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WHO|Globalhealthdiplomacy:theneedfornewperspectives,strategicapproachesandskillsinglobalhealth

BulletinoftheWorldHealthOrganization
Globalhealthdiplomacy:theneedfornew
perspectives,strategicapproachesand
skillsinglobalhealth
IlonaKickbusch a ,GaudenzSilberschmidt b ,PauloBuss c
Introduction
InthepastsaidRobertCooper,oneofEuropespreeminent
diplomatsitwasenoughforanationtolookafteritself.Todayitis
nolongersufficient. 1 Thisisparticularlytrueinthehealtharena.There
isanincreasingrangeofhealthissuesthattranscendnational
boundariesandrequireactionontheglobalforcesthatdeterminethe
healthofpeople.Thebroadpolitical,socialandeconomicimplications
ofhealthissueshavebroughtmorediplomatsintothehealtharenaand
morepublichealthexpertsintotheworldofdiplomacy.Simple
classificationsofpolicyandpoliticsdomesticandforeign,hardand
soft,orhighandlownolongerapply. 2
Diplomacyisfrequentlyreferredtoastheartandpracticeofconducting
negotiations. 3 Itisusuallystillunderstoodtomeantheconductof
internationalrelationsthroughtheinterventionofprofessionaldiplomats
fromministriesofforeignaffairswithregardtoissuesofhardpower,
initiallywarandpeace,andascountriescompeteeconomically
economicsandtrade.Butinrecentyearstherehasalsobeenan
increaseinthenumberofinternationalagreementsonsoftissues,
suchastheenvironmentandhealthitisnowrecognizedthatsomeof
theseissueshavesignificanthardramificationsonnational
economies.Thetermglobalhealthdiplomacyaimstocapturethese
multilevelandmultiactornegotiationprocessesthatshapeandmanage
theglobalpolicyenvironmentforhealth.
Globalhealthdiplomacyisatthecoalfaceofglobalhealthgovernance
itiswherethecompromisesarefoundandtheagreementsare
reached,inmultilateralvenues,newalliancesandinbilateral
agreements.Itisaworldtowhichoutsidersfinditdifficulttorelate,
wheretheartofdiplomacyjuggleswiththescienceofpublichealthand
concretenationalinterestbalanceswiththeabstractcollectiveconcern
ofthelargerinternationalcommunityinthefaceofintensivelobbying
andadvocacy.Nolongerdodiplomatsjusttalktootherdiplomats
theyneedtointeractwiththeprivatesector,nongovernmental
organizations,scientists,activistsandthemedia,tonamebutafew,
sincealltheseactorsarepartandparcelofthenegotiatingprocess.
Globalhealthdiplomacyisgaininginimportanceanditsnegotiators
shouldbewellprepared.Somecountrieshaveaddedafulltimehealth
attachtotheirdiplomaticstaffinrecognitionoftheimportanceand
complexityofglobalhealthdeliberationsothershaveaddeddiplomats
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tothestaffofinternationalhealthdepartments.Theircommonchallenge
istonavigateacomplexsysteminwhichissuesindomesticand
foreignpolicyintertwinethelinesofpowerandconstantlyinfluence
change,andwhereincreasinglyrapiddecisionsandskilfulnegotiations
arerequiredinthefaceofoutbreaksofdisease,securitythreatsorother
issues.MissionstotheUnitedNationsandinternationalorganizations
forexample,inNewYorkandGenevaincreasinglyneedtodeal
withhealthissues,asdotheclassicalbilateralembassies.
Animportantpartofglobalhealthdiplomacystilltakesplacewithinthe
WorldHealthOrganizationindeedithasrecentlygainednew
momentumthroughthenegotiationduringthepastfiveyearsofthe
FrameworkConventiononTobaccoControlandtheInternationalHealth
Regulations.Butthevenueofglobalhealthdiplomacyhasshiftedto
includeotherspacesofnegotiationandinfluence,andthenumberof
organizationsdealingwithhealthhasincreasedexponentially.Atall
levelswearewitnessingadiversificationofactors,themostillustrative
developmentbeingthegrowthofpublicprivatepartnershipsand
platformsaroundamultitudeofhealthissues,allclamouringfor
attentionandfunds.Itisclearthattheprofoundchangeunderway
requiresnewmechanismsandnewskillsforglobalhealthdiplomacy.
Yetaninformalsurveybytheauthorsofstaffoftheinternational
departmentsofhealthincountriesthatbelongtotheOrganisationfor
EconomicCooperationandDevelopment(OECD),inLatinAmericaand
ofhealthattachsinGenevahasconfirmedthatmanydonotfeelwell
preparedforthechallengesthatconfrontthem.

