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After aid: the NHS can also learn from India and China

BMJ 2013; 346 doi: (Published 30 January 2013) Cite this as: BMJ 2013;346:f601
  1. Mala Rao, professor of international health, Institute for Health and Human Development, University of East London, Stratford Campus, Water Lane, London E15 4LZ
  1. m.rao{at}

A recent debate in the BMJ asked whether rich countries should stop sending development aid to India.1 It was published soon after the announcement that all financial aid from the United Kingdom to India will end in 2015.2 This debate is set against a backdrop of a changing world order, from which there will be no turning back. Relationships between the UK and India and the UK and China have matured into partnerships of equals, creating new opportunities for mutual learning and benefit. What may have shaped these changing relationships, and what gains can the three countries anticipate?

The Indian government acknowledges that its own development budget has grown considerably, but it would still value technical support to build the skills and capacity that are essential for social and economic transformation. The outcome of this is that after 2015 the partnership with the UK will focus on programmes where skills and expertise are shared across governments on priorities such as growth, trade, investment, education, skills, and health.2

Learning from China

China’s transformed economic and political status led to the UK closing its bilateral aid programme in 2011.3 Instead, the UK Department for International Development launched the UK-China Global Development Partnership Programme (GDPP) to foster collaboration in areas including the reduction of poverty and achievement of the millennium development goals globally. The programme will build on lessons from China’s unparalleled success in decreasing infant, child, and maternal mortality rates and from China’s recent reforms of its health sector. So the nature of “aid” from the UK to India and China is rapidly evolving into one of technical partnerships, with leaders in disciplines such as science and policy working together, and is intended to benefit the rest of the world as well as all three countries.

Despite the changing world order, compelling arguments exist for fostering these partnerships. Improving global health is vital to the UK’s domestic and international interests.4 The health of the UK population is closely tied to global health, which is determined by factors not confined to national boundaries, such as migration, trade, conflicts, and climate change. The case for the UK to improve national security by helping India and China strengthen their disease control systems, as well as those of other countries, is no more powerfully demonstrated than by the global spread of severe acute respiratory distress syndrome (SARS) in 2003, which originated in Hong Kong and Vietnam.4 Tackling large problems requires global cooperation, and the UK’s best chance of success is through partnership with the two most powerful emerging economies.

Trade is vital to the UK’s economy and is greatly influenced by global interdependence.5 China and India are home to 36% of the world’s population, and their economies continue to grow during the global downturn. China’s 12th five year plan has prioritised improvements in healthcare, social welfare, and education.5 In India too, an increase of public expenditure on health from 1.4% of gross domestic product currently to 2.5% is anticipated by 2017, giving an unprecedented opportunity to work towards universal access to quality healthcare.6

Universal access to healthcare

The principle of universal access that underpins the UK NHS, as well as its efficiency and effectiveness, driven by its institutions such as the National Institute for Health and Clinical Excellence, generate admiration and interest in other countries, keen to explore the adaptability of NHS practices to their systems. Indeed, the Indian government and health professionals responded positively to an analysis of mutual benefits that might accrue from a UK-India primary care collaboration.7 8 NHS institutions, such as the low tech general practice surgery, which cater for most health needs of the population,7 give the UK a competitive edge over many other countries in terms of knowledge it can potentially share. UK funding to support technical cooperation and the opportunity for professional staff to work and learn together must be continued.

Many aspects of the NHS are inspirational, but it also has much scope for improvement. Challenges range from the need to tackle the social determinants of health to variations in care and controlling health expenditure. India and China face similar challenges but, unfettered by the constraints of powerful established systems, they have been highly innovative in, for example, implementing women’s economic empowerment as a means to improve healthcare in poorer communities9 and applying principles of industrial engineering to healthcare solutions that combine high service volume and quality at low cost.10 Disappointingly, the prevailing assumption that learning is unidirectional, with richer countries imparting knowledge to the poorer ones, has resulted in little systematic effort in the NHS to explore what it could learn from the developing world. The challenge of cost containment alone means that such attitudes must change. The move to partnerships creates substantially greater opportunities for the NHS to learn from innovation in India and China.

UK collaboration with India and China

Health collaboration is a powerful agent for good in foreign policy, trade, and investment.4 Trade in health services, drugs, and medical devices contributes substantially to the UK and global economies, and there is much that the UK can gain from partnering India and China for a stronger, fairer, more ethical trade in healthcare. India has the major strategic advantage of a world leading generic drug industry, with benefits to many including the NHS.7 Indian technology and diagnostic companies have the expertise and potential to leapfrog the UK in developing affordable technologies.

India continues to have a considerable burden of ill health and malnutrition, a point highlighted by Agarwal in her proposition for continued aid.1 11 Twenty million children globally have severe acute malnutrition and are 10 times more likely to die than those without it. India is home to nine million of them. Linked to poverty and malnutrition is the heavy burden of neglected tropical diseases12 prevalent among the most marginalised populations in India. A strong moral argument could be made for the UK, which has the technical knowhow, to help India eradicate such suffering sooner.

Establishment of the NHS resulted in a big demand for services and a shortage of trained health workers, which was resolved by bringing in workers from the Commonwealth, including many from India. The NHS would not have been successful without these migrant doctors and nurses.13 The UK has an ethical international recruitment policy and code of practice, but migration of doctors and nurses from India and other parts of the world such as Africa has continued, inviting criticism about the damage that that continues to inflict on healthcare in poorer countries.

The 2007 Crisp report argued for the UK recognising its responsibilities as a global health employer by scaling up the training of health workers in developing countries.14 Collaboration gives the UK an opportunity to fulfil this responsibility towards India, and through the GDPP with China. Furthermore, the UK should not underestimate the benefits to diplomacy that might accrue from facilitation of skills sharing among the diaspora working in the NHS and their counterparts in their countries of ethnic origin.

Partnerships with India and China are important ways in which the UK can maintain its sense of identity and global connection. The UK public is among the most engaged on global issues, and the UK commands global recognition for having been at the forefront of development aid for many years.15 Its aid budget has been translated into such demonstrable gains as lifting millions of people out of poverty and reducing infant and maternal mortality. Its leadership of the Group of Eight (G8) richest countries in 2005 is acknowledged to have placed poverty reduction at the heart of global policy and influenced the overall increase in aid and the provision of debt relief. Yet, public confidence has taken a dive as a consequence of the severe economic crisis, with the 2011 riots triggering a call for serious introspection on the impacts of social inequalities in the UK.16 Establishing partnership working with India and China is not an action born out of generosity, but should be recognised as crucial to restore national confidence and pride, and self recognition of the UK’s place at the top table of nations aiming towards a peaceful and sustainable common future.


Cite this as: BMJ 2013;346:f601


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare that I have been a technical adviser to DFID, contribute to UK government strategies for health collaboration with India, and I have received DFID grants for research and evaluation.

  • Commissioned; not externally peer reviewed.


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