Global Health Diplomacy:

‘Smart Power’ in the 21st Century

Sebastian Kevany, MA MPHInstitute for Health Policy Studies

June 6, 2013

Transcendent Ideals

“The long labor of peace is an undertaking for every nation--and in this effort, none of us can remain unaligned. To this goal, none can be uncommitted.”

--John F. Kennedy, address to the United Nations General Assembly (1963).

Overview

• Background, Theory, & Field Notes

• Values, Alignment, & Training

• Research, Ideas & Conclusions

Background

Foreign Assistance

Designed to promote international economic, social, & political

development

•Health•Education•Infrastructure•Climate Change•Environmentalism

• Agriculture• Democratization• Human rights• Security• Terms of trade

Foreign Policy

The ‘enlightened self-interest’ of nation states - de Tocqueville, 1865

•Regional cooperation•Advancement of human rights•Promotion of democracy•Good governance•Prevention of violent conflicts•Development & economic growth•Diplomacy (subset of foreign policy)

Diplomacy

‘The art of letting others have your own way’

•Negotiation•Conflict resolution

‘The art and practice of conducting negotiations between nations --

skill in handling affairs without hostility’

• Dialogue • Communications

Global Health

• The Global Fund & PEPFAR• Part of foreign assistance & policy• ‘Hearts & Minds’, ‘Transcendent’

‘These are misplaced priorities --what is return on our investment?’ - Chair, House Committee on Foreign

Affairs

The Rise of Global Health

• Dramatic and ongoing increases in funding for global health programs

• A quadrupling in global health expenditure from 1990 to 2007

‘Although there are clearly occasions when programs have different targets, in many cases, the medical, economic,

and political are inseparable’ - Kleinman, 2010

Right Shift in Demand Curve

Changes in:

•Tastes

•Expectations

•Populations

•Other prices

Global Health Diplomacy‘Global health diplomacy is an emerging field, that addresses the dual goals of improving global health and bettering international relations, particularly in conflict areas and resource-poor environments’ – Novotny, 2007

‘To leverage U.S. global health funding to support foreign policy objectives’ – CSIS, 2010

‘Making global health decisions on the basis of “high politics” ’ – Labonte, 2010

Smart PowerHard Power: Influence obtained through use of military coercion to influence behavior or interests of other political bodies. – Wikipedia, 2012

Soft Power: ‘The ability to attract, and co-opt, rather than coerce, rather than using force or money as a means of persuasion…..through international relations, foreign assistance, and cultural exchange’ – Nye, 1990

Smart Power: ‘Developing an integrated strategy, resource base, and tool kit to achieve American foreign policy & diplomatic objectives’ - CSIS, 2010

An Evolving Paradigm

Theory

Paradigm Reversal

• Much current attention to the ‘nexus’ between global health and foreign policy

• Focus on the need to ensure foreign policy contributes to global health (SWAPs)

• Not the focus of this lecture, or the theory under examination – the other way around

High and Low Politics

• The political ascendancy of global health• Changes in expectations & responsibilities

‘The health sector must think how it can advance foreign policy goals and be aware,

and acknowledge, that health policy can have a negative impact on foreign policy and it’s goals’ – Chatham House, 2011

‘Opportunities for stronger political alliances and economic relations…’ – Jones, 2009

The Political Spectrum

‘Global health has become part of the ‘high’ foreign policy agenda’ – Katz, 2011

Can Global Health Contribute?

‘Soft power attracts a diverse and pluralistic world to better opportunities and a sense of dignity. We can appeal to these values, and

inoculate against extremism….’ ‘…to restore our soft power, we need to

change both substance & style of our foreign policy…’

‘…if we were to spend 1 % of the military budget on soft power, it would mean

quadrupling our ‘public diplomacy’ programs.’- Nye, 2004

Same Money - Same Outcome

Complete replacement neither required nor desirable

Diplomacy: In Favour

• Increases sensitivity of interventions• Increases utilization and uptake• Improves adaptability of interventions• Increased involvement of local actors• Improved geographical accessibility• Helps to ensure sustainability of efforts• Collaterals: equity, accessibility,

coverage

Foreign Policy: In Favour

• Increases capacity to attract funding• Diverts money away from ‘hard power’• Increased prestige of global health actors• ‘International image-building’• Non-violent forms of intervention• May save more lives than if ‘stove-piped’• ‘The lesser evil, and the greater good’

Arguments Against• Additional procedural approvals• Review of range of interventions in use• Cost-effectiveness in decision-making• Less likely to select most effective

programs• ‘Corruption’ of high idealism• Manipulation and suspicion• ‘Hijacking’ of global health programs• Specific institutions already exist• ‘Shadow costs’ of broader expectations

Lesser Evil, Greater Good‘A career diplomat urged understanding that if the real goal of global health diplomacy is to improve health outcomes, that is not always

consistent with the goal of traditional diplomacy, and that when judging success of a

given negotiation in health diplomacy, it is important to note that even if health outcomes

are not optimal, the process may have advanced national interests and would, in that

sense, be seen as a success by the foreign policy community.’ – Chatham House, 2011

