Translating Idea Into Policy

Global Health
Teaching Case
From the Harvard
School of Public
Health
Translating an Idea into a Policy:

“Saving Lives and Buying Time” for Antimalarial Medicines
PART A
March 31, 2009
This case was written by Laura Frost, Partner at Global Health Insights, and Michael R.
Reich, Taro Takemi Professor of International Health Policy at the Harvard School of
Public Health. Beth Anne Pratt of Global Health Insights provided research support. It is
intended to be used as a basis for class discussion rather than to illustrate either effective
or ineffective handling of an administrative situation.
Copyright © 2009 The President and Fellows of Harvard College

Introduction
Global public health leaders had cause for worry at the dawn of the 21st century. Old
treatments against malaria were increasingly ineffective. A new malaria medicine—
artemisinin-based combination treatment, or ACT—was highly effective, but two big
problems remained. First, ACTs were too expensive for people who needed the medicine
in malaria-endemic countries. Second, there was a high probability that the malaria
parasite would quickly develop resistance to artemisinin. Public health leaders knew that
these two problems needed to be addressed.
In July 2004, the Institute of Medicine (IOM) Committee on the Economics of

Antimalarial Drugs published a report called Saving Lives, Buying Time: Economics of
Malaria Drugs in an Age of Resistance. The IOM Committee—chaired by Kenneth
Arrow, a Nobel Laureate in economics—recommended the creation of a global-level
subsidy for ACTs as the most economically and scientifically sound solution to the twin
problems of poor access and the risk of early onset of drug resistance. The report
recommended the establishment of a global fund that would purchase ACTs from
manufacturers at the price of one dollar per dose and resell it at one-tenth of that price.
Both the public and private sectors of all malaria-endemic countries could purchase the
subsidized ACTs. The proposed global subsidy would solve the two critical problems at
the same time: it would promote widespread access to effective antimalarials (to “save
lives”) and would delay the emergence of resistance to artemisinin (to “buy time”).
USAID, which commissioned the work of the committee, accepted the recommendation
but took no steps to take the idea forward. The global subsidy idea needed a policy
champion, an individual or organization that could take the research idea and translate it
into global policy. Otherwise, it would remain an untested proposal for improving global
health. How could the report’s innovative idea be translated into policy and action?
The Problem: Malaria and its Treatment
Malaria is a parasitic infection spread from person to person by the bite of the female
Anopheles mosquito. Every year, malaria parasites infect approximately 250 million
people, over half of whom children. 1 Over half of the world’s population currently lives
in malaria-endemic countries, many of which are classified as “less developed” and
already face considerable human and economic development challenges. 2 There are four
types of human malaria; Plamodium falciparum is the most deadly and is also the type
most common to sub-Saharan Africa. Morbidity from P. falciparum has widespread
consequences for both the health systems and economies of developing countries.
In the early 1950s, chloroquine was introduced as the primary first-line drug for malaria.
Affordable and available, it continues to be a widely used treatment in many malaria-
endemic countries But P. falciparum resistance to chloroquine is now so extensive that
chloroquine is no longer considered an effective treatment for this type of malaria. 3 In
response to widespread resistance to chloroquine, many countries in the 1980s and 1990s
began to substitute sulphadoxine-pyrimethamine (SP) as a cost-effective alternative. SP,
like chloroquine, is affordable, available, and commonly prescribed throughout both the
Copyright © 2009 Harvard 2 March 31, 2009

public and private sectors in Africa. But SP resistance has been increasing and the World
Health Organization (WHO) now only recommends the drug for intermittent preventive
treatment in pregnant women. 4
Presently, the only treatment for which P. falciparum malaria has not developed
significant resistance is artemisinin, a drug derived from the Chinese plant Artemisia
annua. In order to preserve artemisinin’s effectiveness and extend the life of other, less
effective antimalarials, WHO recommends that artemisinin derivatives be used in
combination with another partner drug (such as lumefantrine, amodiaquine, SP, or
mefloquine). 5 These combination antimalarials are known as artemisinin combination
therapies, or ACTs. In early 2009, WHO listed ten companies that make artemisinin-
based antimalarials that the agency says are acceptable, in principle, for procurement by
UN agencies. These companies include both western manufacturers such as Sanofi
Aventis and Novartis, as well as a number of Indian generic producers. 6 There are about
a dozen other manufacturers of ACTs, including local manufacturers in Kenya,
Cameroon, Ghana, and Uganda. 7
In April 2002, WHO endorsed the adoption of ACTs as a first-line treatment for
uncomplicated P. falciparum malaria in countries with significant resistance to
chloroquine. To further encourage the transition to ACTs, the Global Fund to Fight
AIDS, Tuberculosis and Malaria (GFATM) in 2004 began reprogramming all approved
grants to procure ACTs in areas where there is demonstrable resistance. 8 But two key
barriers to widespread ACT access are affordability and availability. A single dose of
ACT can cost up to twenty times more than a dose of chloroquine or SP, due to the high
cost of producing the combination therapy. 9 Until August 2007, Coartem®
(manufactured by Novartis) was the only WHO-prequalified fixed-dose combination on
the market. 10 Prequalification meant that Coartem® was the primary drug of choice for
public-sector procurement and for use in clinical trials. The production process of ACT is
complex and involves the long growing cycle of Artemisia, the artemisinin extraction
process, and the difficulties of combining artemisinin with a partner drug. This coupled
with high demand for Coartem® by international and public sector procurement agencies,
led to increasing Coartem® shortages once the reprogramming of GFATM grants got
underway.
There are also concerns about emerging resistance to artemisinin. Artemisinin

monotherapy (AMT) circulates on the market in many countries, threatening the lifespan
of artemisinin. Counterfeit ACTs (drugs that contain fake artemisinin derivatives) and
substandard ACTs (drugs of poor quality) also available and increase the probability of
parasite mutation and resistance. A recent report confirms cases of ACT resistance in
Cambodia. 11 In May 2007, the World Health Assembly passed a resolution requiring
member states to withdraw oral AMT from the public and private sectors, to promote the
use of quality ACTs, and to take measures to prevent counterfeits from being produced
and distributed. Some countries continue to allow AMT to be marketed and as of August
2007, 67 companies continued to produce and market AMT. 12 There is an increasing
sense of urgency among members of the global health community to find innovative

solutions to high ACT prices and supply-side uncertainty, and to delay resistance to
artemisinin.
Designing a Solution: The Institute of Medicine Committee on the Economics of

Antimalarial Drugs
In 2001, the United States Agency for International Development (USAID) asked the
Institute of Medicine (IOM) in Washington, D.C. to convene a panel to assess the
economics of antimalarial drugs. The committee’s task would be to “recommend steps
that could be taken to maximize the influence of both new and established antimalarial
drugs while postponing the development of drug resistance.” 13 USAID was interested in
two key areas: 1) ensuring that new and existing antimalarial drugs were affordable to the
people who needed them, and 2) ensuring that antimalarial drugs were produced,
packaged, and delivered in ways that encouraged adherence to prescribed regiments. 14
USAID wanted to know how to extend the life of SP as an effective antimalarial drug and
how to make artemisinins more affordable. IOM wanted to focus on the broader question
of how to make antimalarial drugs more affordable. 15 After a year of discussions between
the two groups, it was decided that the Committee would focus its attention on the
affordability of antimalarial drugs. During the period of discussion between USAID and
the IOM, WHO had made a recommendation that artemisinins should be used in
combination with other antimalarials to protect the compound from drug resistance. 16
In 2002, the IOM’s Board on Global Health convened a committee—the IOM Committee
on the Economics of Antimalarial Drugs—to examine the questions posed by USAID.
The chair of the Board on Global Health was Dean Jamison, Professor of Public Health
and Education at the University of California in Los Angeles. He asked his former PhD
advisor, Kenneth Arrow of Stanford University, a Nobel Laureate in economics and a
founding member of the IOM, to be chair of the Committee. As Arrow states, “They
convinced me quite quickly to be Chair. I like challenges and had done nothing in this
area of malaria and global health, so I thought this would be an interesting challenge.” 17
Jamison also asked Hellen Gelband and Claire Panosian to staff the Committee; they
were responsible for project management and writing the report. Jamison, Arrow, and
their colleagues then assembled the members of the Committee, seeking a balance
between economists and public health experts with malaria expertise.
The Committee held a series of meetings in Europe and the United States, invited experts
to present their work, and commissioned studies. While USAID provided initial funding
for the Committee’s proceedings, the Bill & Melinda Gates Foundation (BMFG) later
became a co-sponsor. The idea for a global subsidy for antimalarial drugs, accessible by
the public and private sectors, emerged early in Committee proceedings. Jamison, for
one, had been considering the idea since his work at the World Bank, where he learned
the challenges of addressing procurement problems at the country level. 18 Likewise, in
his research and discussions on malaria before the Committee was even constituted,
Arrow learned that the private sector plays a key role in the distribution and delivery of
antimalarials, particularly in Africa. 19 He knew that these distribution and delivery issues
would be central to the Committee’s discussions.

After weighing the advantages and disadvantages of both targeted and broad subsidies, as
well as subsidies administered at country and global levels, the Committee concluded a
broad subsidy at the global level for ACTs would be more efficient and equitable than
targeted subsidies or subsidies at the national or end-user levels. 20 It recommended the
establishment of a global fund that would purchase ACTs from manufacturers at a dollar
price per dose and resell it at one-tenth of that price. The subsidized ACTs would be
accessible by both the public and private sectors of all malaria-endemic countries. The
subsidy would at the same time enable widespread access to effective antimalarials (to
“save lives”) and delay the emergence of resistance to artemisinin for as long as possible
(to “buy time”). The Committee argued that a global subsidy allowed ACTs to flow to
both the public and private sectors, and also freed up countries to pursue malaria policies
most appropriate to their circumstances without having to divert funds better used for
other interventions toward ACT purchase. The Committee also believed that a global
subsidy would give the international community leverage to force artemisinin
manufacturers to stop monotherapy production. The Committee spent time assessing a
number of different alternatives before recommending the global subsidy as a solution to
the challenges of making ACTs more affordable and staving off resistance to artemisinin
compounds for as long as possible. 21
The Committee presented its recommendations in a report called Saving Lives, Buying
Time: Economics of Malaria Drugs in an Age of Resistance, released in July 2004. Prior
to the release of the report, Arrow presented the Committee’s findings to USAID staff
members by phone. USAID accepted the recommendation but took no steps to take the
idea forward. The GFATM, which had recently been established in 2002, did not respond
favorably to the report’s recommendations. Richard Feachem, the Executive Director of
the GFATM, wrote a letter to Arrow stating that the global subsidy was not necessary
because it already existed in the form of the GFATM. He argued that the private sector
could apply for subsidized ACTs from the GFATM (with a 100% subsidy) through the
national-level country coordinating mechanism. 22 Feachem may have also been
concerned that a new global subsidy entity could potentially take resources from the
GFATM. 23 With this kind of opposition, it was clear that the global subsidy idea needed
a sponsor to propel it forward.
In mid-2004, Olusoji Adeyi, Coordinator of Public Health Programs in the World Bank’s
Human Development Network, received a prepublication version of Saving Lives, Buying
Time. He was leaving for vacation so he put the report in his bag and forgot about it.
Later, sitting on the beach in North Carolina, he removed the report and read it. To
Adeyi, the idea of a global ACT subsidy seemed “an incredibly bright and simple idea.” 24
He believed that the global subsidy recommendation was groundbreaking, addressing in a
single stroke the questions of access to treatment, drug resistance, and public-private
channels for treatment. Adeyi stated, “I wanted to get back to the office right away to
start working on the recommendation.” 25 The challenge was how to translate the IOM
report’s core ideas into global policy. Adeyi knew that this would require technical work
to design an architecture and operational plan, including an institutional home for the
proposed global subsidy. Where could the proposed subsidy be located, and who would

