Research Programme on
Global Health Diplomacy
Richard Smith and Kelley Lee
Department of Global Health and Development
BACKGROUND
• As part of the Bellagio Dialogues of 2009
establishing GHD.net, a series of six papers
were commissioned which concerned the
scope of GHD and the associated research
agenda that may be developed, synthesized in:
– Smith RD, Fidler D, Lee K (2009). Global Health
Diplomacy Research. Trade, Foreign Policy,
Diplomacy and Health Draft Working Paper Series,
World Health Organization
GHD.Net research ‘mission’
• GHD.Net shall engage in and disseminate research on all
facets of GHD in order to deepen understanding about the
problems addressed, the players involved, and the processes
utilized.
• GHD.Net shall facilitate research on issues and challenges
facing developing and least-developed countries.
• GHD.Net’s research activities will help identify the
characteristics of health as a foreign policy and diplomatic
issue and provide input for policy debates on how to improve
the protection and promotion of health through foreign policy
and diplomatic means
SCOPE OF RESEARCH
• research agenda needed to understand four
facets of GHD:
– the topics to which GHD is applied
– the actors involved in GHD
– the process of GHD
– the outcome of GHD
KEY SYNTHESIS PAPER RECOMMENDATION
• support production of review papers:
– specific issues in GHD highlighted by meetings
– reviews of diplomatic theory and how this might
apply to health
– research methodology
• case-studies concerning a specific issue, focused on
low- and middle-income countries, or regional
context
• contribute to a special issue of a high profile journal
PROJECT OVERVIEW
• 12-month project as initial stage of longerterm research programme
• outputs will be:
– 6 case-study papers, 1-2 conceptual papers, 1 (or
more) research proposal(s) for 3-5 years
– presented at two half-day conferences in UK
(today!) and Asia (Singapore next week)
– possible special issue of a journal and/or a book
based on the case studies and associated work
PROJECT OBJECTIVES
• further the development of the conceptual and
methodological basis of the term GHD
• conduct selected case studies which illuminate
four specific facets of GHD as described above
• strengthen capacity to conduct research on GHD
and, through collaborations, establish a wider
collaborative research network within GHD.Net
• develop follow-on research proposal(s) for
supporting the research stream of GHD.net to
undertake further research, and in other regions
CASE STUDIES
• 6 case studies, as identified through the
GHD.Net Bellagio dialogue meetings in 2009, as
key areas for exploration
• focus on Asia:
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world’s largest and most populous continent
fast-paced integration in the global economy
emergence as key actor in international GH
build on established links of LSHTM in Asia
optimize comparative analysis across case studies
maximize capacity building and networking efforts
METHODOLOGY
• similar broad methodology – specific variation
– systematic literature reviews (peer–reviewed, grey
literature etc)
– semi-structured in-depth interviews with key
informants at domestic and international level
• recorded and transcribed
– review of official negotiating documents as
available
– review by LSHTM research ethics committee
CASE STUDIES
ASEAN’s role in global health diplomacy
Adam Kamradt-Scott
Lessons from building Thailand’s capacity in GHD
Suriwan Thaiprayoon
Emerging role of China in health aid to Africa
Yiding Jiang
Chronic diseases and marketing to children in India
Rachel Irwin
Role of GHD in Taiwan’s bid to be observer in WHO
Jonathan Herington
Role of GHD in Indonesian virus sharing issue
Rachel Irwin
ASEAN’S ROLE IN GHD
• ASEAN’s primary focus is regional security ties and economic
integration
• engaged to some extent in efforts to improve regional health
since 1970s
• increased interest in health-related activities post-2003 (SARS):
– food security and safety, healthy lifestyles, easing trade and
travel restrictions for TIHS
– mostly focused on communicable disease control
• reflects more conventional security concerns (maintain
social and economic functioning) as much as ‘health’
ASEAN’S ROLE IN GHD