Field Notes

Conflict, Post-Conflict Settings

‘US strategic interests in ‘‘winning hearts and minds’’ have incorporated health

initiatives in a number of contexts. These efforts are likely to continue, despite

criticism of “militarized” aid, and a lack of ability to demonstrate effectiveness, because

most experts believe future conflicts will resemble counterinsurgencies and ‘‘armed

social work’’ more than traditional battlefield confrontations.’ - Feldbaum, 2010

Zimbabwe

Voluntary counseling & testing (CBVCT)

•Access to off-limits regions•Communications & entertainment•International relations

Impossible, without political awareness

Political Awareness in Zimbabwe

South Sudan

Global Fund Malaria, HIV & TB Programs

•Peace-keeping•Nation-building•Support for independence

Impossible, without foreign policy awareness

UNMIS, or UNDP, in South Sudan?

Afghanistan & Iraq

Global Fund Malaria, HIV and Tuberculosis Programs

•International relations•Donor prestige•Conflict prevention & mitigation

Impossible, without diplomatic awareness

Foreign Policy vs. Anti-Corruption?

Triumphs & Failures

• PEPFAR & antiretrovirals• Polio eradication campaigns• Ceasefires for health

• CIA in Afghanistan• PEPFAR & antiretrovirals• Family planning & ‘population control’

What are possible future triumphs & failures?

Values

Values in Development

• Sector-specific (health outcomes)• Humanitarian (alleviation of pain)• Diplomatic (international relations)• Ethical (helping those in need)• Development (wealth redistribution)

“ ‘Smart’ foreign assistance programs: choosing the right interventions,

delivered in the right way” – CSIS, 2010

Measuring ‘Value’

• Foreign assistance programs are far more valuable to the world than people realize

• Programs & practitioners have a much greater range of roles & responsibilities

• Their ‘collateral’ effects have not been done justice (The McNamara Fallacy)

• How can these ‘intangibles’, such as ‘generation of goodwill’, be measured?

Utilitarian Values

Ascendancy of Utilitarianism

• In an ‘ideal world’, all resource allocation decisions would be made based on CEA

• However, should this be applied to allocative efficiency decisions? Or just technical efficiency decisions?

• Variety of other policy considerations involved in health intervention selection

• Responsible for responding to local needs, expertise, diplomacy, humanitarianism

Neo-Utilitarian ValuesResults: Does the program possess a culture of measurement & accountability?’ (CSIS, 2012)

Utilization: Are people utilizing the services provided? (Khumalo-Sakutukwa, 2010)

Adaptability: Does the program respond to other local priorities? (CBVCT, 2012).

Equity: Is there a concern for social justice in the health program? (Novotny, 2007).

Narrow Measures of Success

• Are existing M&E systems too target-specific, not reporting all indirect ‘collateral’ program effects?

• Do M&E reporting capacity, philosophy and systems foster an ‘end justifies the means’ culture?

• Can ‘narrowly-effective’ programs come at the expense of broader benefits?

Broad Measures of Success

‘If they are to succeed, global health advocates should avoid the pursuit of narrow

goals, and proceed with a more general appeal to moral concepts such as social

justice and compassion. This greater generality belies prudence, rather than a lack

of rigour’ – Lee, 2007

‘These systems have not allowed us to answer greater questions about our mission, to

inform broader agency decisions, by understanding the contribution to secure, productive and just communities’ - Mercy

Corps, 2011

Rawlsian Values

Development: Does this intervention stimulate dignity, confidence, self-worth? (USAID, 2010)

Communications: Have achievements been conveyed to local leaders? (CSIS, 2010)

Sustainability: What is the forward-looking commitment to these activities? (CSIS, 2012)

Visibility: Is the positive contribution of the donor clearly visible? (CSIS, 2010)

Kantian Values

Nation-Building: Has this program made any contribution to capacity? (McRae, 2002)

Peace-Keeping: Has this program contributed to stability? (Feldbaum, 2010)

Coordination: Is the program working with other international partners? (CSIS, 2011).

Sensitivity: Are programs aligned with local beliefs and cultures? (CBVCT, 2012)

Machiavellian Values

Target Populations: Do they take into account foreign policy? (Feldbaum, 2010)

Location: Are programs mindful of broader strategic considerations? (CSIS, 2010)

Economics: Does the program assist access to strategic resources? (Feldbaum, 2010)

Prestige: Has this program altered recipient perceptions of donors? (Bonventre, 2007)

Ethical dilemma of expenditure on HIV treatment versus prevention

interventions

Alignment

A New Status Quo‘In the absence of data on broader outcomes, analysts have failed to reach any significant conclusions about the (collateral) results of humanitarian programs’ – Bonventre, 2008

•Clarify definitions, principles & metrics, establish a ‘taxonomy’ (Katz, 2011)•Establish qualitative & quantitative outcome measures (Chatham House, 2011)•Measure health program impact on non-health outcomes and values (CSIS, 2011)

The Case for Alignment

‘The failure to consider foreign policy and international relations principles and

objectives while designing, selecting and implementing international development

programs runs the risk of creating a tense and confusing duality’ – CSIS, 2010

‘High expectations that global health will achieve diplomatic goals beyond technical objectives will be thwarted by these gaps’

– Katz, 2011

Holistic Evaluations

• How can we decide if health programs are diplomatically-effective (or harmful)?