take ownership for it? The plan would also require political strategies to build a coalition
of supporting donors, implementers, and other stakeholders.
Gaining Adoption for the Idea within the World Bank
At the time of the IOM report’s release, Adeyi was serving as chair of the Roll Back
Malaria Partnership’s Working Group on Finance & Resources (RBM FRWG). In its role
as chair, the World Bank convened a FRWG meeting in its Washington, D.C. offices in
September 2004. The primary topic of the meeting was the Saving Lives, Buying Time
report. 26 In the meeting, it became clear that there was opposition to the idea, even within
the World Bank’s Development Economics Research Group (DEC). One concern raised
by participants was whether the subsidy, by encouraging greater use of ACTs, would lead
to increased resistance of the only effective antimalarial currently on the market. 27 To
defuse the opposition, Adeyi sought a small grant from the RBM Secretariat to further
analyze the global subsidy idea. Instead of participating in the study team, Adeyi recused
himself from the analysis and invited Mead Over to participate. Over was a senior
economist at the World Bank and one of the meeting participants that expressed
apprehension about increased resistance. The two other members of the study team were
Ramanan Laxminarayan, a member of the IOM Committee and Fellow at Resources for
the Future in Washington, D.C., and David Smith, a staff scientist at the Fogarty
International Center, National Institutes of Health. The study’s specific objective was to
explore the effects of a global subsidy on both ACT demand and potential drug
resistance.
The researchers modeled a number of different scenarios, including no subsidy, partial

subsidy, full subsidy, and a two-year delayed subsidy. They concluded that any promptly
implemented subsidy of ACTs—whether full or partial—would have a significant effect
on the number of deaths averted. A two-year delay in implementing the subsidy,
however, would lead to increased use of both cheaper artemisinin monotherapy and
partner drug monotherapy and greatly amplify the risk of widespread artemisinin
resistance. The authors recommended that a global ACT subsidy be introduced
immediately on all eligible drug combinations in order to delay resistance and “buy time”
for further research and development of new antimalarial drugs. The study report was
published in July 2005 as a DEC Research Working Paper (and later in Health Affairs in
February 2006). 28
The study findings had a profound effect at the World Bank. On July 28, 2005, the
former Chief Economist and Senior Vice-President of DEC, Francois Bourguignon, and
the former Senior Vice-President for Human Development, Jean-Louis Sarbib, wrote to
Kenneth Arrow. They noted that the IOM’s recommendations on a global subsidy had
clear merit and indicated a willingness to explore its feasibility. The study also reinforced
the sense of urgency among Adeyi, IOM Committee members, and other advocates for
moving forward rapidly on the global ACT subsidy.

Securing Resources for Development of an Operational Plan
In September 2005, the World Bank held a donors’ conference in Paris. The meeting
centered around the World Bank’s new Booster Program for Malaria Control in Africa
and discussion of its framework for action in the Africa region. 29 This effort represented
the Bank’s renewed attention to malaria control and Adeyi had played a key role in its
design. One session at the meeting was devoted to Saving Lives, Buying Time. This
session proved to be an important opportunity to educate senior staff from donor agencies
about the global ACT subsidy idea. The main opposition that arose in the forum was from
supporters of insecticide-treated bednet programs who were concerned that the subsidy
might shift money away from efforts to scale-up bednets. 30
Also at this Paris meeting, RBM asked the World Bank, in its role as chair of the FRWG,
to develop a detailed proposal on behalf of RBM for the design and operation of a global
ACT subsidy. Adeyi welcomed this request as he felt RBM could bring institutional
legitimacy to the global ACT subsidy idea, provide a forum within which the operational
plan could be developed, and lead to widespread ownership of the global subsidy. 31 RBM
itself was not at that time in a position to move the work forward. It was about to embark
on the Change Initiative, facilitated by Boston Consulting Group, which was a
comprehensive redesign of RBM to improve effectiveness. Adeyi agreed to develop the
proposal but needed to find funding for the work. Daniel Kress and Girindre Beeharry of
the Bill & Melinda Gates Foundation (BMGF)—both members of the RBM FRWG—
said they would consider a proposal, and asked that it include architecture (what does the
organizational structure look like), analytics (what are additional questions that need to
be examined), and advocacy (what are the strategies for advocating for this). 32 Beeharry,
who was the point person within BMGF on the Medicines for Malaria Venture (MMV)
drug portfolio, was interested in how to get prices of new antimalarials down so they
could compete with SP in the private market and achieve health impact. 33 Given this
focus on affordability and the private antimalarial drug market, his interest in the global
ACT subsidy was growing. On behalf of RBM, Adeyi and his World Bank team, in
consultation with Ramanan Laxminarayan from Resources for the Future and Hellen
Gelband from IOM, submitted a Letter of Interest to BMGF in early 2006 and then
submitted the proposal for the project on Defining the Architecture and Management of a
Global Subsidy for Antimalarial Drugs in May 2006. After a period of review and
revision, the grant for $4,085,789 was approved in August 2006 for a 22-month period
(and was subsequently extended to March 2009).
Following approval of the grant, the World Bank initiated a procurement process for
consultants who would conduct many of the grant activities. Dalberg Global
Development Advisors, a consulting firm that specializes in international development
and globalization, won the contract. Some members of the RBM community were
unhappy with the selection of Dalberg, and wondered why they had been chosen. The
firm had only recently been established (in 2001) and did not have a long track record in
the field of global health. And unlike some of the other consulting firms bidding for the
project, they did not have previous experience working on malaria. But for these very

same reasons, Dalberg had a lot to prove to the global health community, and they began
the work in December 2006 with enthusiasm.
By the end of 2006, a small group of policy champions had started to form around the
global subsidy idea including Adeyi, Beeharry, Ramanan Laxminarayan from Resources
for the Future, and Hellen Gelband from the IOM. This core group believed that the
World Bank could act as policy sponsor of the global ACT subsidy, but that they also
needed a political sponsor. In the summer of 2006, the group went out to lunch with Rob
de Vos, the Dutch government’s Deputy Director General of Foreign Affairs, to discuss
the subsidy idea. At that time, the Dutch Foreign Affairs staff had been internally
discussing subsidized procurement because of global discussions around advanced
market purchases (AMCs) and the International Finance Facility for Immunization
(IFFIm). 34 The Dutch government had also been a member of the RBM Partnership
Board and de Vos, who had suffered from malaria, had a personal interest in the subsidy
idea. 35 Given these factors, the Dutch government agreed to host a RBM FRWG meeting
in Amsterdam (with the World Bank team and Dalberg carrying out the logistics) that
would bring together the RBM Partnership community and begin to drive the idea of the
global subsidy forward.
Challenges in Translating a Research Report into an Operational Plan
In January 18-19, 2007, the RBM FRWG held the two-day Expert Workshop and
Consultative Forum on a High-Level Buyer Subsidy for Artemisinin-Based Combination
Therapies in Amsterdam. The meeting was attended by representatives of the IOM
Committee (including Kenneth Arrow), World Bank, the U.S. President’s Malaria
Initiative (PMI), UNITAID, WHO, GFATM, UNICEF, MMV, Drugs for Neglected
Diseases initiative (DNDi), BMGF, malaria-endemic and donor countries, NGOs, and the
private sector. 36
Participants in the Amsterdam meeting included two broad groups of people. One group
consisted of the core group of policy champions, many of whom had been developing the
subsidy idea since 2004 when Saving Lives, Buying Time was released. Many of these
advocates had been working hard, often without support and on their own time, to get
internal adoption for the global subsidy from their organizations. They were ready to
move forward and urgently. They were excited about the subsidy idea, and convinced
that it was the right way forward given the research that Arrow and the IOM Committee
had put into it. Their strategy was to provide a forum on key issues related to the global
subsidy, but not to debate the “yes” or “no” of moving forward.
The other group represented the meeting participants who did not know much about the
global subsidy and came to Amsterdam to learn more about it. A number of these people
were very attracted, in principle, to the subsidy idea but were cautious about fully
endorsing it without further debate. Others had read Saving Lives, Buying Time and were
opposed to its recommendation to work through private sector distribution channels. One
concern that participants raised was whether the global subsidy was essentially a subsidy
to pharmaceutical companies, providing manufacturers a disincentive for lowering ACT

prices. Others voiced concerns about whether it was feasible or correct to provide the
subsidy to private sector buyers (a group of people felt the private sector was not needed
to solve the problem). Yet other participants, many of whom supported the subsidy idea,
felt that additional interventions were needed to make the subsidy idea work in the field.
These interventions included pharmacovigilance, social marketing, and monitoring and
evaluation. Some of these participants discounted the global subsidy idea because no
operational research had been done on the idea, and they were not convinced that it
would work in practice. A final category of concerns was from participants who
questioned whether a global subsidy initiative was the best or most efficient way to spend
scarce resources (time and money) at a time when other malaria control efforts were
being scaled-up to meet the goal agreed in the Abuja Declaration of 2000 to halve
malaria mortality in Africa by 2010.
Many of the participants who raised questions at the meeting felt that their views were
not welcomed or heard at the forum. The advocates of the global subsidy, on the other
hand, were frustrated with what they viewed as ideological responses to a new idea that
required new thinking. Both groups described the meeting as “heated.” 37 On the
meeting’s second day, the Deputy Director General of the Dutch Ministry of Foreign
Affairs, Rob de Vos, worked hard to find some consensus. De Vos, in the words of one
participant, was a “skilled diplomat, a negotiator.” 38 Many participants reported that the
actions of de Vos salvaged the meeting in the end. As one person said, “He created a
slight change in the group from ‘no’ to ‘yes’ and this was a critical moment for moving
forward.” 39
One result of the Amsterdam meeting was the creation of an RBM task force, called the
Global ACT Subsidy Task Force, to steer the work forward. The RBM Executive
Committee approved the creation of this task force in February 2007. The Task Force’s
role was to build consensus within the RBM Partnership on key factors related to the
global ACT subsidy and present these to RBM Board members later in the year. Specific
areas of work included making recommendations on a series of technical issues, reaching
out to stakeholders to create awareness and build support for the subsidy project, reaching
out to donors to mobilize funding, and raising awareness among malaria-endemic
countries. 40 The United Republic of Tanzania (Minister of Health David Mwakyusa) and
the Netherlands (Harry van Schooten of the Dutch Ministry of Foreign Affairs) were
chosen as co-chairs of the Task Force. Other members included the core group of
advocates for the global ACT subsidy along with a number of RBM partners. Task Force
membership was open to all RBM partners. The RBM Executive Director, Awa Coll-
Seck, and the RBM Secretariat facilitated and supported this group. The World Bank,
through its subcontract to Dalberg, took on the role of Secretariat for the Task Force.
The conflict experienced at the Amsterdam meeting was a difficult beginning to the
global ACT subsidy’s journey from research report to operational plan. In the view of
some participants, the meeting served to cement key groups’ opposition to the global
ACT subsidy, including the U.S. President’s Malaria Initiative (PMI). Some of these
opposing groups never changed their views on the subsidy and continued to oppose it. 41
Yet it provided a forum for groups to express their views. It also demonstrated to the

