Global Health Diplomacy A New Relationship between Health and Foreign Policy Professor Dr. Ilona Kickbusch

1. Global Health Diplomacy A New Relationship between Health and Foreign Policy Professor Dr. Ilona Kickbusch

2. Global Health Diplomacy: at the interface of health and foreign policy (Kickbusch 2011) “Global health diplomacy is part of the “new diplomacy” agenda by which foreign policy, since the end of the Cold War, has expanded to embrace new issues, new actors and new processes.”(Lee/Gomez 2012) © Graduate Institute Geneva 2012 Kickbusch New York 2012

3. Diplomacy is…………. A specific method for compromise and consensus (negotiation) and a system of organisation – within a legitimate international order. (Henry Kissinger) © Graduate Institute Geneva 2012 Kickbusch New York 2012

4. System and methods Diplomacy is a system of representation with a body of rules and practices of communication (method): Establishing relations, joining international organisations, representations, accreditations, immunities, privileges, missions, embassies, ambassadors, consulates, modes of correspondence, diplomatic channels, protocols, language………. NOTE: IN PRINCIPLE DIPLOMATS REPRESENT STATES NOT GOVERNMENTS – but they receive instructions from governments. © Graduate Institute Geneva 2012 Kickbusch New York 2012

5. Evolution of the system of diplomacy Bilateral: 15th century: representations 1626 first ministry of foreign relations FRA Multilateral: 19th century: Great power conferences 20th century: Universal membership organization (open diplomacy, global parliamentary assemblies) 21st century: polylateral diplomacy Modern Post modern © Graduate Institute Geneva 2012 Kickbusch New York 2012

6. Diplomacy has changed………… From a state craft to a management tool: managing globalisation From the management of order to the management of change From a policy instrument to an international process of social involvement managing relationships (soft power) Has gained in scope and relevance Cartoon from Genevalunch.com. © Graduate Institute Geneva 2012 Kickbusch New York 2012

7. Skills of diplomatic actors • Expertise of negotiatingfor positive results • States wantdiplomatstosafeguardtheirinterests and values in global governance. Theythereforehavetoput a premium on agentsthatperformbest in thistask • The capacitytobeabletoconnectwithsomethingcomplex and inherentlyuncertain, theact in situations not underonescontrol; toworkfor an outcomethatis still uncertain; and tojoinwithothers and torecruitothersintothiseffort. • (Novotny 2012) © Graduate Institute Geneva 2012 Kickbusch New York 2012

8. Diplomacy has changed: Megadiplomacy Mega diplomacy is a reminder that diplomacy has always been about anyone who has the status, the prestige, the resources, the authority to be involved in negotiations on an international, on a global level. ………….the authoritative actors are not just governments but they include companies, humanitarian agencies, NGOs, universities, religious groups and churches, private mercenary armies, sub-state units like cities and city governments and mayors…………………... All of these are very important players in global diplomacy today, so mega diplomacy is about the diplomacy of bringing those together into new coalitions, that emerge across the dot gov world, the dotcom world, the dot org world, the dot edu world. That is mega diplomacy. (Parag Khanna 2011) © Graduate Institute Geneva 2012 Kickbusch New York 2012

9. Foreign policy has changed In the past it was enough for a nation to look after itself - today that is no longer sufficient. (Robert Cooper 2006) The difference between „we“ and „them“ is melting away.(Juergen Kleiner 2012) © Graduate Institute Geneva 2012 Kickbusch New York 2012

10. Functions of foreign policy Ensuring national security Protecting national economic power and wellbeing Fostering development of strategically important regions and countries Supporting human dignity (Fidler 2008) Foreign policy makers are increasingly confronted, in their traditional areas of operation, with health related isues problems and crisis. Frequency and intensity has increased since the end of the cold war GLOBALISATION © Graduate Institute Geneva 2012 Kickbusch New York 2012

