, medicines for cardiovascular ailments, and injections, among others. Under the Vaccine Maitri or Vaccine Friendship Initiative, India has been expanding its health cooperation with African countries, especially during the ongoing pandemic. India’s “Vaccine Maitri” Mission is an ideal combination of soft power and hard power, seamlessly converging into smart power. According to the Ministry of External Affairs (2021), Indian health diplomacy has been fulfilling the geopolitical and geo-economic interests of the country (Annual Report, MEA, 2020–21). Since 20 January 2021, the GOI has provided the Indian-made Covaxin and Covishield to several African countries. Seychelles was the first African country to receive vaccines. During the handover ceremony, the Seychelles Minister of Foreign Affairs and Tourism, Sylvestre Radegonde, said that “gesture cements the ties of solidarity, friendship, and cooperation that exists between our two countries” (African News, 2021). Several countries have received the COVID-19 vaccines from India including: Morocco (7,00,000); Mauritius (200,000); Seychelles (50,000); Egypt (50,000); Algeria (50,000); South Africa (1,0 00,000); Ghana (6,00,000); Congo (1,7 16,000); Angola (6 24,000); Kenya (1,020,000); Lesotho (36,000); Rwanda (200,000) and Senegal (3 24,000) (African News, 2021).

Geopolitical challenges

COVID-19 has been considered a strategic game-changer, not only in terms of healthcare challenges, rather also for the changing global order along with a lot of geopolitical implications. COVID-19 has created opportunities and challenges for the major and medium powers in terms of geopolitical competitions and cooperation. Against this background, India and China have been engaging with African countries through their health diplomacies. China is one of the major players that has heightened its geopolitical and geo-economic influence in the African continent. During the ongoing pandemic, China has given a very important place to the African continent in its health diplomacy. China had dispatched medical protective equipment, masks, ventilators, test kits, protective suits, and sent many medical and paramedical staff to more than 50 African countries to bolster their response to the pandemic. The primary goal of this medical aid is to elevate China’s status as a leading humanitarian aid and public health goods provider to African countries. As mentioned above, China has been expanding its strategic footholds in the African continent and outpacing India in the region by leveraging its global health diplomacy. Though the strategies and tactics of India and China’s health diplomacy differ, both are used to operate in the same region and to compete for expanding their influence in the region. Against this background, China is one of the major competitors vis-à-vis Indian health diplomacy, thereby creating geopolitical challenges for India.

The outbreaks of the pandemic had left t indelible imprints on the international geopolitical landscape. The world order has been emerging in which China has created concerns not only for the major power of the world - the US, rather for the emerging and potential powers as well. In the changing world order, China has pursued GHD in terms of its “Mask Diplomacy,” “Digital Silk Road,” and “Health Silk Road” Diplomacy, in general, and for the African continent in particular. Furthermore, this health diplomacy is a new initiative, a new branch of the Belt and Road Initiative (BRI) in Africa. With its “Mask Diplomacy”, China has provided medical supplies to African countries, which subsequently turned into Wolf Warrior Diplomacy (WWD). Through the WWD, China has been using social media and communication channels to vehemently defend Beijing against the global anti-China narratives. Through the same channels, China has been portraying itself as transparent, accessible, and comprehensive in its response to the pandemic from the beginning of the outbreak of pandemic (The Print, 2020).

Moreover, China has bolstered anti-contagion cooperation with African countries, enhanced joint prevention and control with technological means, and mitigated the effects of the pandemic through the digital economy, actively fostering cooperation in the development of several African countries (NDRC, PRC, 01 June 2020). Since 2015, Beijing has been extending health cooperation to improve public health governance in the African continent. Additionally, COVID-19 has provided an opportunity to launch the Health Silk Road (HSR) initiative globally and for African countries in particular. The BRI partner African countries will be the new incubators for China’s healthcare system and technology. China is using the HSR to boost its image, which has been tarnished due to allegations of its role in COVID-19 origination. The BRI is also helpful in extending China’s engagement in African countries.

In terms of changing geopolitical contours, China’s strategic forays into African countries have been emerging as a major geopolitical challenge for the Indian interests in the region. China’s new initiative Health Silk Road and Digital Silk Road, which are the Belt and Road Initiative offshoots, are considered as ambitious but controversial connectivity programs. India has refused to join these connectivity projects. As a result, India is skeptical and apprehends that China has been taking advantage of the healthcare crisis to begin a new round of soft power offensive in the African continent. To counter the same, India has been expanding its engagements with its South Asian neighbors, the Maritime Silk Road Passes. On the other hand, India has been strengthening the Asia-Africa Growth Corridor.

Conclusion

India can be seen as an emerging soft power with tremendous capabilities and potentialities. India has made soft power a pillar and an effective tool in its foreign policy. The COVID-19 pandemic has presented India with an opportunity to use soft power through health diplomacy and promote itself as a trustworthy and compassionate partner to African countries. Indeed, during the peak of the pandemic, India’s response to the needs of African countries has become even more collaborative and generous. Through its humanitarian aid by sending healthcare equipment, vaccines, and medicines, India has played a significant role in assisting African nations. Besides, by extending the cooperation with medical institutions, providing medical education and the best opportunity and destination for medical tourism, India had won the goodwill of African countries. These actions further strengthened the bonds and have contributed positively to “win–win” engagements. Thus, India has emerged as a responsible and benevolent player in the international arena through its health diplomacy as its soft power, even though many international actors have not reacted adequately and positively during this crisis. On the other hand, though China’s engagements with its growing geopolitical influence are posing difficulties in the region, India has been making the best efforts to contain the Chinese influence to protect and promote its geopolitical interests. Finally, the paper concludes that, in the 21st century, India has great potential and a plethora of chances that can pave the road for it to further enhance its status as a “rising global soft power.”