policy champions and Dalberg that the technical and political challenges involved in
moving forward with the global ACT subsidy were more complex than they originally
thought.
There continued to be vocal opponents to the global subsidy idea. Richard Feachem,
director of the GFATM, argued that even with the subsidy, ACT prices would still be
unaffordable for many poor people. People may start a course of treatment but then stop
because they could not afford the rest of the treatment, and this would lead to drug
resistance. He also stated that the global subsidy would undermine pharmaceutical
innovation on antimalarial drugs and distract ongoing work toward malaria targets.
Finally, he argued that the subsidy’s policy champions had created a picture of consensus
for the global subsidy, when in fact serious criticisms had not been addressed.
In the United States, PMI also continued to raise concerns about the global subsidy. As
Bernard Nahlen, deputy coordinator of PMI later stated to the National Journal Magazine,
“The U.S. Government has been consistent from day one on this, which is, there needs to
be some evidence for this. You have to go to a few countries and try this out and see if
it’s going to work. Nobody has all the answers to this. To propose one particular model to
solve all these problems, I think, is going far out on a very thin limb.” 42
Some representatives of northern NGOs also continued to oppose the global subsidy.
They opposed the idea of working through private sector distribution and delivery
channels.
Designing Strategies for Addressing Opposition
Given this opposition to the global subsidy idea, Adeyi and others in the core group
realized that more of their attention needed to be on educating and engaging stakeholders
about the IOM report’s core idea. In particular, they began to think about specific
strategies that would address skepticism and opposition from some key members of the
global malaria community. After the decision from Roll Back Malaria to create a task
force in February 2007, the core group knew that these strategies for stakeholders would
have to be designed and implemented in tandem with the technical work to develop an
architecture and operational plan for the global subsidy program.

Case Study Questions:
1. What were the main barriers to ACT access in poor countries?
2. What was the IOM Committee’s recommendation in Saving Lives, Buying Time
and how does it propose to address these access barriers?
3. Conduct a stakeholder analysis to assess the feasibility of the IOM’s

recommendation.
 First, identify the groups in the global health community that are stakeholders
in the global ACT subsidy and assess their views of the subsidy.
 Second, develop specific strategies that the core group of policy champions
could use to engage opponents of the global ACT subsidy idea and improve
the feasibility of the proposal.

Acknowledgments
The writing of this teaching case was commissioned and funded by the World Bank as an
independent research project. We would like to thank Dr. Olusoji Adeyi and Ms. Sonalini
Khetrapal of the World Bank for answering our many questions about the case and for
fact-checking dates and events. We would also like to express our gratitude to the many
people who gave their time and shared their perspectives on the process of developing the
Affordable Medicines Facility for Malaria (AMFm).
Notes

1
World Health Organization, World Malaria Report 2008 (Geneva: WHO, 2008), 10.
2
World Health Organization, World Malaria Report 2008, 31.
3
Nicholas White, “Antimalarial drug resistance,” The Journal of Clinical Investigation 13 (2004): 1084.
4
White; World Health Organization, World Malaria Report 2008.
5
World Health Organization, World Malaria Report 2008, 25.
6
WHO, Antimalarial Medicines Procured by WHO,
http://www.who.int/malaria/pages/performance/antimalarialmedicines.html (retrieved March 26, 2009).
7
Artepal, Inventory of ACT Producers,
http://www.artepal.org/index.php?option=com_content&task=blogcategory&id=39&Itemid=100 (retrieved
March 26, 2009).
8
Rima Shretta, Catherine Adegoke, and Peter Segbor. Global Fund Grants for Malaria: Lessons Learned
in the Implementation of ACT Policies in Nigeria (Geneva: Roll Back Malaria Partnership, 2007), 1.
9
Kenneth Arrow, Claire Panosian, and Hellen Gelband, eds. Saving Lives, Buying Time: Economics of
Malaria Drugs in an Age of Resistance, (Washington, D.C.: National Academies Press, 2004).
10
A number of new drugs have been prequalified since, including an artesunate + amodiaquine
combination from Guilin, China (August 2007), artesunate + amodiaquine combination from Ipca India
(April 2008), artesunate + amodiaquine combination from Sanofi-Aventis (October 2008), and an
artesunate + amodiaquine combination from Cipla India (November 2008).
11
William Rogers, Rithy Sem, Thong Tero, Pharath Chim, Pheaktra Lim, Sinuon Muth, Dong Socheat,
Fréderic Ariey, and Chansuda Wongsrichanalai, “Failure of artesunate-mefloquine combination therapy for
uncomplicated Plasmodium falciparum malaria in southern Cambodia,” Malaria Journal 8 (2009).
12
World Health Organization, Informal Consultation with Manufacturers of Artemisinin-Based
Pharmaceutical Products in Use for the Treatment of Malaria (Geneva: WHO) August 24, 2007: iii.
13
Arrow, Panosian, and Gelband.
14
Arrow, Panosian, and Gelband.
15
Interview #27 by author (Laura J. Frost).
16
World Health Organization, Antimalarial Drug Combination Therapy: Report of Technical consultation
(Geneva: World Health Organization, 2001).
17
Interview with Professor Kenneth Arrow on February 25, 2009 by author (Laura J. Frost).
18
19
20
Arrow, Panosian, and Gelband, 95.
21
The IOM Committee examined other interventions, such as insecticide-treated bednets (ITNs) and indoor
residual spraying (IRS). It endorsed the idea, suggested by the RBM Partnership in 2003, of a Malaria
Medicines and Supply Service (MMSS) as a means of expanding access to other forms of malaria control,
in addition to drugs. However, the Committee still believed a global subsidy was necessary to engage the
private sector and force monotherapies from the market. The RBM Secretariat began implementing the
MMSS in 2005. Kenneth Arrow, Claire Panosian, and Hellen Gelband.
22
23
24
Interview with Olusoji Adeyi, February 4, 2009, by author (Laura J. Frost).

25
Interview with Olusoji Adeyi, February 4, 2009, by author (Laura J. Frost).
26
The session is available online at http://info.worldbank.org/etools/docs/voddocs/632/1289/lo.htm.
27
Ramanan Laxminarayan, Mead Over, and David L. Smith, “Will a global subsidy of new antimalarials
delay the emergence of resistance and save lives?” Health Affairs 25 (2006): 325-336.
28
Laxminarayan, Over, and Smith, “Will a global subsidy of new antimalarials delay the emergence of
resistance and save lives?” 2006.
29
World Bank, “Framework for Action: Booster Program for Malaria Control in Africa, Scaling up for
Impact” (Working Paper, Donors’ Conference, Paris) September 8-9, 2005.
http://siteresources.worldbank.org/INTAFRBOOPRO/Resources/framework_for_action.pdf (retrieved
March 25, 2009).
30
31
32
33
34
35
36
RBM, “Global subsidy for ACTs agreed in Amsterdam,” RBM E-update, (January 2007),
http://www.rollbackmalaria.org/eupdate/rbmEupdate2007-02-06.htm, (Retrieved March 23, 2009).
37
Interviews #4, 7, and 22 by author (Laura J. Frost).
38
39
40
The World Bank, Terms of Reference for a Consulting Project.
41
This view has not been validated by staff of the U.S. President’s Malaria Initiative, who declined to be
interviewed for this study.
42
Jonathan Rauch, “Can Markets Cure Malaria?” National Journal Magazine. October 11, 2008.
http://www.nationaljournal.com (retrieved April 6, 2009).

Global
Health
Teaching
Case
Adopting National Health Insurance in West Africa*
In 2000, the opposition Patriotic Party won the national elections in this West African country, and took
control of the presidency and the legislature. This was the country’s first multi-party election that resulted
in a change of power, an important symbol of increasing democracy. They took over from the Democratic
Party, which had won the two previous elections and had its roots in a military regime that came to power
in a coup two decades earlier. The newly elected Patriotic Party sought to establish its legitimacy and win
the next elections scheduled for 2004.
During the 2000 election campaign, the Patriotic Party attacked the then ruling Democratic Party for its
health policy that relied on user fees paid by individual patients. The Patriotic Party promised to establish
a national health insurance system that would provide financial protection for many healthcare services
for everyone in the country, including the very poor. The problem of user fees as a financial barrier to
healthcare had been recognized since the early 1970s, and various groups had proposed different health
insurance policies as solutions. Faith-based organizations had initiated community prepayment schemes
in many local areas all over the country. Both the Democratic Party and the military regime from which it
emerged had considered health insurance as a major policy issue. The Democratic Party had undertaken
policy development in the MOH through pilot projects on health insurance. The mass media reported that
the general public wanted user fees abolished and replaced with health insurance. The public expectation
was also based on the constitutional provision that “the State shall promote just and reasonable access by
all citizens to public facilities and services,” which included health as a public service.
After the 2000 elections put the Patriotic Party into the seats of power, party leaders sought to fulfill their
promise. They wanted something that could be scaled up quickly to cover the entire population; they
wanted a policy that would be identified with their party and not their competitors; and they wanted a
policy that could be pushed through Parliament and implemented before the 2004 election campaign
began. Now in 2003, three years into the Patriotic Party’s term had already passed.
Party leaders confronted a number of challenges in introducing a new policy for national health insurance.
First, the committee of technical experts they had appointed (the “change team”) was moving slowly and
raising difficult questions that could delay implementation of the policy. Party leaders considered the idea
of appointing a new committee of consultants who were more politically aligned with the party; they
would be more flexible and responsive to party requests. Second, the Democratic Party (in the opposition)
was adamantly resisting the new policy, even though they had been working on a similar policy for years,
saying they would boycott any efforts to pass a law through Parliament. Patriotic Party leaders wondered
whether they should just use their majority to push the law through or seek a compromise package that
might win the opposition’s support; but some strategists thought that compromise would not lead to

