Research Programme on Global Health Diplomacy

1. Research Programme on Global Health Diplomacy Richard Smith and Kelley Lee Department of Global Health and Development

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. CASE STUDIES ASEAN’s role in global health diplomacy Adam Kamradt-Scott Lessons from building Thailand’s capacity in GHD Suriwan Thaiprayoon Emerging role of China in health aid to Africa Yiding Jiang Chronic diseases and marketing to children in India Rachel Irwin Role of GHD in Taiwan’s bid to be observer in WHO Jonathan Herington Role of GHD in Indonesian virus sharing issue Rachel Irwin

11. 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’

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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?

18. 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

19. 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?

20. 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

21. 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)

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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?

29. 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?

30. 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?

31. 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?

32. 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?

33. 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!