• domestic political considerations and lack of trust
impact on regional cooperation resulting in silo-style,
nationally-focussed activities
• key strengths of ASEAN w.r.t GHD:
– discussion forum, from high-level politicians to technical
bureaucrats
– bridges HIC and LMIC otherwise divided between two WHO
regional offices (WPRO and SEARO)
• challenges:
– lack of trust
– lack of technical expertise (within the Secretariat) and
capacity; too many targets and objectives
LESSONS FROM BUILDING THAILAND’S
CAPACITY IN GHD
• GHD requires stronger capacity at
national level for:
– health agencies to interact with the wider
diplomatic community (often focused on
trade and security)
– diplomatic organisations to understand
and incorporate health concerns within
wider remit
• Thai experience of ‘TRIPS-plus’
negotiations with USA in 1990s led to
MoPH forging greater engagement in
the trade negotiation processes to
address health concerns
LESSONS FROM BUILDING THAILAND’S
CAPACITY IN GHD
 build capacity in strategic, systematic and formalised manner
– INNE Model: Individual (‘International Health (IH) Scholar Program’), Node
(IHPP, Trade and Health Programme, etc), Network, Enabling environment
 mechanisms of collaboration among agencies should be
institutionalised rather than ad hoc
– institutional mechanisms establish formal relationships, interagency
cooperation via inter-agency committees, National Health Assembly (new
multi-stakeholder forum)
 informal network and personal connection also essential within
and between countries
EMERGING ROLE OF CHINA IN HEALTH AID TO
AFRICA
• expansion of aid programme to Africa
since 1994
– natural resource-backed concessional loans to
fund infrastructure built by Chinese
construction firms (heavily tied aid)
– China Africa Policy (2006)
• long history of health diplomacy to Africa
since 1960s to build solidarity with
developing world
– 20,000 medical staff treating 250 million
patients by 2009
– construction of health infrastructure
– Chinese youth volunteers to Africa since 2007
– Chinese Navy medical ship launched in 2010
(500 beds, 8 operating theatres)
EMERGING ROLE OF CHINA IN HEALTH AID TO
AFRICA
• early recognition of importance of “soft power” in foreign
policy (+ bottom up, solidarity with local people)
• opportunity for China as developing country to create new
modalities of aid
• complex aid bureaucracy locates health aid as tool of foreign
policy
• risks of scaling up African presence
– heavy emphasis on bilateral over multilateral channels adds to existing
aid coordination problems
– founding principles of non-conditionality and self-reliance at risk if
health diplomacy too closely tied to economic policies
CHRONIC DISEASES AND MARKETING TO
CHILDREN IN INDIA
• agreements reached at international
level (via GHD) need to be
implemented at national level
• 63rd WHA (2010) adopted “Set of
Recommendations on the Marketing of
Food and Non-alcoholic Beverages to
Children”
– member states to create policies to reduce
marketing of fatty, sugary, salty foods to
children
• appears as ‘successful’ GHD (health
interests over trade).. but is it?
– What happens at national level after
negotiations conclude?
CHRONIC DISEASES AND MARKETING TO
CHILDREN IN INDIA
• global versus national context:
– obesity not main problem (2% children overweight, 43% underweight);
focus of problem among urban wealthy
– cultural factors make recommendations ‘irrelevant’ as reflects ‘Western’
view of problem and how to address
• role of non-government sector unappreciated
– ‘India Pledge’ with companies vulunteering to market ‘appropriately’
• lack of coordination
– 6 government agencies deal with food and children
– NCD recently put agenda but lack of experience and resources
• global health diplomacy trumped by national health diplomacy
ROLE OF GHD IN TAIWAN’S BID TO BE OBSERVER
AT WHA
• People’s Republic of China occupying
UN seat since 1972
• Taiwan efforts to greater access to
WHO since 1970s
– KMT concerted efforts to gain observer
status from 1997
– punctuated by SARS outbreak and IHR
revision negotiations
• Taiwan health authorities attend 2009
WHA (as “Chinese Taipei”) for first time
since 1971
• example of health diplomacy
overcoming foreign policy goals?
– was it ‘business as usual’ or a new form of
diplomacy?