This case was prepared by Michael R. Reich, Ph.D., Harvard School of Public Health. It is intended as a basis for
class discussion rather than to illustrate either effective or ineffective handling of an administrative situation. Case
development support was provided by the World Bank Institute. ©2012 by The President and Fellows of Harvard
College.
1
agreement. The political system gave the President authority to introduce appropriation bills in
Parliament, and some party strategists urged the President to use his powers to push the bill through.
Financing the new national health insurance scheme was a particularly troublesome point. The policy was
intended to provide health insurance to the country’s poorest people, who had no capacity to pay an
annual premium. Some leaders of the Patriotic Party wanted exemptions to cover many groups—
especially pensioners, children, pregnant women, and the poor—in order to deliver the benefits promised
in the election. But where would the funds for the insurance come from? The current government budget
was stretched thin, and foreign development agencies were not likely to provide financing every year.
Some party members suggested a sin tax (on cigarettes or alcohol); others suggested a new value added
tax; still others suggested a cross-subsidy from social security funds collected from employees in the
formal sector; another possibility was a small premium payment from enrollees. The cross-subsidy from
social security funds was vehemently opposed by the Democratic Party and by powerful labor unions; but
some leaders of the Patriotic Party thought they could tolerate that resistance. The ruling Patriotic Party
wanted to provide a broad social safety net quickly; some combination of financing would be necessary,
even if it came with some political costs. In addition, decisions needed to be made about the many
community-based health insurance schemes that had grown up around the country. The leader of the
federation of community plans proposed that the plans receive official recognition so that they could
receive government subsidies under the new insurance scheme.
A debate also arose over which services should be covered by the new insurance program: low-cost out-
patient services provided at health centers; more expensive health problems treated at secondary and
tertiary hospitals; or high-cost catastrophic problems that affected only a small portion of the population.
Technocrats in the policy design team proposed an incremental expansion of benefits, starting with the
most inexpensive and most common. But leaders of the ruling Patriotic Party wanted immediate tangible
effects that people would appreciate—and therefore wanted to focus on curative care. They also insisted
on no co-payments, which they thought would remind people of the old regime of patients paying for
services. Some technocrats urged a co-payment, to help contain costs and control over-use of services.
Debate also arose over whether to include preventive services along with curative services in the plan.
Other policy actors also expressed concerns about the proposed policy for national health insurance. The
national medical association urged the ruling party to move quickly on enacting their campaign promise,
along with payments to private doctors to deliver services. A provincial party leader argued for a
decentralized system. External development agencies took different positions; some urged the
government to move cautiously toward health insurance, others supported local community prepayment
schemes, and still others remained silent. Local pharmaceutical companies supported the national
insurance plan, as long as it would cover a broad list of essential drugs produced by national companies.
Leaders in the ruling Patriotic Party were seeking advice on the policy’s content and on political strategies
to assure the policy would be adopted by the legislature. The upcoming elections meant that the ruling
party could not afford to wait; party leadership wanted immediate action that would show people they had
delivered on past promises. What should they do, and how should they do it?
2
The Case for a  
Global Health Strategy  
for Canada 
John Kirton, James Orbinski and Jenilee Guebert 
Global Health Diplomacy Program,  
Munk Centre for International Studies 
University of Toronto 
 
Submitted on March 31, 2010 
Prepared for  
the Strategic Policy Branch in the International Affairs Directorate of  
Health Canada 
The views expressed in this report are those of the authors

and do not represent those of Health Canada or the Government of Canada.
The Case for a  
Global Health Strategy  
for Canada 
John Kirton, James Orbinski and Jenilee Guebert1 
Global Health Diplomacy Program,  
Munk Centre for International Studies, 
 University of Toronto 
March 31, 2010 
Prepared for  
the Strategic Policy Branch in the International Affairs Directorate of  
Health Canada 
Abstract 
Health is increasingly recognized as a global as well as a domestic issue. This study 
thus  examines  the  case  for  developing  a  Canadian  global  health  strategy.  It 
highlights the major strands of global health strategies already in place in Canada, 
the  primary  Canadian  players  in  the  field  and  the  motivation  for  past  actions.  It 
examines  the  impact  of  global  health  trends  on  Canadians,  and  indicates  where 
Canada has led and where it will be importantly involved in the future. It assesses 
whether there is a resulting need for an overall global health strategy for Canada, 
and  specifies  the  benefits,  costs,  risks  and  risk‐mitigation  measures  that  could 
arise  in  developing  such  a  strategy.  It  suggests  how  a  Canadian  global  health 
strategy might be designed and what it might contain. 
Canada could derive many benefits from a global health strategy. There are also 
costs  and  risks  that  could  arise.  However,  a  properly  prepared,  designed  and 
executed  global  health  strategy  would  lead  to  better  health  both  within  and 
outside Canada. A global health strategy would help to improve the effectiveness 
and  efficiency  of  the  various  actors  and  activities  operating  in  global  health.  It 
would provide a clear  focus for Canada’s  global health goals, would  mobilize and 
concentrate scarce human and monetary resources, and would provide a plan for 
how  to  reach  Canada’s  global  health  objectives.  Without  a strategy,  Canada  risks 
falling  behind  those  consequential  countries  that  already  have  or  are  likely  to 
develop a strategy and it will be more difficult for Canada to compete and partner 
effectively with leaders in the field.  
                                                 
1
  The  authors  gratefully  acknowledge  the  research  assistance  of  Caroline  Bracht,  Robin  Lennox, 
Julia Kulik and Sophie Langlois. 
About the Authors 
John Kirton 
John Kirton is co‐director of the Global Health Diplomacy Program, director of the 
G8 Research Group and co‐director of the G20 Research Group based at the Munk 
Centre  for  International  Studies  at  Trinity  College,  and  a  professor  of  political 
science  at  the  University  of  Toronto.  He  has  advised  the  World  Health 
Organization and the Canadian and Russian governments, and has written widely 
on global health governance and G7/8 and G20 summitry. His most recent books 
include  Innovation  in  Global  Health  Governance:  Critical  Cases  (co‐edited  with 
Andrew F. Cooper, Ashgate, 2009), Governing Global Health: Challenge, Response, 
Innovation  (co‐edited  with  Andrew  F.  Cooper,  Ashgate,  2007)  and  Canadian 
Foreign  Policy  in  a  Changing  World (Thomson  Nelson,  2007).  He  is  co‐author  of, 
among other articles, “Making G8 Leaders Deliver: An Analysis of Compliance and 
Health  Commitments,  1996–2006,”  Bulletin  of  the  World  Health  Organization 
(March  2007).  Kirton  is  also  co‐editor  of  three  book  series  published  by  Ashgate 
Publishing  and  the  editor  of  Ashgate’s  five‐volume  Library  of  Essays  in  Global 
Governance, including a volume on global health published in 2009. 
James Orbinski 
James  Orbinski  is  co‐director  of  the  Global  Health  Diplomacy  Program  at  the 
Munk Centre for International Studies at Trinity College, and a professor of both 
medicine  and  political  science  at  the  University  of  Toronto.  He  also  practises 
clinical  medicine  at  St.  Michael’s  Hospital.  As  president  of  Médecins  Sans 
Frontières (MSF) from 1998 to 2001, he launched its Access to Essential Medicines 
Campaign  and  accepted  the  Nobel  Peace  Prize  awarded  to  MSF.  He  led  MSF 
missions  in  Zaire  and  Rwanda  and  served  as  medical  coordinator  in  Afghanistan 
and Somalia. He co‐chaired MSF’s  Neglected  Diseases Working Group, which led 
to  the  Drugs  for  Neglected  Diseases  Initiative.  He  is  co‐founder  of  Dignitas 
International  and  has  served  on  the  boards  of  the  Global  Alliance  for  TB  Drug 
Development, the Stephen Lewis Foundation and Canadian Doctors for Medicare. 
He is a founding member of the editorial boards of Open Medicine and Conflict and 
Health. Orbinski is a member of the Climate Change and Health Council and the 
World  Economic  Forum’s  Global  Agenda  Council  on  Health  Care  Systems  and 
Cooperation.  He  is  the  author  of  the  award‐winning  An  Imperfect  Offering: 
Humanitarianism in the 21st Century (Doubleday, 2008) and was the subject of the 
2007 documentary Triage: Dr. James Orbinski’s Humanitarian Dilemma. 
Kirton, Orbinski and Guebert: The Case for a Global Health Strategy for Canada  3 
Jenilee Guebert 
Jenilee  Guebert  is  the  director  of  research  for  the  Global  Health  Diplomacy 
Program as well as for the G8 Research Group and the G20 Research Group, based 
at the Munk Centre for International Studies in Trinity College at the University of 
Toronto. Her work embraces global health governance, the climate change–health 
connection,  environment’s  lessons  for  global  health  governance,  G8  health 
diplomacy  and  compliance,  and  Canadian  and  NAFTA  responses  to  the  H1N1 
outbreak.  Recent  works  include  “Looking  to  the  Environment  for  Lessons  for 
Global Health Diplomacy,” “Canada’s G8 Leadership on Global Health,” “Bringing 
Health into the Climate Change Regime,” and “Moving Forward on Global Health 
Diplomacy:  Implementing  G8  and  APEC  Commitments.”  She  has  had  previous 
experience working for the Calgary Health Region, Statistics Canada and Elections 
Ontario.  She  has  been  a  member  of  the  field  teams  of  the  G8  and  G20  Research 
Groups on site at several G8 and G20 summits and has been involved in a number 
of  workshops  and  conferences  focused  on  global  health  and  Canada’s  year  as  G8 
host in 2010. 
Table of Contents 
Executive Summary  6
Introduction  8
Canadian Principles for Global Health  10
Global Health Strategies and Canada  11
Current Health Strategies in Canada  11
Major Players in Global Health in Canada  12
Motivation for Canadian Action on Global Health  12
The Need for a Strategy Now  13
Benefits, Costs and Risks of a Strategy  15
Potential Areas for Action and Initiative  18
Components of a Canadian Global Health Strategy  20
Canadian Priorities  20
Global Demands  20
Canada’s Comparative Advantage  21
Canada’s Partners  22
References  26
Appendix A:  Canada’s Global Health Contributions  34
Appendix B:  Global Health Actors in Canada  36
Appendix C:  Canada’s Role in Regional and International  
Health‐Related Organizations  37
Appendix D:  Canadians Affected by Diseases  38
Appendix E:  Canadian Public Opinion on Health Issues  39
Appendix F:  Benefits, Costs and Risks of a Global Health Strategy  
for Canada  41
Appendix G:  Canada’s Free Trade Agreements  43
Appendix H:  Effects of Climate Change on Human Health Identified by the 
Intergovernmental Panel on Climate Change  44
Appendix I:  Comparison of National Global Health Strategies  45
Appendix J:  Steps for Creating a Canadian Global Health Strategy  48
Appendix K:  Research Methodology  49
 
