Global Health Diplomacy
short introduction
Professor Dr. llona Kickbusch
Director
Global Health Programme
The 21st century dynamics
• Globalization impacts
health
• Health impacts
globalization
Kickbusch Introduction Health
Diplomacy 2008
Global Health
Global Health refers to those health issues
which transcend national boundaries and
governments and call for actions on the
global forces and global flows that
determine the health of people.
Kickbusch 2006
Kickbusch Introduction Health
Diplomacy 2008
The global health dynamics
• The growing health
gap between and
within countries
• The return of
infectious diseases
• The chronic disease
epidemic
• Health is a
determinant of growth
and productivity,
wealth and quality of
life
• Direct and indirect
economic impact of
disease outbreaks
and lifestyle changes
Kickbusch Introduction Health
Diplomacy 2008
A “cosmopolitan moment”
• (Beck 2007:109) is a prism which brings into focus the
need to address a problem at the global level through
collective action. It can includes both a normative
dimension - “We have a global responsibility” - and a
dimension of Realpolitik - “The national interest can only
be resolved through joint global action”. Indeed moral
obligation (as well as indignation!) and “enlightened self
interest” have become two strong driving forces of global
health governance. Cosmopolitan moments usually open
up new political spaces and allow – and sometimes
oblige - new actors to join the global governance effort.
Kickbusch Introduction Health
Diplomacy 2008
3 key dimensions of global health
• Public health can no longer be pursued just at
the national level – it needs strong global
institution, mechanisms and funding
• The health sector can no longer deal with the
emerging challenges on its own – it needs
multisectoral action and broad public and private
partnerships at national and international level
• Health can no longer be seen as a purely
professional and technical endeavour – it needs
the strong voice and the support of civil society
and of political leaders to address the equity and
human rights issues at stake.
Kickbusch Introduction Health
Diplomacy 2008
Global inequality and poverty
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Health
Gender
Demography
Education
Social disparities
Information
Security
Geopolitics
Kickbusch Introduction Health
Diplomacy 2008
st
21
century risk society:
interdependence
• Global governance:
• Risks are
transnational
• Local governance
• Global risk production
is localized through
the globalization of
everyday life
• Impact?
Preparedness?
Response?
Kickbusch Introduction Health
Diplomacy 2008
A new global environment
“(…) the interdependence produced by
globalization has broken down traditional
ways of conceptualizing and organizing
the medical, economic, political and
technological means to improve health”
Nick Drager and David Fidler Foreign policy, trade and health: at cutting
edge of global health diplomacy The World Health Organization
Bulletin, Volume 85, number 3, March 2007, the Editorials.
Kickbusch Introduction Health
Diplomacy 2008
Global health governance:
• a mechanism of collective problem solving
for improved health through the interplay
of different institutional forms and actors at
different levels.
• Like other forms of governance it is
subject to reconfigurations of power – it is
therefore always also a political
undertaking.
Kickbusch Introduction Health
Diplomacy 2008
Health in foreign policy
We are witnessing an increased role of
health in global and foreign affairs,
including in particular trade and security, as
exemplified in the recent SARS epidemic
and fears of biological terrorism;
Health is now part of the G8 summits, UN
General Assembly, poverty reduction
strategies
Kickbusch Introduction Health
Diplomacy 2008
Oslo Declaration 2007
7 Ministers of foreign affairs propose an
action plan for health in foreign policy and
declare that „health impact“ must become
a key lens through which to conduct
foreign policy
Norway France Thailand South Africa Brazil
Senegal Indonesia
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Diplomacy 2008
CH: Agreement on health foreign
policy objectives
• Aim: better interdepartmental collaboration in sectors
where the MFA does not have the lead (retreat of Swiss
Federal Council 18.5.2005)
• Agreements on shared objectives between FDFA and
other sectoral department : First application: Health
• Health Foreign Policy (HFP) was signed and submitted
to the Federal Council on 9.10.2006 by the heads of the
Federal Department of Home Affairs Pascal Couchepin
and the head of the Federal Department of Foreign
Affairs Micheline Calmy-Rey
Kickbusch Introduction Health
Diplomacy 2008
CH: Three Aspects of Health
Foreign Policy (HFP)
Global Health Policy
1. Tool to improve health in Switzerland
2. Health as a pillar of development
policy
3. Coherence with general foreign
policy
Kickbusch Introduction Health
Diplomacy 2008
• How has diplomacy changed?
