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 longer-term 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:– 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 STUDIESASEAN’s role in global health diplomacy

Adam Kamradt-ScottLessons from building Thailand’s capacity in GHD

Suriwan ThaiprayoonEmerging role of China in health aid to Africa

Yiding JiangChronic diseases and marketing to children in India

Rachel IrwinRole of GHD in Taiwan’s bid to be observer in WHO

Jonathan HeringtonRole 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 GHDIN 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”

• IGWG/OEWG negotiation resulted in ‘framework’ passed at WHA 2011

Indonesian Minister of Health Siti Fadilah Supari, WHA (2007)

ROLE OF GHDIN 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:– 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 long-term 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!