 
Executive Summary 
Health is increasingly a global issue. National health challenges often have global 
sources and their solutions thus require global responses. Canada and its citizens 
are vulnerable to health challenges from abroad. And Canadians are committed to 
achieving better health outcomes at home and abroad for all. 
For decades Canada has played an active role in global health. It has developed 
several  health  strategies  to  address  a  variety  of  health  challenges.  It  has  worked 
with governments, non‐governmental organizations, businesses and academics to 
improve health outcomes. Canada has participated in numerous  global forums to 
craft  global  health  initiatives  and  commitments.  And  Canada  has  committed 
significant  resources  to  improve  the  health  and  safety  of  Canadians  and  citizens 
abroad. 
In  the  current  climate  Canada  needs  a  global  health  strategy.  There  is  an 
increasing  number  of  health  threats  as  well  as  greater  mobility  of  individuals  and 
health workers. Resources are limited and need to be used in the most effective and 
efficient  manner  possible.  Research  on  global  health  challenges,  trends  and 
approaches  has  proliferated  in  recent  decades  and  it  is  now  understood  that 
coordinated,  global  approaches  are  necessary  for  the  effective  governance  of 
health. Canada is hosting three international summits in 2010 where it will have an 
opportunity  to  lead  on  global  health.  There  has  been  a  push  for  stronger 
accountability  in  the  international  system  to  ensure  that  countries,  including 
Canada,  are  keeping  their  global  health  commitments.  Other  countries  have 
already  developed  global  health  strategies,  which  have  proven  useful  for 
mobilizing resources, setting clear priorities and improving internal collaboration, 
coordination, efficiency and effectiveness. And while governments have continued 
to focus attention and resources on global health challenges, the number of people 
inflicted with disease has continued to increase and thus an adequate global health 
response is still required.  
Many benefits would arise from  developing a  Canadian global health strategy. 
It  would  lead  to  improved  health  in  Canada  and  globally.  It  would  provide 
Canadian  global  health  actors  with  a better  understanding of  the  health  activities 
currently  underway.  It  would  provide  greater  transparency  regarding  Canada’s 
global  health  priorities  and  objectives.  It  would  help  Canada  focus  on  which 
activities  should  be  enhanced,  eliminated  or  reformed  in  resource‐constrained 
times.  It  would  support  collaboration,  coordination  and  cooperation  among  the 
many  departments,  agencies  and  other  actors  that  deal  with  health  in  Canada, 
fostering  a  more  coherent  and  cost‐effective  approach.  It  would  strengthen 
national security and international partnerships. It would mobilize more resources 
by giving Canadian and international actors clear, compelling priorities to support 
on  a  broad  scale.  It  would  ensure  that  Canada  could  respond  effectively  to  the 
unexpected health crises that will inevitably arise. It would offer an opportunity for 
Canadians  and  others  to  cultivate  a  global  heath  regime  that  supports  Canada’s 
interests  and  values.  It  would  advance  Canada’s  foreign  policy  and  international 
economic development goals. 
Several  costs  also  could  arise  from  a  Canadian  global  health  strategy.  It  will 
take  time  and  resources  to  develop  a  global  heath  strategy.  It  could  generate 
conflicts  over  whether  there  should  be  a  strategy,  what  it  should  contain,  who 
should  be  involved  and  who  should  lead.  It  could  divert  attention  away  from 
problems that also require attention. It could require a modification of mandates or 
operating  procedures for  certain  actors.  It  could  complicate  relationships  between 
different levels of government, departments or other actors.  
Risks could also arise if the strategy is not developed properly. If the strategy is 
too  inflexible,  general,  under‐ambitious  or  over‐ambitious,  it  could  be  ineffective. 
Satisficing, log rolling and accountability demands could all have potential negative 
affects as well. However, several measures could mitigate these costs and risks. 
Canada’s  global  health  strategy could  focus  on  the  health‐related  Millennium 
Development  Goals  (MDGs),  the  global  health  issues  that  have  already  had  a 
significant  impact  on  Canadians  at  home,  the  international  issues  or  institutions 
where Canada plays a significant role, the global health commitments that Canada 
has  already  made  but  not  yet  met,  niche  areas  where  Canada  has  medical  and 
research  expertise,  neglected  topics  where  Canada  could  carve  out  a  leadership 
role, or health issues that are critical in countries where Canada has a key foreign 
policy  or  development  interest.  Any  one  or  combination  of  these  factors  could 
form the core of a Canadian global health strategy. 
Available  evidence  suggests  that  Canada  should  develop  a  global  health 
strategy and that the strategy should be commenced as soon as possible. 
Introduction 
There is an increasing range of health issues that transcend national boundaries and 
require  action  on  the  global  forces  that  determine  the  health  of  people.  The  broad 
political,  social  and  economic  implications  of  health  issues  have  brought  more 
diplomats  into  the  health  arena  and  more  public  health  experts  into  the  world  of 
diplomacy. Simple classifications of policy and politics — domestic and foreign, hard 
and soft, or high and low — no longer apply.  
— Ilona Kickbusch, Gaudenz Silberschmidt and Paulo Buss 
Since  the  2000  G8  Okinawa  Summit,  there  has  been  a  significant  shift  in  global 
heath. The number of actors in the field has grown exponentially (Orbinski 2007). 
International  health  commitments  have  expanded  in  number  and  ambition 
(Guebert  2009;  Sridhar  2009).  Financial  pledges  to  global  health  have  risen 
substantially  (see  Appendix  A;  Fallon  and  Gayle  2010).  Global  health  has 
increasingly been a priority for international development and a key component of 
foreign policy, security, trade and the environment. 
At  the  same  time,  countries  recognize  that  challenges  to  public  health  and 
safety  at  home  often  have  global  sources  and  that  their  solutions  thus  require 
global  responses.  The  recent  outbreaks  of  severe  acute  respiratory  syndrome 
(SARS)  and  the  H5N1  and  H1N1  influenza  viruses  have  dramatically  shown 
Canadians  and  others  how  countries  and  societies  are  now  integrally 
interdependent (Sridhar 2009; Fidler 2004). Canada and its citizens are vulnerable 
at  home  to  diseases,  pathogens,  toxic  contaminants  and  the  effects  of  climate 
change  that  cross  borders  via  the  atmosphere,  humans,  animals,  wildlife  and 
imported  food.  Food  safety  in  Canada  depends  partially  on  the  regulatory 
structures  of  other  countries  (as  in  the  case  of  melamine  in  Chinese  baby  food 
exports,  the  emergence  and  spread  of  bovine  spongiform  encephalopathy  [BSE], 
and the use or non‐use of bovine growth hormone in beef). The effects of climate 
change  in  Canada  are  largely  due  to  human  activities  outside  Canada.  The  2.5 
million  Canadians  who  live  abroad,  the  50  million  Canadians  who  travel  abroad 
and  the  250,000  citizens  who  migrate  to  Canada  every  year  are  vulnerable  to 
abundant  health  risks  beyond  Canada’s  borders,  some  of  which  they  bring  with 
them  when  they  return  (Cannon  2010;  Canada,  Department  of  Citizenship  and 
Immigration 2009). 
Canada’s  role  in  global  health  has  grown.  Pathogens  and  health  “problems 
without  passports”  have  diminished  the  ability  of  governments  to  protect  their 
people by erecting defences at their borders. This is especially the case for Canada, 
which has one of the longest land borders and the longest coastline in the world. 
Health  issues  must  thus  be  dealt  with  at  their  source,  anywhere  in  the  world, 
before disease can erupt, spread and intrude into Canadians’ homes. At the same 
time,  Canada  remains  committed  to  improving  the  health  of  all  people, 
particularly the poorest and most vulnerable, in the world outside.  
Various  actors  involved  in  global  health  within  and  outside  Canada  have 
cooperated on past projects. But Canada has no overarching global health strategy 
to  guide  a  more  comprehensive,  collaborative  and  coordinated  approach.  Such 
coordinated  responses  for  global  and  domestic  action  have  become  critical  to 
solving  many  “national”  health  problems  (Switzerland,  Federal  Department  of 
Home  Affairs  and  Federal  Department  of  Foreign  Affairs  [FDHA/FDFA]  2006). 
Thus  an  inclusive,  coherent  global  health  strategy is  critical  to  governing  health. 
Several  consequential  countries  and  communities  close  to  Canada  have  already 
developed  their  own  global  health  strategies,  among  them  the  United  Kingdom, 
the  European  Union  and  Switzerland.  Other  significant  countries  including  the 
United  States  are  working  toward  one  (Ali  and  Narayan  2009;  Fallon  and  Gayle 
2010). Now is the time for Canada to identify the benefits, costs and risks of such a 
strategy to determine whether and why Canada should develop one of its own. 
Canadian Principles for Global Health 
The  case  for  developing  a  Canadian  global  health  strategy  is  supported  by  the 
consistency  and  coherence  of  the  basic  health‐related  principles  that  have  been 
highlighted  by  Canadian  governments  led  by  both  major  political  parties in  their 
defining doctrines of national and international policy since 1945.2 
•  The  first,  fundamental  principle,  appearing  since  1949,  is  a  high‐quality 
national  healthcare  program,  equally  benefiting  all  Canadians  regardless  of 
economic status.  
•  The  second  principle,  first  appearing  in  1957,  is  the  agricultural–health 
pathway,  which  has  been  a  development  priority  that  includes  food, 
agriculture,  famine  relief  (as  in  Ethiopia  in  1984)  and,  by  2010,  nutrition  for 
children’s and maternal health abroad as well as a domestic priority involving 
food safety.  
•  The third principle, arising first in 1967, is the link between the environment 
and health, and the resulting need for a multi‐stakeholder partnership among 
government,  academics  and  the  private  sector;  by  2002  climate  change 
appeared as the key environmental element affecting health.  
•  The fourth principle, emerging in 1970 in the wake of the Nigerian civil war, is 
the  international–domestic  link,  affirming  that  Canadians’  health  cannot  be 
protected if infection is rampant in other parts of the world.  
•  The fifth principle, starting in 1989, is the need for a focus on a wide range of 
health‐related  issues:  HIV/AIDS,  drug  abuse  and  aging‐associated  illnesses, 
with breast cancer and tobacco‐related illnesses added in 1997, AIDS‐affected 
children  in  1999,  SARS,  avian  influenza  and  AIDS  in  Africa  in  2004,  H1N1 
influenza in 2009, and children’s and maternal health in 2010.  
•  The sixth principle, foreshadowed in 1957, is the high priority afforded to the 
institutions  of  the  United  Nations  and  instruments  of  Canadian  official 
development  assistance  (ODA),  with  a  recent  focus  on  the  Millennium 
Development  Goals  (MDGs),  a  possible  G20  summit  on  health,  access  to 
affordable  medicines,  the  creation  of  the  Public  Health  Agency  of  Canada 
(PHAC)  in  2004  and  the  prominent  place  of  children’s  and  maternal  health 
on the agenda of the Canadian‐hosted G8 summit in 2010.  
There is thus a cumulatively clear, consistent, coherent, comprehensive set of 
core principles on which a Canadian global health strategy can now be built. 
                                                 