Kickbusch Introduction Health
Diplomacy 2008
Bi lateral diplomacy
• „Old diplomacy“
• Directed primarily towards to the conduct
of relations on a state to state basis via
resident missions with the resident
ambassador as the key actor
Kickbusch Introduction Health
Diplomacy 2008
“New diplomacy”: Multilateral
international diplomacy
• Multilateral diplomacy
involves the art of
building and managing
coalitions before, during,
and after negotiations on
a particular issue across
national boundaries –
frequently within the
context of international
organizations.
• High level of complexity:
Multi actor, multi issue,
multi roles, multi values
Kickbusch Introduction Health
Diplomacy 2008
„The breaking of nations“
• 1989 end of balance of power system
• In the past it was enough for a nation to
look after itself - today that is no longer
sufficient.
• Post modern perspective: the objective of
foreign policy is taken to be peace and
prosperity rather than power and prestige
• Robert Cooper 2006
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Diplomacy 2008
Diplomacy today………..
• the shift from international (between
states) to global (trans-boundary/ multiactor) challenges, indeed there are some
who have suggested that departments of
foreign relations be renamed to fit their
new purpose: global affairs;
Kickbusch Introduction Health
Diplomacy 2008
Diplomacy today…………
• the importance assigned to “soft power”
strategies as well as “nation building” and the
role health plays within such approaches
• the recognition that certain “global public goods”
need to be negotiated and ensured and that
regimes in the area of trade and economic
development need to be complemented by other
goods such as health
Kickbusch Introduction Health
Diplomacy 2008
Trans-boundary collective human
security issues
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Trade/mobility
Global Crime
Terrorism
Environment
Infectious disease
Intellectual property
Disaster response
Kickbusch Introduction Health
Diplomacy 2008
I
H
R
International (health) law
Pooling sovereignty
and right to intervene
on behalf of the
health of the global
community
Kickbusch Introduction Health
Diplomacy 2008
New response to the global
health crisis
• The crisis is primarily not a disease
crisis, it is a crisis of governance –its
key characteristic is a weakening of
public policy and interstate
mechanisms as a consequence of
global restructuring and a fragmentation
of actors and programs.
Kickbusch Introduction Health
Diplomacy 2008
Global Health Diplomacy
Health diplomacy may be defined as a political activity that
meets the dual goals of improving global health while
maintaining and strengthening international relations,
particularly in conflict areas and resource-poor environments
(Novotny, Leslie, Adams, Kickbusch 2008)
Global Health Diplomacy refers to the multi-level and multi actor
negotiation processes that shape and manage the global policy
environment for health.
(Kickbusch 2007)
Kickbusch Introduction Health
Diplomacy 2008
3 key objectives of Global Health
Diplomacy
Ideally global health diplomacy results in
better health security and population health outcomes for
each of the countries involved (thus serving the national
and the global interest)
improving the relations between states and strengthening
the commitment of a wide range of actors to work to
improve health
a common endeavour to ensure health as a human right
and a global public good and delivering results that are
deemed fair ( “for all” - reducing poverty, increasing
equity)
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Kickbusch Introduction Health
Diplomacy 2008
The diplomatic space
A major part of global health diplomacy
takes place within the United Nations
specialized agency for health - the World
Health Organization - but the range of
actors and “spaces” is expanding rapidly.
This includes venues such as the World
Trade Organization, the World Bank,
regional organizations and new
organizations such as global alliances,
global funds and global forums.
Kickbusch Introduction Health
Diplomacy 2008
….the new political space
• Health and…..
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Foreign policy
Security policy
Economic policy
Trade policy
Demographic Geopolitics
(Migration)
• Global “interhuman” Ethics: Make poverty history
Kickbusch Introduction Health
Diplomacy 2008
The new health diplomats
• Increasingly the negotiations on global
health matters are not only conducted
between public health experts
representing health ministries of nation
states but include a growing array of other
national actors as well as major players in
the global arena such as NGOs, the
private sector, academia and foundations .
Kickbusch Introduction Health
Diplomacy 2008
Global Health Diplomacy within a fragmented
POLITICAL ECOSYSTEM
MSF
CLINTON
BONO
WEF
PHA
World Bank
150 PPPH
Kickbusch Introduction Health
Diplomacy 2008
Forms of power
• new forms of power and influence that
take place in the many transnational
arenas
• discoursive power, decision making power,
legal power and resource based power.