11. Globalisation A process or (set of processes) which embodies a transformation of the spatial organization of social relations and transactions – assessed in terms of their extensity, intensity, velocity and impact – generating transcontinental, interregional or global flows and networks of activity, interaction and of the exercise of power”(Held et al, 2003: 68). • Flowrefers to the cross-border movement ofgoods, products, merchandise, persons, symbols, drugs, pathogens, information etc. and • Networksrefers to the regularisation of mechanisms and patterns of interactionamong actors © Graduate Institute Geneva 2012 Kickbusch New York 2012

12. Globalisation and Health “Globalization takes the issue of health from the relative obscurity in which it found itself, especially in developing countries, and brings it to the front page where it is featured not as health as we know it, but as global health in combination with foreign policy, which we are still struggling to define”. (Alcazar 2008) © Graduate Institute Geneva 2012 Kickbusch New York 2012

13. Oslo Ministerial Declaration -global health: a pressing foreign policy issue of our time launched in September, 2006, in New York/ Oslo on March 20, 2007 In today’s era of globalisation and interdependence there is an urgent need to broaden the scope of foreign policy. …We believe that health is one of the most important, yet still broadly neglected, long-term foreign policy issues of our time. .... We have therefore agreed to makeimpact on healtha point of departure and a defining lens that each of our countries will use to examine key elements of foreign policy and development strategies, and to engage in a dialogue on how to deal with policy options from this perspective. © Graduate Institute Geneva 2012 Kickbusch New York 2012

14. Cognitive Spatial temporal Global health is here and there.. Movement of people – goods – services – ideas – life styles - viruses ………. © Graduate Institute Geneva 2012 Kickbusch New York 2012

15. 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) • Global health and public health are indistinguishable. (Frenk 2011) © Graduate Institute Geneva 2012 Kickbusch New York 2012

16. Global Health Diplomacy Three dimensions of Global Health Diplomacy: A) In multilateral negotiations: a methodfor reaching compromise and consensus in matters pertaining to health, usually in the face of other interests (power, security, economic interest) but also to values and principles B) In bilateral/geopolitical contexts: a soft power strategyusing health for foreign policy goals, including security C) In crisis situations: a bridge to peace © Graduate Institute Geneva 2012 Kickbusch New York 2012

17. Strategic relevance of health in the global arena has changed Economic agenda – trade agenda Geopolitical agenda: soft and hard power Security agenda Social Justice agenda - human rights agenda - UN Survival Agenda (R2P) Domestic - foreign policy Agenda for emerging economies - rising states - BRICS Charity/philanthropic agenda Integral part of interdependent global crisis and challenges (food, climate, energy, water………….) A global public goods agenda © Graduate Institute Geneva 2012 Kickbusch New York 2012

18. Trans boundary economic agenda India’s move to strip German drugmaker Bayer of its exclusive rights to a cancer drug has set a precedent that could extend to other treatments, including modern HIV/AIDS drugs, in a major blow to global pharmaceutical firms, experts say. http://www.dawn.com/2012/03/13/india-cancer-ruling-opens-door-for-cheaper-drugs.html economic impactof poor health on development or of pandemic outbreaks on the global market place, the economic relevanceof the health sector, of certain industries such as tobacco, food and pharmaceuticals and the growing global marketof goods and services in relation to health: medical devices and diagnostics, m-health © Graduate Institute Geneva 2012 Kickbusch New York 2012

19. Geopolitical agenda: Brazil Brazil is perhaps the rising power that is strategically most successful in connecting its global health activities – for example the fight against HIV/AIDS and access to medicines - with itsdeclared foreign policy objective of becoming a global player in international affairs, both economically and politically. Its programmes of expanded South-South cooperation facilitate its trade relationships with Africa as a “commercial frontier” and at the same time supports the building of alliances and trust for agendas such as the reform of the UN Security Council(membership) and the international monetary system. © Graduate Institute Geneva 2012 Kickbusch New York 2012