2
  The analysis of Canadian principles relevant to global health was based on a systematic review of 
health‐related  passages  in  the  Speeches  from  the  Throne  and  major  foreign  policy  statements 
issued by the Government of Canada since 1947. 
Global Health Strategies and Canada 
Current Health Strategies in Canada 
The  Canadian  government  has  long  led  in  advancing  important  global  health 
initiatives.  When  the  World  Health  Organization  (WHO)  was  established,  Dr. 
Brock Chisholm — a former Canadian deputy minister of health — was appointed 
as  the  first  head.  During  the  framing  of  the  WHO  constitution,  a  Canadian 
delegate  aptly  argued  for  broad  and  inclusive  membership  in  the  organization, 
stating: 
We cannot afford to have gaps in the fence against disease; and any country, no 
matter what its political attitudes or affiliations are, can be a serious detriment 
to the effectiveness of the World Health Organization if it is left outside. It is 
important  that  health  should  be  regarded  as  a  world‐wide  question,  quite 
independent of political attitudes in any country in the world (Sharp 1947). 
Canada  has  subsequently  developed  specific  strategies  to  address  individual 
health  challenges.  They  cover  a  wide  range  of  demographic  groups  including 
youth,  aboriginal  people  and  women;  diseases  including  diabetes  and  cancer; 
mental  health;  the  determinants  of  health  including  food;  and  animal  safety 
(Health  Canada  1999;  PHAC  2005,  2007,  2008a;  Mental  Health  Commission  of 
Canada  undated‐a,  undated‐b;  Government  of  Canada  2008b).  These  strategies 
have  largely  been  internally  oriented,  but  have  been  influenced  by  or  have 
contained  an  inherent  international  dimension.  Canadian  stakeholders  have 
suggested that Canada should develop additional health strategies. These include a 
global health strategy for indigenous peoples and a Canadian global health strategy 
(Smylie 2004; Singer 2009). 
Canada currently invests approximately $550 million annually on global health 
initiatives  (Singer  2009).  Federal,  provincial  and  territorial  departments  and 
agencies  have  devoted  substantial  resources  to  developing  and  implementing 
strategies  to  tackle  specific  global  health  challenges.  These  include  G8  health 
action plans and pandemic plans — particularly since the SARS outbreak in 2003, 
the  H5N1  scare  in  the  mid  2000s  and  the  recent  H1N1  pandemic  (Canada, 
Department  of  Finance  2006;  PHAC  2010a,  2010b;  G8  2003).  Several  research 
institutes in Canada, many strongly supported by Canadian government resources, 
have  developed  collaborative  national  and  international  partnerships  on  health 
initiatives  as  well  (Canadian  Institutes  of  Health  Research  [CIHR]  2002;  Health 
Research  Council  of  New  Zealand  2009;  CIHR  2008;  Ray,  Daar,  Singer  and 
Thorsteinsdóttir 2009).  
Canada  has  taken  a  leadership  role  in  hosting  meetings  on  global  health.  It 
hosted  the  first  meeting  of  the  Global  Health  Security  Initiative  (GHSI)  in 
November 2001 (GHSI 2001). In October  2005, Canada convened an  international 
meeting  to  collaborate  and  coordinate  pandemic  influenza  preparedness  (DFAIT 
2009). Canada is also one of five independent industrialized countries often called 
on to chair or mediate delicate global health negotiations (Silberschmidt 2009).  
A  Canadian  global  health  strategy  could  thus  strengthen,  improve  and  foster 
comprehension,  communication  and  coherence  among  this  rich  array  of 
component  sectoral  strategies  and  partnerships.  It  could  avoid  unnecessary 
duplication and mobilize actors to work together for maximum impact in meeting 
Canada’s global and national health goals. 
Major Players in Global Health in Canada 
Within Canada, many actors play a key role in global health (see Appendix B). At 
the international and regional levels, Canada has a role in many intergovernmental 
institutions  involved  in  global  health  (see  Appendix  C).  Given  the  number  and 
diversity of these institutions, there are benefits in having Canadian participation 
in each flow from a single global health strategy at home. 
Within civil society and the private sector, there are many academic, research, 
business  and  non‐governmental  organizations  (NGOs)  —  nationally  oriented, 
transnational  in  nature  or  linked  internationally  —  that  are  dedicated  to  global 
health.  For  example,  Canadian  civil  society  organizations  such  as  the  Canadian 
Public Health Association (CPHA) worked with the WHO and many international 
governmental  and  non‐governmental  partners  to  establish  the  1986  Ottawa 
Charter  for  Heath  Promotion.  This  seminal  international  charter  focused  on 
enabling  people  to  increase  control  over  their  health  and  on  building  healthy 
public  policy  across  all  domains  of  government  beyond  the  health  sector. Led  by 
Canadian civil society through the 1990s and now into the 21st century, this charter 
has  resulted  in  the  globally  successful  Healthy  Cities  project  that  looks  at 
environmental  aspects  of  sustainable  urban  development  as  a  determinant  of 
health  (Kickbusch  1989).  In  2005,  an  offshoot  of  this  process  produced  the 
domestically  successful  BC  Healthy  Communities  Project,  an  initiative  to  build 
capacity for healthy thriving and resilient communities in Ontario, New Brunswick 
and Quebec (see <www.bchealthycommunities.ca>).  
Motivation for Canadian Action on Global Health 
Canadians  have  been  motivated  to  act  on  global  health  as  a  result  of  the  direct 
impact  of  global  health  challenges,  such  as  pandemic  disease,  food  safety  and 
security,  and  climate  change  on  health  at  home  and  abroad  as  well  as  by  the 
international  and  domestic  application  of  the  core  values  that  Canadians  share. 
Many Canadians suffer from infectious and chronic diseases, many of which have 
spread  from  other  countries  (see  Appendix  D).  Canadians  want  to  maintain  and 
improve their health and, at the same time, the health of others around the world 
(see  Appendix  E;  International  Development  Research  Centre  [IDRC]  2008). 
Beyond  self‐interest  and  altruism,  Canadians  increasingly  recognize  the 
interdependence of the health of people at home and the health of people abroad.  
Protecting  the  health  and  safety  of  Canadians  has  been  a  deep  and  durable 
priority of the Canadian government for decades. Canada spends 10.1% of its gross 
domestic  product  (GDP)  on  health  —  one  of  the  highest  in  the  world 
(Organisation for Economic Co‐operation and Development [OECD] 2009b). The 
government  has  long  pursued  a  foreign  policy  that  reflects  Canadians’  values  of 
democracy, peace and equity and its distinctive national values of antimilitarism, 
environmentalism,  openness,  multiculturalism,  globalism  and  international 
institutionalism  (Singer  2010;  Kirton  2007).  This  pursuit  has  led  to  supporting 
actions  and  initiatives  on  global  health,  such  as  the  Global  Polio  Eradication 
Initiative (GPEI) since 1985, the MDGs since 2000, the Global Fund to Fight AIDS, 
Tuberculosis  and  Malaria  since  2002,  the  Framework  Convention  on  Tobacco 
Control (FCTC) since 2003 and the International Health Regulations (IHR), which 
Canada  was  involved  in  negotiating  and  revising  since  2004  and  which  entered 
into  force  in  2007.  Numerous  bilateral  initiatives  have  been  taken  as  well  (see 
Appendix A).  
Increasingly,  the  government  has  recognized  that  Canada’s  interests  are 
connected with the rest of the world (Government of Canada 2010). Thus actions 
on  global  health  not  only  promote  Canadians’  values  and  a  broad  range  of 
Canadian  interests,  but  are  also  necessary  to  directly  protect  Canadians’  own 
health.  
The Need for a Strategy Now 
Now  is  the  time  for  Canada  to  develop  its  own  global  health  strategy. Countries 
cannot govern health adequately on their own (United Kingdom, HM Government 
2008;  Cooper,  Kirton  and  Schrecker  2007).  Infectious  diseases  do  not  respect 
borders  and  therefore  collaboration  to  deal  with  health  threats  at  their  distant 
source  is necessary for a successful response.  Development strategies are integral 
to  advancing  democracy  and  human  rights,  to  creating  a  more  prosperous, 
democratic and equitable world, to stopping and preventing terrorism, to building 
a  stable  global  economy,  to  stopping  and  preventing  conflicts,  and  to  preventing 
and containing global pandemics (Clinton 2010).  
All  states,  including  Canada,  have  become  increasing  vulnerable  to  global 
health  threats  (Fischer  2009).  This  vulnerability  became  clear  after  the  anthrax 
attacks  in  the  United  States  immediately  following  the  attacks  of  September  11, 
2001,  and  the  cases  of  SARS,  H5N1  and  H1N1  (Bennett  2009;  Chan  2009a,  2009b; 
