1. Global Health Diplomacy short introduction
Professor Dr. llona Kickbusch
Director
Global Health Programme

2. The 21st century dynamics
Globalization impacts health
Health impacts globalization
Kickbusch Introduction Health Diplomacy 2008

3. 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

4. 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

5. 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

6. 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

7. Global inequality and poverty
Health
Gender
Demography
Education
Social disparities
Information
Security
Geopolitics
Kickbusch Introduction Health Diplomacy 2008

8. 21st 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

9. 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

10. 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

11. 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

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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
Kickbusch Introduction Health Diplomacy 2008

13. 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 )
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 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

14. 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
In der Gesundheitsaussenpolitik gilt es drei wesentliche Aspekte unter einen Hut zu bringen:
Die internationale Zusammenarbeit als Mittel zur Förderung der Gesundheit in der Schweiz
Gesundheit als wesentlicher Pfeiler der Entwicklungszusammenarbeit und
Kongruenz mit der allgemeinen Aussenpolitik, welche auch im Bereich der Gesundheit nicht ignoriert werden kann.
Kickbusch Introduction Health Diplomacy 2008

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How has diplomacy changed?
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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

17. “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

18. „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 today………..
the shift from international (between states) to global (trans-boundary/ multi-actor) 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

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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

21. Trans-boundary collective human security issues
Trade/mobility
Global Crime
Terrorism
Environment
Infectious disease
Intellectual property
Disaster response
IHR
Kickbusch Introduction Health Diplomacy 2008

22. International (health) law
Pooling sovereignty and right to intervene on behalf of the health of the global community
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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

24. 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

25. 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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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

27. ….the new political space
Health and…..
Foreign policy
Security policy
Economic policy
Trade policy
Demographic Geopolitics
(Migration)
Global “interhuman” Ethics: Make poverty history
Kickbusch Introduction Health Diplomacy 2008

28. 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

29. Global Health Diplomacy within a fragmented POLITICAL ECOSYSTEM
MSF
CLINTON
BONO
PHA
WEF
150 PPPH
World Bank
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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.
Kickbusch Introduction Health Diplomacy 2008

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Forms of legitimacy
universalistic structure (one country – one vote)
moral standing (Health for All),
quality of technical expertise (expert legitimacy),
ability to achieve commonly set goals (resultsbased legitimacy)
ability to act in the face of crisis
results based legitimacy - a characteristic of market multilateralism
Kickbusch Introduction Health Diplomacy 2008

32. Kickbusch 2006

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Looking back at 150 years of health diplomacy
Kickbusch Introduction Health Diplomacy 2008

34. International Sanitary Conferences
Paris 1851
Paris 1859
Constantinople 1866
Vienna 1874
Washington 1881
Rome 1885
Venice 1892
Dresden 1893
Paris 1894
Venice 1897…….1938
Kickbusch Introduction Health Diplomacy 2008

35. 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)
Kickbusch Introduction Health Diplomacy 2008

39. 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

40. 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
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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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WHO
„the coordinating authority
on international health work“
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
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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)
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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
Smith 2008
Kickbusch Introduction Health Diplomacy 2008

46. The range of policy instruments in global health has expanded considerably over time
"Soft"
"Hard"
Advisory
Technical Advisory
Groups
Expert Advisory Panels Expert Committees
Study and Scientific Groups
Commissions
Normative
Resolutions
Codes
Regulations
Conventions and treaties
Collaborative
Network or alliance
Independent governance, borrowed legal identity
Independent legal identity
Operative
WHO Secretariat Strategy
WHA noted or endorsed strategy
WHA negotiated strategy
Kickbusch Introduction Health Diplomacy 2008
Smith 2008

47. 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. Director-General, World Health Organization 2006
Kickbusch Introduction Health Diplomacy 2008

48. 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.
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The Commission on Intellectual Property Rights, Innovation and Public Health
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

50. 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
“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)
Three phases:
19th century: nation states
20th century: multinational organisations and companies
21st century: people
Thomas Friedman
The world is flat 2007
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52. 2007 Different concepts of the goal of global health diplomacy
Risk
Threat
Justice and development
Market
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Power shifts
Power shift 1
Power shift 2
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54. 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
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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.
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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.
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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.
Kickbusch Introduction Health Diplomacy 2008

58. A global compact: The Millennium Development Goals
The Millennium Development Goals are time-bound and measurable goals and targets to be achieved between 1990 and 2015, they include:
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)
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60. 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
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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“
Muldoon et al 2005
Kickbusch Introduction Health Diplomacy 2008