20. Trans-boundary collective security issues • Trade • Mobility/Migration • Environment • Infectious disease • Intellectual property • Food • Disaster response • Global Crime • Terrorism • High degree of uncertainty • High degree of interconnectedness • Need for collective action IHR © Graduate Institute Geneva 2012 Kickbusch New York 2012

21. A global social justice agenda • Protestors demand that $500m of unspent funds from the US government's Aids programme be freed to provide life-saving antiretroviral treatment. • The protesters shouted: "Treatment is prevention, treat a million now", a reference to a government commitment to double the number of Kenyans on antiretroviral treatment (Art) by 2015. That pledge was made at the same time as Obama vowed to raise the number of people on Art globally to 6 million by 2013. © Graduate Institute Geneva 2012 Kickbusch New York 2012

22. Survival agenda The Millennium Development Goals 2015 • 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 © Graduate Institute Geneva 2012 Kickbusch New York 2012

23. Rising states agenda: BRICS Health Ministers meeting The first meeting, hosted 2011 by the Government of China, aimed to identify opportunities for BRICS countries to promote wider access to affordable, quality-assured medicines,with a view to reaching the Millennium Development Goals and other public health challenges. © Graduate Institute Geneva 2012 Kickbusch New York 2012

24. Extensive health cooperation by theChinese government • Multilateral: WHO, World Bank, ASEAN, Shanghai Cooperation Organization, GF, UNAIDS • Bilateral: 300 cooperation agreements with 89 countries • South-South: China-Africa Cooperation( Chinese medical teams) • South-North: 11 regular Ministerial Dialogue with US, France and others • Public-Private: Clinton Foundation, Gates Foundation, Project Hope Prof. CHEN Zhu, Minister of Health, China 19 Nov 2009, Havana © Graduate Institute Geneva 2012 Kickbusch New York 2012

25. Philanthropic agenda • “Guided by the belief that every life has equal value, the Bill & Melinda Gates Foundation works to help all people lead healthy, productive lives. In developing countries, it focuses on improving people’s health and giving them the chance to lift themselves out of hunger and extreme poverty. “ © Graduate Institute Geneva 2012 Kickbusch New York 2012

26. A global public goods agenda A global public good is a public good with benefits that are strongly universal in terms of countries (covering more than one group of countries), people (accruing to several, preferably all, population groups), and generations (extending to both current and future generations, or at least meeting the needs of the current generation without foreclosing development options for future generations). © Graduate Institute Geneva 2012 Kickbusch New York 2012

27. Interdependent crisis: Climate Change © Graduate Institute Geneva 2012 Kickbusch New York 2012

28. Foreign Policy today……. 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 others in areas such as environment and health – FINANCE – ENVIRONMENT - HEALTH © Graduate Institute Geneva 2012 Kickbusch New York 2012

29. Political process Health Diplomacy is - as is all diplomacy - an essentially political process and as health again becomes politically more relevant - in domestic and in foreign policy and at the global level - health diplomacy plays an increasingly important role © Graduate Institute Geneva 2012 Kickbusch New York 2012

30. Goals – outcomes If well conducted global health diplomacy results in: better health security and population health outcomes for each (and all) of the countries involved and an improved global health situation; improved relations between states and a commitment of a wide range of actors to work together to improve health and outcomes that are deemed fair and support the goals of reducing poverty and increasing equity. © Graduate Institute Geneva 2012 Kickbusch New York 2012

31. Multilateralism has changed 20th century 21st century Creation of multi- stakeholder hybrid organisations and initiatives New multilateralism GLOBAL - transnational • Creation of universal membership organisations • League of Nations • United Nations • INTERNATIONAL © Graduate Institute Geneva 2012 Kickbusch New York 2012