Global  Health  Security  Initiative  2009).  Canada  is  also  vulnerable  to  the  looming 
health  impacts  of  climate  change,  such  as  increasing  incidence  of  malaria 
(Berrang‐Ford et al. 2009). 
Demand  for  attention to  global  health  and international  health  standards  has 
been  increasing  due  to  the  increased  mobility  of  individuals  and  health  workers 
(through  migration  and  travel),  rising  costs,  increasing  scientific  knowledge  and 
the growing technical complexity of health challenges and capacity to respond to 
those challenges (FDHA/FDFA 2006). By placing more emphasis on health abroad, 
Canada  can  help  to  limit  diseases  from  spreading  to  its  territory.  More 
collaboration  and  regulation  on  food  and  product  safety  challenges  such  as  BSE 
and  avian  influenza  will  help  limit  the  negative  health,  trade  and  economic 
impacts  that  can  result.  For  example,  it  is  estimated  that  $1.5  billion  was  lost  in 
economic revenue in Ontario alone as a result of SARS (Price‐Smith 2009). Better 
collaboration and cooperation could prevent or at least limit similar impacts in the 
future. Both the awareness of global health challenges and global health research 
have  increased  and  much  more  is  known  about  the  interconnectedness  and 
interdependence of health challenges  (Kirton  2009). There is thus more evidence 
to support the development of a global health strategy now. 
In  2010,  Canada  has  a  unique  opportunity  to  play  a  leadership  role  on  global 
health as it will host the G8 summit in Muskoka and the G20 summit in Toronto in 
June and the North American Leaders’ Summit in September. The Prime Minister 
has already declared that children’s and maternal health is a top priority for the G8 
Muskoka Summit. A strategy could support the initiatives that have already been 
put forward at Muskoka and other international meetings.  
A  strategy  could  also  help  keep  Canada  and  others  accountable  to  their  past 
and  future  health  commitments,  including  the  MDGs,  which  remain  far  from 
being  reached.  As  the  Prime  Minister  said  at  the  World  Economic  Forum  in 
January 2010, “Accountability … is the prerequisite for progress” (Harper 2010b). A 
global  health  strategy  could  help  Canada  reach  the  MDGs by  their  2015  deadline 
(HM Government 2008). It could also assist in ensuring accountability on Canada’s 
commitments made in a broad array of international forums in recent years. 
Other  countries  have  recently  recognized  the  benefits  of  developing  a  global 
health  strategy.  The  growing  number  includes  some  of  Canada’s  closest 
international  partners.  Switzerland,  now  one of  Canada’s  free  trade  partners,  was 
the first to adopt a global health strategy, doing so in October 2006 (Sridhar 2009; 
FDHA/FDFA 2006). The United Kingdom and European Union adopted strategies 
in  2007  and  2008  respectively  (Commission  of  the  European  Communities  2007; 
HM  Government  2008).  The  United  States,  China  and  Brazil  are  currently 
considering  similar  policies  (Kickbusch  and  Erk  2009;  Ali  and  Narayan  2009; 
Fallon and Gayle 2010). Norway, which allocates the highest percentage of GDP to 
ODA  and  has  taken  the  lead  in  pushing  countries  to  reach  MDGs  4  and  5,  is 
considered one of the most active countries in global health (Silberschmidt 2009). 
To  be  competitive  with  its  peers  and  to  partner  effectively  with  them,  Canada 
needs its own global health strategy. 
Moreover,  Canada  should  develop  a  global  health  strategy  because  the  world 
simply will not wait. Population growth, climate–health impacts and the spread of 
infectious  disease  will  not  improve  unless  drastic  measures  are  taken  to  prevent 
and stop them. The health, economy, security and stability of many at home and 
abroad will suffer greatly without action. 
Why Now? 
1.  Vulnerability to global health threats has increased. 
2.  Individuals and health workers are more mobile. 
3.  Better,  more  effective  use  of  scarce  resources  is  needed  in  today’s  time  of 
restraint. 
4.  More is known about the interdependencies, intersections and impacts of health. 
5.  Canada  will  host  three  major  summits  in  2010  at  which  global  health  could  be  a 
focal point. 
6.  Increased accountability for compliance on health commitments is needed. 
7.  More countries are developing global health strategies. 
8.  The world will not wait. 
A global health strategy would help ensure the health and safety of Canadians. 
It  would  strengthen  progress  and  plans  for  future  actions.  It  would  help  outline 
Canada’s  short‐,  medium‐  and  long‐term  global  health  goals and  ensure  that  the 
individual health‐related commitments Canada makes in international forums and 
at  home  are  consistent  and  coherent  parts  of  an  overall  approach.  It  would  help 
render  consistent  and  synergistic  provincial,  national  and  international  plans.  It 
would  provide  a  mechanism  for  better  coordination.  It  would  clearly  set  out 
Canada’s  global  health  priorities  so  that  all  the  actors  involved  have  a  clear 
understanding  of  Canada’s  objectives.  It  would  enable  Canada  to  take  a  more 
proactive role on global health (as opposed to a reactionary and defensive one). It 
would provide more effective and efficient responses that are increasingly needed 
to  save  and  enhance  human  lives  and  to  reduce  the  soaring  social  and  economic 
costs both in Canada and abroad (Kates, Fischer and Lief 2009). 
Benefits, Costs and Risks of a Strategy 
There  are  benefits,  costs  and  risks  that  could  come  from  developing  a  Canadian 
global health strategy (see also Appendix F).  
Benefits 
Canada  could  derive  many  benefits  from  the  process  of  developing  a  Canadian 
global  health  strategy  as  well  as  from  the  strategy  itself. A  global  health  strategy 
would  lead  to  better  health  in  Canada  and  abroad  (World  Vision  International 
2009;  HM  Government  2008).  It  would  provide  the  various  Canadian  actors 
involved  in  global  health  with  a  clearer  understanding  of  what  their  relevant 
colleagues  are  currently  doing.  It  would  provide  greater  transparency  and  a  clear 
framework of what Canada’s global health priorities are, how Canada plans to meet 
them  and  what  each  actor’s  role  should  be.  This  framework  would  also  help  to 
focus research efforts. It would provide guidelines for collaboration, coordination 
and cooperation particularly among actors from non‐health areas and those with 
traditional health backgrounds. It would improve internal cooperation and provide 
shared  objectives  and  better  clarity  for  all  Canadian  actors  in  the  field  of  global 
health  and  the  Canadian  public  as  a  whole  (FDHA/FDFA  2005).  It  could  help  to 
build  stronger  partnerships  with  key  international  actors.  It  would  help  ensure 
that  Canada  is  using  its  scarce  resources  to  best  effect.  It  would  catalyze  others, 
including philanthropists, to contribute more resources to defined, identified and 
compelling  priorities.  It  would  help  improve  preparation  and  response  for 
unexpected  health  crises  that  will  inevitably  arise.  It  would  promote  Canadian 
interests  and  values  (see  Appendix  E).  And  it  would  help  to  ensure  that  Canada 
meets it foreign policy and international development goals. 
Benefits 
1.  Improved health in Canada and globally. 
2.  Clearer understanding of current and relevant global health activities. 
3.  Greater transparency. 
4.  Clear framework of Canada’s global health priorities. 
5.  Guidelines for collaboration, coordination and cooperation. 
6.  Strengthened international partnerships. 
7.  More effective and innovative application of resources. 
8.  Better response to unexpected health crises. 
9.  Promotion of Canadian interests and values. 
10. Support for Canadian foreign policy and international development goals. 
Costs 
A  global  health  strategy  will  bring  some  costs  to  Canada.  It  will  take  time  and 
resources  to  develop.  There  will  be  potentially  conflict‐generating  conversations 
about  whether  such  a  strategy  is  necessary,  how  it  should  be  done,  who  should 
lead, what the role of each actor is and what the common priority goals should be.3 
The process of developing the strategy could divert attention from other individual 
and  immediate  problems.  It  may  require  some  actors  to  change  their  missions, 
expertise  and  even  authorizing  legislation  to  play  their  full  intended  part  as  an 
integral  component  of  the  larger  whole.  It  might  also  require  that  an  analysis  of 
current  commitments  and  component  strategies  be  conducted,  which  would  be 
time consuming and would delay progress. Canada’s complex  federal system also 
adds complications.
                                                 