ROLE OF GHD IN TAIWAN’S BID TO BE
OBSERVER IN WHO
• international health actors and fora played role in applying
political pressure
– health officials able to ‘move more freely’
– health became focus of political concern (SARS, IHR)
• BUT health arguments remain subordinate to traditional
diplomatic concerns
– observer not member, and name of Chinese Taipei as compromise
– observer status renewable annually (subject to foreign policy decision)
– closely enabled by state of, and dependent on,Beijing-Taipei relations
• need to acknowledge role and limitations of GHD, and ensure
engagement with traditional diplomatic practice to remove
blocks to global health initiatives
ROLE OF GHD
IN INDONESIAN VIRUS SHARING ISSUE
• Global Influenza Surveillance
Network (GISN) operated for ~50
years:
– countries share samples of viruses
which are used by WHO to assess
which strains pose most threat and
recommend control and vaccine
production
• 2007 Indonesia ceased sharing:
– equity and ‘affordability of vaccines’
– accusations of threats to “global health
security”
Indonesian Minister of Health Siti
Fadilah Supari, WHA (2007)
• IGWG/OEWG negotiation resulted
in ‘framework’ passed at WHA 2011
ROLE OF GHD
IN INDONESIAN VIRUS SHARING ISSUE
• reasons and context for GH issues on agenda
– breakdown of trust between Indonesia & ‘system’
• role of individuals
– Siti Fadilah Supari (health minister) accused US of
using samples to create biological weapons
– US Ambassador to the UN (Richard Holbrooke) stated
not-sharing as “morally reprehensible”
• role of domestic context
– Internal politics and wider foreign policy
• highlight gaps in current system – IHR, CBD
KEY LESSONS – 1
 domestic politics matters and shape GHD processes:
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Marketing Food to Children in India
Role of GHD in the Indonesian Virus Sharing Issue
Lessons from Building Thailand’s Capacity in GHD
The Emerging Role of China in Aid to Africa
 “Global” in GHD may distract us from domestic interests,
aspirations, and perceptions which shape strategies
– need to align ‘global’ with ‘local’ to engage action
KEY LESSONS – 2
• Domestic institutional capacity shapes GHD
strategies
– Marketing Food to Children in India
– The Emerging Role of China in Aid to Africa
– The Role of GHD in the Indonesian Virus Sharing Issue
• Need to institutionalise aspects related to wider
global context within MoH and wider governmental
system
KEY LESSONS – 3
• Importance of civil society’s role in
influencing/strengthening GHD processes
– The Role of GHD in Taiwan’s Campaign to Become an
Observer in the WHO
– Marketing Food to Children in India
– Lessons from Building Thailand’s Capacity in Global Health
Diplomacy
• Piggy-back on other issues
• Capacity building at local level
KEY LESSONS – 4
• analysis of GHD has to be undertaken over the longterm as causal processes are slow moving, entailing
gradual institutional and policy shifts:
– The Role of GHD in Taiwan’s Campaign to Become an
Observer in the WHO
– Lessons from Building Thailand’s Capacity in Global Health
Diplomacy
– The Emerging Role of China in Aid to Africa
– Role of GHD in the Indonesian Virus Sharing Issue
– Marketing Food to Children in India
KEY LESSONS – 5
 Impact of political regime will influence the key state
actors and their relative involvement
– Lessons from Building Thailand’s Capacity in Global Health
Diplomacy
– The Emerging Role of China in Aid to Africa
 Health officials and other departments can identify
synergies and help each other make their arguments
more persuasive when engaging in international
negotiations
– rolling alliances built for specific purpose
RESEARCH AGENDA – 1
need to understand more about domestic
drivers for GHD
– role of GHD in international image building
– role of institutions in development of international agenda
and engagement in GHD
– use of domestic political science:
• origins of political, bureaucratic, and civil societal interests and
commitment to GHD
• why and how nations craft new domestic institutions for international
trade negotiations
How do domestic politics shape global health
negotiations?
RESEARCH AGENDA – 2
What factors influence an issue being deemed
a GHD issue?
– national ‘security’
– economic/financial impact
– morbidity/mortality
How do global health issues relate to other
“new diplomacy” issue areas?
RESEARCH AGENDA – 3
Who engages in GHD?
– To what extent is there a set of actors in GHD
distinct from global health?
What is the relative power and influence of
specific actors?
Are GHD actors in Asia different from actors in
other regions?
RESEARCH AGENDA – 4
Where does GHD take place?
– What is the relative importance of formal versus
informal settings
– To what extent is GHD integrated with other realms
of diplomacy/foreign policy and hence venues
– How is the shifting balance of power in world
politics affect GHD?
RESEARCH AGENDA – 5
How can we judge ‘successful’ GHD?
– How important has GHD been in facilitating agreement on
global health issues requiring collective action?
– What factors influence the success or failure of GHD in
facilitating collective action?
– What can GHD teach us about the challenges of
strengthening collective action in an increasingly global
world?
– What criteria are used to establish ‘success’ and over what
time period?
NEXT STEPS…
• Submissions to secure substantial future funding for
GHD.Net research stream
• Significant expansion of GHD.Net collaborators
across public health and international relations
• Enhancing capacity on GHD research
• Publication of case-studies and other papers
So...over to you!