32. Multi Stakeholder diplomacy • A collective and collaborative public effort to examine an issue from different points of view prior to taking a decision, deliberative processes strengthen policy design by building recognition of common values, shared commitment and emerging issues, and by providing a comprehensive understanding of causal relationships.”(Swanson et al, 2009) • Collaboration depends “on achieving a virtuous cycle between communication, trust, commitment, understanding, and outcomes” © Graduate Institute Geneva 2012 Kickbusch New York 2012

33. Mulitilateral diplomacy: WHO governing bodies © Graduate Institute Geneva 2012 Kickbusch New York 2012

34. Some major WHO negotiations & instruments • Health for All Policy (Alma Ata declaration 1978) • International Code of Marketing of Breast-milk Substitutes (1981) • Framework Convention on Tobacco Control (2003) • International Health Regulations (2005) • Intergovernmental Working Group (IGWG) on Public Health, Innovation and Intellectual Property Rights (PHI) + CEWG • Code of Practice of International Recruitment of Health Personnel • Intergovernmental Meeting (IGM) on Virus and Benefit Sharing/ Pandemic Influenza Preparedness PIP Framework • WG SSFFC (falsified medicines) • NCD (WHO & UN) © Graduate Institute Geneva 2012 Kickbusch New York 2012

35. History of the International Health Regulations © Graduate Institute Geneva 2012 Kickbusch New York 2012

36. The global response to address non-communicable diseases (WHO centred) © Graduate Institute Geneva 2012 Kickbusch New York 2012

37. Multilateral diplomacy: Health at the United Nations Security Council HIV AIDS 2000 Millennium Development Goals 2000 UNGASS HIV AIDS 2001 General Assembly: Global Health and Foreign Policy 2009 General Assembly: Non Communicable Diseases 2010/2011/2012 © Graduate Institute Geneva 2012 Kickbusch New York 2012

38. Health in Clubs …. An increased role of health in global and foreign affairs,heads of state in particular trade and security and development: health is now part of the G7/8/20/77 summits, BRICS…….. © Graduate Institute Geneva 2012 Kickbusch New York 2012

39. Regional level: EU Council conclusions 2010 Council of the European Union Adopts Conclusions on the EU Role in Global Health 10 May 2010 The Council welcomes the Commission Communication on the EU Role in Global Health which highlights the need to take action to improve health, reduce inequalities and increase protection against global health threats. Health is central in people's lives, including as a human right, and a key element for equitable and sustainable growth and development, including poverty reduction. © Graduate Institute Geneva 2012 Kickbusch New York 2012

40. “Decides to establish a Health Implementation Unit (HIU) at the OIC” Headquarters in Jeddah to serve as the permanent secretariat of the Steering Committee on Health; facilitate monitoring the implementation of the resolutions and declarations emanating from the OIC Health Ministerial Conferences and promoting health cooperation and coordination among Member States, OIC Institutions and relevant international organizations; © Graduate Institute Geneva 2012 Kickbusch New York 2012

41. Health as an instrument… • ……means winning the hearts and minds of those abroad by strategically exporting medical care and humanitarian aid, building in-country capacity, and providing health education, training and personnel. • Health diplomacy encompasses a range of services, such as delivering life-saving AIDS medications in remote African and Caribbean villages; delivering emergency health care, medications and medical supplies in Haiti, Indonesia and Pakistan following devastating natural disasters; providing polio vaccinations for children in India; partnering with medical researchers in Ireland and Brazil; and working with influenza epidemiologists in China. (Tommy G. Thompson former secretary of health USA) © Graduate Institute Geneva 2012 Kickbusch New York 2012

42. China - Cuba Chinahas cumulatively sent over 15,000 doctors to more than 47 African countries and treated approximately 180 million African patients. China’s foreign policy interests in Africa lie primarily with ensuring long term energy and food resources and in “soft power” support of its investment strategies it is building hospitals and research centers in a number of African countries Cuba has sent medical personnel to about 70 countries and provided free medical training for thousands of developing country students at Cuban medical schools. Since 2006 Cuba has engaged in a major bi-lateral exchange programme: about 20 000 “medical diplomats” are sent to Venezuela in return for 100,000 barrels of oil per day to Cuba, discounted by as much as 40 percent… © Graduate Institute Geneva 2012 Kickbusch New York 2012