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Diplomacy 2008
Forms of legitimacy
• universalistic structure (one country – one vote)
• moral standing (Health for All),
• quality of technical expertise (expert legitimacy),
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ability to achieve commonly set goals (resultsbased
legitimacy)
• ability to act in the face of crisis
• results based legitimacy - a characteristic of market
multilateralism
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Diplomacy 2008
Global Health Diplomacy Action Sphere
Collective Security
Rule of law
Global public goods
Development
Commitments for
health
Human rights
Justice
Collective rights
Global welfare
Kickbusch 2006
Governing
interdependence
• Looking back at 150 years of
health diplomacy
Kickbusch Introduction Health
Diplomacy 2008
International Sanitary Conferences
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Paris 1851
Paris 1859
Constantinople 1866
Vienna 1874
Washington 1881
Rome 1885
Venice 1892
Dresden 1893
Paris 1894
Venice 1897…….1938
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Pan American Sanitary Bureau
1902
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Religious Missions
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Red Cross Movement
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Foundations
• 1913
• Rockefeller
International Health
Division: basic health
research, training of
personel, model
health programmes
• (yellow fever vaccine)
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Diplomacy 2008
OIHP: Office International d‘Hygiene
Publique
• 1907: 23 European Countries establish the
OIHP located in Paris: Bulletin
• Role: collection and dissemination of new
knowledge on infectious diseases:
cholera,plague, yellow fever
• Later widened to 60 countries and a range
of other infectious and vector borne
diseases………………
Kickbusch Introduction Health
Diplomacy 2008
Basis for the „new“ diplomacy
• „a completely novel form was added to the
institutional repertoire of states in 1919:
• The multipurpose, universal membership
organization- instantiated first by the
League of Nations and then by the United
Nations
Kickbusch Introduction Health
Diplomacy 2008
League of Nations
• International health
studies
• Field assistance to
countries
• 1921
• Subdivision:
„prevention and
control of diseases“
• Health organization of
the League of
Nations, later the
Health Committee of
the League
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• 1945 San Fransisco Conference agrees to
establish a health organization
• 1946 Constitution is adopted
• 1948 Constitution comes into force
• 1951 International Sanitary regulations
• 1969 International health regulations
• 1978 Alma Ata
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Diplomacy 2008
WHO
„the coordinating authority
on international health work“
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First decade: major diseases
Second decade: liberation of former colonies – health manpower
development
Third decade: eradication of small pox, new issues such as family planning
Fourth decade: Primary health care WHO UNICEF Health for All – Equity –
cooperation
Fifth decade: investment in health, poverty eradication
• Sixth decade: common health security and health as a global public
good
Kickbusch Introduction Health
Diplomacy 2008
WHO Constitution
• Articles 19-23
• Enable the WHO to adopt conventions or
agreements, regulations and recommendations
in all public health endeavors
• A highly radical approach to International Law at the
time of its creation
• Persuasive approach
• Soft law (norms that fall between morality and binding law)
• Hard law (legal obligation)
Kickbusch Introduction Health
Diplomacy 2008
The WHO Constitution describes a series of
policy-making instruments available to WHO
Category
Current Examples
Conventions and Agreements
(Articles 2 (k),19-20)
Framework Convention on Tobacco
Control
Regulations
(Articles 2 (k), 21-22)
International Health Regulations
(2005)
Recommendations
(Articles 2 (k), 23)
Global strategy and plan of action on
public health, innovation and
intellectual property
Nomenclatures
(Article 2 (s))
International Nonproprietary Names
Standards
(Article 2 (u))
Codex Alimentarius Commission
Kickbusch Introduction Health
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Smith 2008
The range of policy instruments in global health
has expanded considerably over time
"Soft"
Advisory
Normative
Technical
Advisory
Groups
Smith 2008
Expert Advisory Panels
Expert Committees
Study and Scientific Groups
Resolutions
Collaborative Network or
alliance
Operative
"Hard"
WHO
Secretariat
Strategy
Codes
Regulations
Commissions
Conventions
and treaties
Independent governance,
borrowed legal identity
Independent
legal identity
WHA noted or endorsed
strategy
WHA
negotiated
strategy
Kickbusch Introduction Health
Diplomacy 2008
Framework Convention Tobacco Control
27.05.2005
• "The WHO FCTC negotiations
have already unleashed a
process that has resulted in
visible differences at country
level. The success of the WHO
FCTC as a tool for public
health will depend on the
energy and political
commitment that we devote to
implementing it in countries in
the coming years. A successful
result will be global public
health gains for all."
• Dr LEE Jong-wook. DirectorGeneral, World Health
Organization 2006
Kickbusch Introduction Health
Diplomacy 2008
International Health Regulations
• The renewed mandate given to
Member States and WHO
under the IHR(2005) has also
increased their respective roles
and responsibilities. In
particular, States Parties* to
the IHR(2005) are required to
develop, strengthen and
maintain core surveillance and
response capacities to detect,
assess, notify and report public
health events to WHO and
respond to public health risks
and public health
emergencies.
