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

Global Health Diplomacyshort introduction

Professor Dr. llona Kickbusch

Director

Global Health Programme

Kickbusch Introduction Health Diplomacy 2008

The 21st century dynamics

• Globalization impacts health

• Health impacts globalization


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


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


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.


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.


Global inequality and poverty

• Health• Gender• Demography• Education• Social disparities• Information• Security• Geopolitics


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?


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.


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.


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


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


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


CH: Three Aspects of Health Foreign Policy (HFP)

1. Tool to improve health in Switzerland2. Health as a pillar of development policy3. Coherence with general foreign policy

Global Health Policy


• How has diplomacy changed?


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


“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


„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


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;


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


Trans-boundary collective human security issues

• Trade/mobility

• Global Crime

• Terrorism

• Environment

• Infectious disease

• Intellectual property

• Disaster response

IHR


International (health) law

Pooling sovereignty and right to intervene on behalf of the health of the global community


• 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.

New response to the global health crisis


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)


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)

.


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.


….the new political space

• Health and…..

• Foreign policy• Security policy• Economic policy• Trade policy• Demographic Geopolitics• (Migration)

• Global “interhuman” Ethics: Make poverty history


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 .


Global Health Diplomacy within a fragmented POLITICAL ECOSYSTEM

BONO

CLINTON

MSF

150 PPPHWEF PHA

World Bank


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.


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

DevelopmentCommitments for health

Governinginterdependence

Global Health Diplomacy Action Sphere

Human rightsJusticeCollective rightsGlobal welfare

Collective SecurityRule of lawGlobal public goods

Kickbusch 2006


• Looking back at 150 years of health diplomacy


International Sanitary Conferences

• Paris 1851• Paris 1859• Constantinople 1866• Vienna 1874• Washington 1881• Rome 1885• Venice 1892• Dresden 1893• Paris 1894• Venice 1897…….1938


Pan American Sanitary Bureau

1902

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http://profiles.nlm.nih.gov/VV/B/B/C/D/

http://profiles.nlm.nih.gov/VV/B/B/F/D/


Religious Missions


Red Cross Movement


Foundations

• 1913

• Rockefeller International Health Division: basic health research, training of personel, model health programmes

• (yellow fever vaccine)


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………………


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


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


• 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


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


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)


The WHO Constitution describes a series of policy-making instruments available to WHO

Category Current ExamplesConventions 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


"Soft" "Hard"

Advisory Technical Advisory

Groups

Expert Advisory Panels Expert Committees

Study and Scientific GroupsCommissions

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

The range of policy instruments in global health has expanded considerably over time

Smith 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. Director-General, World Health Organization 2006


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.


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…”


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


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


2007 Different concepts of the goal of global health diplomacy

ThreatRisk

Justice and development

Market


Power shifts

• Power shift 1

• Power shift 2


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


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.


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.


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.


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:

1. halving extreme poverty and hunger 2. achieving universal primary education3. promoting gender equality 4. reducing under-five mortality by two-thirds5. reducing maternal mortality by three-quarters6. reversing the spread of HIV/AIDS, malaria and TB7. ensuring environmental sustainability8. developing a global partnership for development, with targets

for aid, trade and debt relief


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)


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.


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)


A new focus?????

Global domestic politics


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

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

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