• How can we determine if they contribute to (or hinder) foreign policy goals?

• How can we recognize, reward, and quantify the value of these contributions?

• Step 1: Literature Review: ‘smart power’, ‘public health diplomacy’, foreign policy

Who, What, When, Where

Who: ‘Are you using staff trained in diplomatic procedures? Languages?’What: ‘Is there a risk that this program may offend cultural sensibilities?’When: ‘Is this program sustainable after the end of the funding period?’ Where: ‘Have broader geopolitical issues been considered?’How: ‘Has this program made contributions to international relations?’

Diplomatic Criteria

What are the criteria for judging the success of global health diplomacy? –

Chatham House, 2011

•Location•Coverage•Equity•Utilization•Visibility

• Partnerships• Adaptability• Sustainability• Perceptions• Local

priorities

Foreign Policy Criteria

How can we determine the value of health as a tool of foreign policy? – Feldbaum,

2010

•Strategic awareness•‘Hearts & Minds’•Alignment•Target populations•‘Positive influence’

• ‘Image-building’• Donor economy• Recipient

economy• Regime change• Geo-stability

Identifying Threats

Transfer of Responsibilities

Training

Training in Foreign Policy

‘The United States explicitly supports global health initiatives as a projection of “smart power,” which depends on public health professionals, and researchers, to achieve their technical objectives as an

element of the country’s broader foreign policy strategies. To date, U.S. agencies

have not systematically given those professionals a framework for

understanding the political milieu in which they act.’ – Katz, 2010

Training in Diplomacy‘These are complex problems that require

improved leadership, training, and research in both health and international relations to bring about conflict resolution, equitable distribution

of resources, and improvements in development…’

‘…a capable health diplomat must have a sophisticated understanding of the structures,

programs, approaches, and pitfalls surrounding these relationships to achieve success, whether

working in the clinical setting or at the policymaking table’ – Novotny, 2007

Training Components• Understanding of principles of international

relations, foreign policy & global politics.• Training in interaction with communities,

organizations, and government officials• Health professionals represent governments

‘Offering an orientation in “practical diplomacy” to students on a global health career track

would help them to understand where efforts fit in the context of global issues’ – Katz, 2010

Research & Ideas

Intervention Adaptability

Monitoring & Evaluation

High Politics

Defining Criteria

Conclusions

Rightward Shifts Revisited

Changes in…

•Awareness•Scope•Effectiveness•Expectations

..of global health

programs

Implications for Government

‘The deepening links between health and foreign policy require both the diplomatic

and global health communities to reexamine the resources necessary to achieve their

mutual objectives’ – Katz, 2011

•Development of ‘political analysis liaison units’ within donor organizations?

•Development of ‘global health liaison units’ within donor governments

Visibility & Funding

‘The characterization of health as a foreign policy issue will bring greater visibility’

--Katz & Singer, 2007

The more evidence that can be generated on the manifold impacts of global health

programs likewise provides powerful support for the case for more aid’

--Benyon, 2001

Enlightened Self-Interest

‘Success in engaging national governments in health operations is more likely in those areas where global health efforts can be shown to benefit the national interest’ - Harris, 2004

‘The implications of successful global health programs without foreign policy considerations are just as dangerous to human dignity as the

reverse’ – Fidler, 2007

A Post-Partisan Approach

‘Even at it’s recent peak, the amount of money spent on the world’s poorest people,

who suffer most of humanity’s infectious and preventable diseases, represented

merely 0.0005 percent of worldwide health spending’ – Garrett, 2012

‘The structure of global health efforts is like a house of cards, highly vulnerable to

prevailing winds’ – Garrett, 2012

Expanding the ScopeWhy stop at government? Adapting

arguments & criteria for corporations

•Healthy consumers•Access to markets•Corporate prestige•International relations•Return on investment•‘Getting them involved’

The ‘Big Picture’: Missiles into Medicines

Key MessagesAltruism Revisited: The ‘greater good’ of international relations should never be

jeopardized by the ‘lesser evil’ of optimizing a narrow range of program-specific outcomes.

‘In all cases, these are political choices, and they are likely to be made badly if governed chiefly by

philanthropic considerations. Instead, it is necessary to think about the two-in-one character

of humanitarian aid’ – Foreign Affairs, 2011

‘The price of peace is eternal vigilance’

Wheels within Wheels

Thank You

sebastian.kevany@ucsf.edu