Kickbusch Introduction Health
Diplomacy 2008
The Commission on Intellectual
Property Rights, Innovation and
Public Health
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Dreifuss Commission
• “…to collect data and
proposals from the different
actors involved and produce
an analysis of intellectual
property rights, innovation, and
public health, including the
question of appropriate funding
and incentive mechanisms for
the creation of new medicines
and other products against
diseases that
disproportionately affect
developing countries…”
Kickbusch Introduction Health
Diplomacy 2008
In diplomatic practice
• Policy coherence: Agreements between ministries of
foreign affairs and health SWI, BRAZ, National global
health strategies UK
• Staff exchanges: diplomats into MOH, public health
experts into diplomatic missions „strengthen the bonds“
• Diplomats with health brief: MEX US border health
commission
• Health section in MFA: USA
• New composition of delegations
• Diplomatic leadership of health negotiations IHR FCTC
• Action plan: Oslo Declaration of 7 MFA
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Global developments
• Three phases:
“Globalisation can be
defined as the “widening,
deepening and speeding
up of worldwide
interconnectedness in all
aspects of contemporary
social life”.
(Held,et al 1999)
• 19th century: nation
states
• 20th century:
multinational
organisations and
companies
• 21st century: people
Thomas Friedman
The world is flat 2007
Kickbusch Introduction Health
Diplomacy 2008
2007 Different concepts of the goal
of global health diplomacy
Threat
Risk
Justice and
development
Market
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Power shifts
• Power shift 1
• Power shift 2
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Value base of health diplomacy?
• A European approach to global health is
based on three fundamental values: to
protect and improve health as
• (1) a human right,
• (2) a key dimension of human security and
development and
• (3) a global public good.
European Global Health Glossary 2006
Kickbusch Introduction Health
Diplomacy 2008
Alma Ata 1978
I The conference strongly affirms that
health…. is a fundamental human right
and that the attainment of the highest
possible level of health is a most important
world wide social goal whose realization
requires the action of many other social
and economic sectors in addition to the
health sector.
Kickbusch Introduction Health
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Alma Ata 1978
II The existing gross inequality in the health
status of the people particularly between
developed and developing countries as
well as within countries is politically,
socially and economically unacceptable
and is,therefore, of common concern to all
countries.
Kickbusch Introduction Health
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Alma Ata 1978
V Governments have a responsibility for the
health of their people which can be fulfilled
only by the provision of adequate health
and social measures. A main social target
of governments, international
organizations and the whole world
community in the coming decades should
be the attainment by all peoples of the
world by the year 2000 of a level of health
that will permit them to lead a socially and
economically productive
life.
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A global compact: The Millennium
Development Goals
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The Millennium Development Goals are time-bound and
measurable goals and targets to be achieved between 1990
and 2015, they include:
1.
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5.
6.
7.
8.
halving extreme poverty and hunger
achieving universal primary education
promoting gender equality
reducing under-five mortality by two-thirds
reducing maternal mortality by three-quarters
reversing the spread of HIV/AIDS, malaria and TB
ensuring environmental sustainability
developing a global partnership for development, with targets
for aid, trade and debt relief
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New instruments
• A global health treaty
• should ensure a common high level of health protection
and health rights for all citizens of the world
• from those risks and threats to their health, safety and
well being which are beyond the control of individuals
and communities
• cannot be effectively tackled by nation states alone but
need to be multiactor (e.g. health threats, unsafe
products, unfair commercial practices). (Kickbusch 2006)
Kickbusch Introduction Health
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Global health framework
convention
• Focus on ‘basic survival needs.’ It would commit
States to a set of targets, both economic and
logistic, and dismantle barriers to constructive
engagement by the private and charitable
sectors. It would stimulate creative public/private
partnerships and actively engage civil society
stakeholders. It would also set achievable goals
for global health spending; define areas of cost
effective investment to meet basic survival
needs; build sustainable health systems; and
create incentives for scientific innovation for
affordable vaccines and essential medicines.
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Values
• “The very values of an enlightened and
civilized society demand that privilege be
replaced by generalized entitlements – if
not ultimately by world citizenship then by
citizens rights for all human beings of the
world.” (Ralf Dahrendorf)
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A new focus?????
Global domestic politics
Kickbusch Introduction Health
Diplomacy 2008
Diplomacy today
• „Today‘s diplomat has a dual
responsibility:to promote his or her
country‘s interest and to advance the
interests of the global community“
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Muldoon et al 2005
Kickbusch Introduction Health
Diplomacy 2008