Regional Health Governance:
A suggested agenda for Southern African
health diplomacy
14 September 2015
Pieter Fourie & Erica Penfold
In this presentation
 Hard truth
 Background
 The emergence of health in foreign policy
 Niche diplomacy
 Health in the new multilateralism, and regionalism
 A suggested agenda for SADC health diplomacy
 Conclusion
Hard Truth:
Policy utopianism vs.
 Narrative 1: policy sovereignty
 But “best practice” comes from elsewhere
 Narrative 2: policy solidarity
 But state policies are not always aligned supranationally
 Reality 1: policy coercion
 “Best practice” darlings (Botswana, Uganda, and (lately) South Africa)
 Medical triumphalism
 Reality 2: the money is going elsewhere, geographically as well as
 So what can African and other developing states do?
Background: multilateral/regional
health diplomacy?
 Will Global Health save George W. Bush’s foreign policy
 2002: Global Fund to Fight AIDS, TB and Malaria
 2003: President’s Emergency Plan for AIDS Relief
 Middle powers also interested in health diplomacy
 Niche diplomacy
 Challenge rather than affirm the status quo
 Regional health diplomacy: South America: yes
Southern Africa…?
The recent institutionalisation of health
in foreign policy
 March 2007: Oslo Ministerial Declaration launches the
Global Health and Foreign Policy Initiative
 Brazil, France, Indonesia, Norway, Senegal, South Africa,
“We believe that health is the most important, yet still
broadly neglected, long-term foreign policy issue of our
time. […] We have therefore agreed to make impact on
health a point of departure and a defining lens that each of
our countries will use to examine key elements of foreign
policy and development strategies, and to engage in a
dialogue on how to deal with policy options from this
Health foreign policy agenda includes
Global health security
Shortage and global maldistribution of trained health workers
Aligning action in cases of natural disasters
Concerted response to the AIDS pandemic in particular
Combat climate change, and its consequences for health
Use health to identify development priorities, allocation of aid
Establish trade policies, esp. re. pharmaceutical access
Develop a new global health governance architecture
Mainstream health into training of diplomats
BUT: Do not overemphasize health security concerns at the expense
of issues regarding justice and equity
Where is the regional?
Niche diplomacy
 Gareth Evans: “Niche diplomacy involves concentrating resources
in specific areas best able to generate returns worth having, rather
than trying to cover the field.”
 Successful foreign policy = ability to focus
Why? To build soft power:
 Carter administration’s “medical diplomacy” in 1978
 Michael Leavitt (Secretary of health and human services):
 “Soft power builds trust for moments when hard power is required.”
 “I have heard HIV/AIDS victims in distant villages in Africa say the
words ‘U-S-A’ with their lips and ‘thank you’ with their eyes.”
Developing countries need niches too
 Brazil recognizes right to health in its 1988 constitution
 After HAART in 1996 Brazil challenges pharmaceutical IPRs
 Transnational issue coalitions
 Leader in negotiating the Framework Convention on Tobacco Control
 Cuba, Venezuela and an “anti-imperialist” global agenda
 Norm entrepreneurship, with a health lens
 Brazil, India, and South Africa’s Treatment Action Campaign
 Challenging WTO TRIPS agreement in the Doha Dev. Round
 This can strengthen emerging middle powers, who are “ideally suited to
partner with (I)NGOs in the pursuit of selected issues on the international
 Traditional middle powers (Australia, Canada, Norway) confirm status
 Emerging middle powers (India, Brazil, South Africa, Mexico, Turkey)
challenge status quo
Health in the new multilateralism (and
 Post-Westphalian global order
  Multilateralism + Niche = Real Agency for developing countries?
 Health = opportunity for norm entrepreneurship?
 Southern African Development Community (SADC)
 UN Security Council non-permanent 10
 India-Brazil-South Africa (IBSA)
 G-20
 Brazil-Russia-India-China-South Africa (BRICS)
 But also the H-8 (WHO, IBRD, GAVI Alliance, UNICEF, UNFPA,
UNAIDS, Global Fund, Gates Foundation)
But health diplomacy does not feature
prominently in most of these
 A new kind of (issue) regionalism needed?
 Alma Ata declaration (1978): “Health for all by 2000”
 Health as a human rights issue
 Health prominent in MDGs and in the new SDGs
 Brazil (1988) and SA (1996) have Right to Health explicit in
their constitutions
 PAHO in South America
SADC to the rescue?
 From SADCC to SADC
 ‘Service organisation’, to support national policies (bottom-
up), rather than regional leadership body (top-down)
 Pallotti (2004): ‘A development community without a
development policy’
 Donors have much influence on health policies in Southern
 But ODA is decreasing (at worst), or flat-lining (at best)
So, we propose a tentative list of five agenda items for SADC
Recommendation 1: Civil society
 ‘Catalytic diplomacy’: civil society intra- and inter-regional
 A transnational social contract, democracy
 Alma Ata (1978): citizen participation
 Community-Based Organisations, Civil Soc. Organisations
 Technical needs
 Disease surveillance partners
 Access to healthcare and medicines
 Canada, Brazil: FTCT
 SA, India, Brazil: TRIPS
Recommendation 2: Trade
 Focus on health NTBs can help implement SADC Trade
Movement of pharmaceuticals and health products
Aligning national social policy responses
Emergency responses to disease control
Health personnel and health systems (health-promoting
Harmonise differing drug registration authorities in region
SADC regional interface with WHA,WTO, etc.
But beware a dominant South Africa
Recommendation 3: Training health
 Training and retaining health professionals
 Brain drain
 Africa: 2.3 health workers per 1,000 people;
USA: 24.8 workers per 1,000
Most African states fail to meet the ‘Health for All’ minimum
standard of 1 doctor per 5,000 people
Prioritise HR, staff exchanges
Dialogue on health migration
GATS provides scope to negotiate multilateral governance
Recommendation 4: Training for health
 Very technical skills
 SADC could facilitate training of Southern African health
diplomats, but also S-S
University of Pretoria: the only MDip (but no health)
Graduate Institute (Geneva): strong health diplomacy
Key skills focusing on regional health profile
Multilateral resolutions and interfacing at WHA
Recommendation 5: South Africa’s
role, and establishing a PAHO
 The regional giant – but selfish
 Set health diplomacy agenda, rather than waiting for ‘best
practice’ from the global north
 Pan African Health Organisation?
Also, consider:
 Manufacture of generic medicines
 Engage with big pharma
 Learn from good practices in India, Brazil
 Reduced drug prices
 Integrated (regional) health system (‘patient identifier’)
 Coordinated regional response
 Focus on social determinants of health, rather than vertical
 Coodinate interaction with donors
Penfold, E. D. and Fourie, P. (2015) ‘Regional
health governance: a suggested agenda for
Southern African health diplomacy’, in
Global Social Policy,
DOI: 10.1177/1468018115599817