Strengtheninghealthdiplomacy
AnneMarieSlaughterstatesinher
Understandingdomestic
influentialbookonglobalpolicy
issuesinaregionalorglobal
networks:Understandingdomestic
contextmustbecomepartof
issuesinaregionalorglobal
doingagoodjob.
contextmustbecomepartofdoing
Increasingly,theoptimal
agoodjob.Increasingly,theoptimal
solutiontotheseissueswill
solutiontotheseissueswilldepend
dependonwhatis
onwhatishappeningabroad,and
happeningabroad,andthe
thesolutionstoforeignissues,in
solutionstoforeignissues,
correspondingmeasure,bywhatis
4
incorrespondingmeasure,
happeningathome. Inthe
bywhatishappeningat
followingsectionwegiveashort
home.
descriptionofhealthdiplomacy
initiativesintwocountries,
SwitzerlandandBrazil,inwhichthe
authorshavebeeninvolved,and
whichunderlineandillustrateSlaughterspoint.
Switzerland:ensuringpolicycoherence
Asglobalizationprocessesexpanditbecomesessentialforcountriesto
manageatwowayprocess:astheinterdependenceofcountriesgrows,
allnationalhealthpolicieshaveasignificantglobaldimension,andas
thenumberofinternationalagreementsgrows,theimpactofsuch
agreementsonnationalpolicymakingwillalsoincrease.Therecognition
oftheneedforpolicycoherence,strategicdirectionandacommon
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valuebaseinglobalhealthisonlyjustbeginningtoemergeatthelevel
ofnationstates.AfewEuropeancountriesarebeginningtoaddress
globalhealthmoreconsistentlyatthenationallevelbymappingmany
activitiesinglobalhealthacrossallgovernmentsectors,establishing
newmechanismsofcoordinationwithingovernmentanddevelopinga
nationalglobalhealthstrategy,frequentlyattheinitiativeofthe
internationaldepartmentsintheministriesofhealth.Themostrecent
andpossiblythefirstsuchpolicydocumenthasbeendevelopedin
Switzerland,whereajointstrategicapproachtoglobalhealthwas
developedbytheDepartmentsoftheInterior(representedbytheSwiss
FederalOfficeofPublicHealth)andtheDepartmentofForeignAffairs.
Thisdocument,Agreementonforeignhealthpolicyobjectives,was
presentedtotheSwissFederalCouncil(thegovernmentcabinet)in
October2006. 5 Itisthefirstofanumberofspecialstrategic
agreementsthattheDepartmentofForeignAffairsisdevelopingwith
differentpolicysectorswithingovernmentthisinitselfisasignificant
signalofthechangeindiplomacythatisunderway.
Thedocumentbringstogetherthreemajorstrandsofglobalhealthaction
thatgenerallyruninparallelwithlittlecoordinationorevenin
competition.Theseare:theactivitieswithinthehealthsectorthat
addressnormativehealthissues,internationalagreementsand
cooperation,globaloutbreaksofdiseaseandpandemicsthe
commitmenttohealthinthecontextofassistancetowards
developmentandthepolicyinitiativesinothersectorssuchas
foreignpolicyandtrade.ItunderlinesthecommitmentofSwitzerlandto
humanrightsanddefinesfiveprioritiesinforeignhealthpolicy:the
healthoftheSwisspopulation,thecoherencebetweennationaland
internationalhealthpolicy,thestrengtheningofinternationalhealth
cooperation,theimprovementoftheglobalhealthsituation,andthe
strengtheningoftheSwisscommitmentashostcountrytoWHOandto
majorhealthindustries.
Brazilshealthpolicygoals
Coalitionsofdevelopingcountriesaswellasleadershipfromsomeof
themiddleincomecountriessuchasBrazilhavecontributedtoa
significantpowershiftwithinglobalhealthdiplomacy.Thedetermining
factorinBrazilianhealthdiplomacyisthefactthatinBrazilhealthisa
rightofthepeopleandanobligationoftheBrazilianstateasset
downintheBrazilianconstitution.HadBrazilcompletedfreetrade
agreementswiththeUnitedStatessuchastheFreeTrade
AgreementortheFreeTradeAgreementoftheAmericasitwouldnot
havebeenpossibletoassuredeliveryofthehealthservicesanddrugs
thatarecurrentlyavailabletothepopulation.Brazilsactionsatthe2001
WorldTradeOrganizationconferenceinDoha,Qatar,anditsposition
concerningtheAgreementonTradeRelatedAspectsofIntellectual
PropertyRightsdeclarationwhichrecognizedhealthasapriorityover
internationaltradearecasesinpoint.Brazilianglobalhealth
diplomacynowstartsfromthepremisethatitisthehealthofthe
populationthatneedstobethecentreofattentionofdiplomacy.
OneofthebestexamplesoftheclosecooperationbetweentheMinistry
ofForeignAffairsandtheMinistryofHealthinBrazilisglobalpolicyon
humanimmunodeficiencyvirus/acquiredimmunodeficiencysyndrome
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(HIV/AIDS),inparticular,theaccesstoantiretroviraldrugs.The
presenceofhealthexpertswascrucial,sinceadiplomatwhen
discussinghisownfieldofexpertise,suchasintellectualproperty,does
notnecessarilyknowaboutspecificaspectsoftheproductionofdrugs
inthecountryorthepoliciesregardingdrugprices.TheMinistryof
ExternalRelationshaspointedoutthatthevisibilityoftheMinistryof
Health,bothinthetechnicalandpoliticallevels,wascrucialforthe
credibilityofthisposition.Ourleadershipwas,therefore,doubtlessly,a
resultofthiscredibility.
TheparticipationoftheBraziliandiplomatsinthefightagainsttobacco
reinforcedthecountrysleadingroleininternationalhealthforums,and
hasfurtherstrengthenedthebondsbetweenhealthanddiplomacy.
WhenassumingthepresidencyoftheIntergovernmentalNegotiating
Body,AmbassadorCelsoAmorimfromBrazilreaffirmednotonlythe
needtobringhealthintoforeignpolicy,butalsotobringforeignpolicy
intohealth.Brazilianglobalhealthdiplomacywasgroundedonthe
countryssolidpreparationbackhomewiththeNationalCommission
forTobaccoControl,headedbytheMinistryofHealthandgathering
representativesfromdifferentministries(health,agriculture,international
relations,treasury,education,environment,tradeandindustry,and
communications).Againthisillustratesthepointthatgoodglobalhealth
governancebeginsatthenationallevel:thisintensivemultisector
preparationallowedtheBraziliandelegationtointerveneinalmostall
workinggroupsofthenegotiationprocess.Thefinaldocument,
therefore,hadmajorcontributionsfromtheBraziliandelegation,which
underlinedthecruciallinkbetweenthenationalandtheglobaland
furthermanifesteditselfinthesuccessoftheTobaccoandOther
CancerRiskFactorsNationalControlPrograminBrazil.