43. Health as a bridge for peace • The War and Health Program at McMaster University has defined health-to-peace initiatives as “any [initiative] that intends to improve the health of people and that simultaneously heightens that group’s level of peace.” multitrack diplomacy strategy • Using health during the peace process, after violence has ceased or diminished, can ease tensions, promote understanding and peace, and rehabilitate and reinforce the institution of health. © Graduate Institute Geneva 2012 Kickbusch New York 2012

44. Vaccination Diplomacy A one page letter stating an endorsement of the antipolio campaign by the Taliban Polio vaccinations in Afghanistan: A new letter of endorsement is provided for every polio campaign, ten times in 2009 alone In the insurgent-dominated areas, the Taliban select the local vaccination teams and their supervisors. They then receive the vaccine and the documentation from government health offices, and report back the results. Albon 2010 © Graduate Institute Geneva 2012 Kickbusch New York 2012

45. Diplomacy today Health policy 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) ”Today‘s minister of health has a dual responsibility: to promote his or her country‘s health and to advance the health interests of the global community“. © Graduate Institute Geneva 2012 Kickbusch New York 2012

46. Defining features of 21st century (health) diplomacy (1) • needs to function within a multi polar world and within a multi level and multi dimensional global governance structure – context of interdependence and increased contacts between states • is by no longer conducted only by the foreign office but byheads of government, other government department: diffusion – outsourcing - secondments • is by no longer conducted only byprofessional diplomats – i.e. accredited NGOs © Graduate Institute Geneva 2012 Kickbusch New York 2012

47. Defining features of 21st century (health) diplomacy (2) • is challenged to manage a “complicated and interactive network” not only the relations between states (bi- and mulit-lateral) but also the relations between states and other actors (polylateral) and it manages these relationships in various diplomatic venues and with a wide range of instruments. © Graduate Institute Geneva 2012 Kickbusch New York 2012

48. Defining features of 21st century (health) diplomacy (3) • is increasingly engaged in public diplomacy vis a vis an informed public and many actors at home and in the host country – the web……. • is involved and contributes to a whole host of issues which are on the international agenda – issues of globalisation • needs to consider a much closer interface between domestic and international policies and cooperate with national ministries. © Graduate Institute Geneva 2012 Kickbusch New York 2012

49. Capacities for global health diplomacy Itis essential thatALL countries arebetterpreparedfor international negotiationsforhealth- in health and non- healthorganisations; forroles on boards, in assembliesetcthrough: Strong international/global healthdepartmentswith well trainedstaff Strong representation in Geneva and othervenues of decisionmaking such as Brussels and New York – keyembassies Cooperationwithforeignaffairs – regularlybriefings – twoway In depthpreparationformeetings and negotiations(also at regional level) and forkeyfunctionsat regional and global level (EB) Role of MOH, MFA, WHO HQ, regional and countryoffices, national institution, trainingprogrammes © Graduate Institute Geneva 2012 Kickbusch New York 2012

50. Cooperation MOH - MFA 2006 Swiss Health Foreign Policy –renewed 2012 2007 Oslo declaration on Foreign Policy & Global Health by ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa & Thailand 2008 UK Strategy – Health is Global – renewed 2011 2009 US Global Health Initiative 2010 EU Council conclusions on global health 2010 Japan‘s global health policy 2011 - 2015 2010 Norwegian cross-government WHO strategy, 2012 White paper on global health 2011 Sweden’s Strategy for WHO 2011-2015 2011 Brazil and Switzerland nominated ambassadors for health, Sweden followed 2012 Many other activities in countries like China, Thailand, Brazil, Kenya, Germany etc. © Graduate Institute Geneva 2012 Kickbusch New York 2012