Actionincapacitybuilding
Theseexamplesunderlinetheneedtobuildcapacityforglobalhealth
diplomacybytrainingpublichealthprofessionalsanddiplomats
respectively.Twotypesofimbalanceneedtobeaddressedasa
priority:imbalancesthatcanemergebetweenforeignpolicyandpublic
healthexperts,andimbalancesthatexistinthenegotiatingpowerand
capacitybetweendevelopedanddevelopingcountries.
BothBrazilandSwitzerlandhavetakeninitiativestoaddressthese
imbalancesthroughnetworking,experienceexchangeandcapacity
building.Switzerlandhasinitiatedanexperienceexchangebetween
headsofdepartmentofinternationalhealthfromOECDcountriesto
tracktheirchangingroleinglobalhealthdiplomacy.Brazilhasmadeits
experiencesavailablethroughcooperationwithmostLatinAmerican
countriesandwiththePortuguesespeakingAfricancountries.The
MinistryofHealthhasalsoembarkedonadialoguewiththeBrazilian
SchoolofDiplomacytoexploreatwowaycapacitybuildingexercise
togetherwiththeNationalSchoolofPublicHealthandtheOswaldoCruz
Foundation.TheSwissFederalOfficeforPublicHealthissupportingan
initiativetointroduceglobalhealthintograduatestudiesinforeign
relationsattheGraduateInstituteofInternationalStudiesinGeneva.A
newprogramme,Globalhealthdiplomacy,willseektoexplorethe
uniqueinterfacebetweenthetheoryandthepracticeofinternational
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relationsinthefieldofhealthandusetheuniquelocationofGenevaas
theglobalhealthcapitaltointroducetheglobalpublichealthcommunity
tothechallengesfacedinglobaldiplomacy.
DiplomacytoparaphraseRobertCooperoncemore 1 needsapost
modernperspective.Theobjectiveofforeignpolicy,hewrites,is
takentobepeaceandprosperityratherthanpowerandprestige.
Diplomacyopenedinthe1950stoeconomyandtrade,enlargedinthe
1980stotheenvironmentandstartsthe21stcenturywithhealthasits
focus.

References
1. RCooper.Thebreakingofnations.Orderandchaosinthe21st
century.NewYork:AtlanticMonthlyPress2003
2. IKickbusch.Globalhealthgovernance:somenewtheoretical
considerationsonthenewpoliticalspace.In:LeeK,ed.
Globalizationandhealth.London:Palgrave2003:192203.
3. GRBerridge.Diplomacy.Theoryandpractice.LondonandNew
York:Palgrave,Macmillan2005.
4. AMSlaughter.Anewworldorder.PrincetonandOxford:Princeton
UniversityPress2004.
5. Agreementonforeignhealthpolicyobjectives.Adoptedbythe
SwissFederalDepartmentofForeignAffairsandtheSwissFederal
DepartmentofHomeAffairsinBerne,Switzerland,on9October
2006.Availablefrom:www.bag.admin.ch/international
Affiliations
a. GraduateInstituteofInternationalStudies,ruedeLausanne132,CH
1211Geneva21,Switzerland.Correspondencetothisauthor(email:
kickbusch@bluewin.ch).
b. SwissFederalOfficeofPublicHealth,Berne,Switzerland.
c. OswaldoCruzFoundation,Manquinhas,RiodeJaneiro,Brazil.

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