3
  Because  there  is  a  diverse  array  of  actors  involved  in  global  health  in  Canada,  conflicting  or 
competing  objectives  may  arise.  For  example,  actors  in  trade  may  have  different  views  and 
objectives  from  those  in  development,  complicating  the  treatment  of  issues  such  as  access  to 
affordable  medicines  (Silberschmidt  2009).  Similarly,  environmental  actors  and  health  actors 
may have different views  on the use of  dichlorodiphenyltrichloroethane  (DDT)  to fight malaria. 
These varying views will be challenging to overcome. 
Costs 
1.  Time and resources. 
2.  Conflict‐generating conversations. 
3.  Diverted attention from individual and immediate problems. 
4.  Possible changes for actors’ missions, expertise and authorizing legislation. 
5.  Time‐consuming analysis of current commitments and component strategies. 
6.  Complications from federal‐provincial relations. 
Risks 
As  with  any  new  development,  there  are  potential  risks  to  developing  a  global 
health  strategy.  Inflexibility  in  policy  and  resource  investment  could  result  from 
developing  a  fixed  comprehensive  approach.  This  in  turn  would  make  it  more 
difficult  for  Canada  to  shift  its  priorities  after  putting  a  public  global  health 
strategy  in  place.  An  emerging  crisis  that  requires  immediate  attention  might  be 
ignored or dealt with inappropriately or inadequately as a result. At the other end 
of the scale, there is the danger of setting objectives that are too general in scope 
or provide insufficient guidance. Such generality may contribute to confusion due 
to  multiple  interpretations.  Under‐ambition  could  result  from  a  consensus  that 
rests  at  the  lowest  common  denominator  or  defines  global  health  too  narrowly. 
Over‐ambition  may  result  from  defining  global  health  too  broadly.  A  poorly 
designed global health strategy could alienate key actors that should be involved in 
the  process,  causing  further  division  and  inconsistency. There  is  also  a  chance  of 
overcrowding, with too many actors diluting the usefulness of such an exercise or 
making  it  unmanageable.  Satisficing  could  result  as  actors  may  meet  merely  the 
minimum  requirements  to  comply  with  their  obligations,  preventing  more 
ambitious commitments from being achieved. Log rolling — exchanging favours to 
mutual benefit — could cause incoherence and synthetic, forced synergies. There 
is also the risk that existing commitments could be disregarded. The specification 
of  goals  in  a  global  health  strategy  could  imply  that  they  trump  older,  but  still 
important, commitments. 
Risks 
1.  Inflexibility. 
2.  Generality. 
3.  Under‐ambition. 
4.  Over‐ambition. 
5.  Alienation. 
6.  Overcrowding 
7.  Satisficing. 
8.  Log rolling. 
9.  Diverted or neglected attention to existing commitments. 
Cost and Risk Mitigation Measures 
Measures can be taken to mitigate the costs and risks involved in a global health 
strategy.  
First,  a  list  of  all  the  possible  costs  and  risks  should  be  identified.  This  will 
ensure that measures are taken to prevent or reduce them. 
Second,  the  global  health  strategy  should  be  properly  thought  through.  An 
exercise undertaken in haste is more likely to produce unintended risks and costs.  
Third, all the relevant actors should be included in developing a global health 
strategy. A comprehensive and consultative approach will help  guarantee a sense 
of  inclusiveness  and  a  coherent,  synergistic  and  successful  strategy.  Any 
competing, inconsistent on irrelevant proposals can be tackled at an early stage.  
Fourth,  goals  and  limitations  should  be  clearly  identified  at  the  outset.  The 
articulation of why a global health strategy is desirable and what it aims to achieve 
is critical to creating a coherent and useful strategy.  
Fifth,  it  is  important  to  identify  who  will  supply  the  resources  necessary  to 
developing the global health strategy. 
Sixth, the global health strategy needs to be properly balanced. It needs to be 
sufficiently flexible to adapt to emerging crises, yet be bound in such a way that it 
is clear, concise and constraining in what it hopes to achieve. 
Seventh,  it  must  respect  existing  commitments  and  support  their 
implementation.  Doing  so  will  uphold  the  integrity  of  the  actors  involved  in 
developing  the  global  health  strategy  and  keep  them  accountable  for  their  past 
promises. 
Potential Areas for Action and Initiative 
Canada’s  global  health  strategy  could  focus  on  several  subjects,  in  particular  the 
following: 
•  The  health‐related  MDGs  that  deal  with  children’s  and  maternal  health, 
which the Prime Minister has already set as one of Canada’s priorities for the 
G8 Muskoka Summit (Harper 2009, 2010a; Government of Canada 2010).  
•  Global  health  issues  that  have  already  significantly  affected  Canadians  at 
home, such as West Nile virus, SARS, BSE and H1N1 (see Appendix D; Maioni 
2008;  Bennett  2009;  Price‐Smith  2009;  Chan  2009a,  2009b;  PHAC  2009d, 
2010b).  
•  Those  international  issues  or  institutions  where  Canada  has  played  a 
significant role in the past, such as the Global Fund, polio, the International 
AIDS  Vaccine  Initiative  (IAVI),  tuberculosis,  the  GAVI  Alliance,  the 
International Partnership for Microbicides, infant and child health, maternal 
health,  micronutrient  deficiencies  and  the  strengthening  of  health  systems 
(see  Appendix  A;  Government  of  Canada  2008a;  Kirton  and  Guebert  2010a; 
Singer 2009; Cannon 2010).  
•  Other health commitments already made on the global stage but not yet met, 
such as pledges made at the G8 summit (Guebert 2009). 
•  Any niche where Canada has medical and research expertise, such as diabetes 
or global health research (Phillips 2001; CNW Group 2009a; Singer 2009).  
•  The  identification  of  a  neglected  topic  where  Canada  could  carve  out  a 
leadership role, such as global health diplomacy, neglected tropical diseases, 
food security, gender equality, the definition of global public health goods or 
innovation (Singer 2009).  
•  Health  issues  that  are  critical  in  countries  where  Canada  has  a  key  foreign 
policy  and  development  interest,  notably Afghanistan,  Haiti,  the Dominican 
Republic,  India,  El  Salvador,  Guatemala,  Honduras  and  Nicaragua  (see 
Appendices A and G).  
Components of a Canadian Global Health Strategy 
Canadian Priorities 
A  Canadian  global  health  strategy  will  reduce  pandemic  risk  and  improve  the 
health  and  safety  of  Canadians  at  home  and  abroad.  It  will  help  ensure  that 
Canadians  are  protected  from  security  threats such  as  bioterrorism.  It  will  foster 
innovation  in  global  health.  It  will  help  Canada  plan  and  protect  its  citizens 
against  the  negative  health‐related  effects  of  climate  change,  unsafe  food  and 
products, and migration (Berrang‐Ford et al. 2009; Kirton and Guebert 2010b). 
A  global  health  strategy  will  also  express  Canadians’  interests  and  values 
abroad. Canadians believe that health care is one of the most important domains 
that  politicians  should  address.  In  repeated  public  opinion  surveys,  Canadians 
have identified health care as the most important (or one of the most important) 
issues for politicians to deliberate on. Canadians approve of them doing so abroad 
as well as at home (see Appendix E; Bildook 2008; Public Works and Government 
Services  Canada  2008;  Robbins  SCE  Research  2010;  Association  of  Faculties  of 
Medicine of Canada et al. 2010). 
As  an  integral  part  of  protecting  Canadians’  health  and  promoting  their 
interests  and  values,  a  global  health  strategy  will  help  meet  Canadians’ 
international  responsibilities  in  the  many  communities  that  they  share  with 
others.  These  responsibilities  start  geographically  with  the  North  American  and 
Arctic  communities  and  extend  to  the  Americas,  the  Atlantic  and  Asia  Pacific 
regions,  Africa  through  the  Commonwealth  and  Francophonie,  and  the  global 
community as a whole. 
Canada  has  also  committed  to  solving  global  health  challenges  in  a  variety  of 
international forums over the past decades. Many of these commitments still need 
to  be  fulfilled.  In  addition  to  the  MDGs  and  commitments  made  at  G8  summits, 
promises  made  at  Asia  Pacific  Economic  Cooperation  (APEC)  summits  and  at 
Commonwealth and la Francophonie heads of government  meetings, Canada has 
bilateral  commitments  with  countries  including  Afghanistan,  Haiti  and  Sudan 
(CIDA  2009a).  Canada  could  use  a  global  health  strategy  to  help  meet  these 
objectives in a reasonable and responsible way. 
Global Demands 
Many  actors  have  devoted  time  and  resources  to  developing  and  using  global 
health  strategies  because  many  health  challenges  are  increasing,  are  often 
inherently  global  and  therefore  require  global  coordination  in  response 
(FDHA/FDFA  2006;  HM  Government  2008;  Commission  of  the  European 
Communities 2007; Sridhar 2009).  
There has also been an increasing recognition that non‐health influences actors 
from abroad — especially those that are inherently and fully global — can severely 
affect  human  health  (Sridhar  2009;  HM  Government  2008;  Kirton  and  Guebert 
2010b).  Non‐health  influence  begin  with  climate  change,  food  and  agriculture, 
trade and migration. The Intergovernmental Panel on Climate Change (IPCC) has 
identified  numerous  connections  between  climate  change  and  health  (see 
Appendix  H;  IPCC  2007a,  2007b).  A  2007  survey  showed  that  82%  of  Canadians 
were concerned with “climate change and its impact on health” (Canadian Medical 
Association 2007).  
The  food  and  agriculture–health  connection  was  highlighted  by  recent 
experiences with BSE, H5N1 and H1N1 (Government of Canada 2008b).  
The  Agreement  on  Trade‐Related  Aspects  of  Intellectual  Property  (TRIPS)  at 
the  World  Trade  Organization  (WTO)  forged  a  necessary  collaboration  between 
trade and health, while Canada’s  growing array of bilateral  free trade agreements 
intensify the trade‐health connection as well (DFAIT 2010a; see Appendix G).  
The  migration  of  health  workers  remains  a  challenge  for  countries  of  origin, 
many  of  which  are  already  suffering  from  major  deficiencies  in  health  workers 
(WHO  2007).  Canada  is  home  to  more  than  15,000  scientific  and  health‐related 
professionals from developing countries (Singer 2010). There is also the possibility 
that current and prospective Canadians and other citizens who enter or immigrate 
to  Canada  can  bring  illness  contracted  abroad  that  may  spread  (Kirton  and 
Guebert 2010b). 
The levels and trends in some major communicable diseases such as HIV/AIDS, 
and  non‐communicable  diseases  such  as  diabetes,  obesity,  cancer  and  tobacco‐
related illnesses have risen and are predicted to continue to rise (see Appendix D; 
WHO 2006, 2009). 
The public has increasingly demanded that governments justify their spending, 
particularly  in  recent  times  when  resources  have  become  limited  (Clinton  2010). 
Global health strategies provide a tool for governments to communicate why it is 
important  to  spend  money  on  global  health  initiatives  and  to  clearly  indicate 
where funding is allocated. 
Canada’s Comparative Advantage 
Canada  can  contribute  to  global  health  and  improve  its  impact  on  the  health  of 
Canadians  and  others  through  international  leadership,  accepting  global 
responsibilities and expanding its international influence. Canada has a strong and 
capable  community  of  health  professionals,  facilities,  research,  development, 
innovation and training to mobilize in a coordinated way (Singer 2009). Canada’s 
academic  institutions,  private  sector  innovators,  civil  society  actors  and 
organizations, and research bodies, led by the CIHR and IDRC, can all contribute 
to  a  strong  Canadian  global  health  strategy  (Singer  2010;  Canadians  for  Health 
Research 2008). 
Canada  can  contribute  financially  to  global  health  through  public  sector, 
private sector, civil society and other non‐governmental disbursements, including 
to those global initiatives where Canada has already made a leading contribution 
(see Appendix A; CIDA 2009a).  
Canada  can  lead  on  global  health  issues  in  key  international  institutions, 
starting with the hosting of the G8, G20 and North American Leaders’ Summit in 
2010.  Canada  has  already  made  health  a  priority  of  the  G8  Muskoka  Summit  in 
June.  The  stated  topic  of  children’s  and  maternal  health  could  also  be  discussed 
with  the  G20,  which  deals  with  the  health‐related  issues  of  finance,  trade,  food 
security and development (Silberschmidt 2009; Kirton and Guebert 2010a). At the 
North  American  Leaders’  Summit  in  September,  a  continued  discussion  of 
pandemic  preparedness  and  planning  and  best  practices  would  be  useful  (Kirton 
and Guebert 2010c, 2010d). 
Canada  could  build  on  its  global  health  leadership  by  seeking  to  appoint 
respected  officials  to  the  executive  boards  and  senior  staffs  of  health‐related 
international  organizations  of  consequence,  including  the  WHO,  Pan  American 
Health  Organization  (PAHO)  and  the  OECD.  It  could  encourage  any  new 
international health organizations that arise to locate their secretariats in Canada. 
It  could  make  sure  that  Canadian  representatives  at  health‐related  meetings  of 
consequence includes high‐level officials. It can draw on the Canadian experience 
of those who are already in positions of power, and those  such as WHO  director 
Margaret Chan, who obtained her medical degree from the University of Western 
Ontario. 
Canada  could  also  lead  in  creating  a  platform  to  explore  and  support 
innovation  as  it  applies  to  global  health.  This  would  mean  recognizing  that 
innovation includes seeking success through experimentation while accepting that 
risk  is  a  necessary  component  of  innovation,  because  tolerance  for  failure  is  a 
learning  stage  in  developing  genuinely  effective  new  global  health  initiatives  and 
strategies. Such a process would draw from domestic and international civil society 
actors, the private sector, academia, philanthropic entities, and governmental and 
intergovernmental  bodies  to  explore  and  experiment  with  the  factors,  actors  and 
enablers  that  can  lead  to  resilient  and  healthy  individuals  and  communities 
domestically and globally.  
Canada  could  also  consider  identifying  specific  responsibilities  and  assuming 
leadership  in  neighbouring  and  strategic  regions,  including  the  Arctic,  the  North 
American community, Haiti and Afghanistan. Within these areas,  it should  focus 
on the most vulnerable first. 
Canada’s Partners 
With  regard  to  a  partnership  strategy,  several  lessons  can  be  learned  from  the 
evidence and cases of what others have done (see Appendix I).  
First, it is important to establish why a strategy would be useful and beneficial 
in  Canada.  This  report  and  the  companion  one  written  by  Ronald  Labonté  and 
Michelle  Gagnon  (2010),  as  well  as  others  exploring  a  Canadian  global  health 
strategy,  should  be  shared  with  the  various  Canadian  global  health  actors.  Their 
comments and questions should be taken into consideration and explored further 
where necessary.  
Second, Canada should determine the factors  driving  it to consider a national 
global  health  strategy.  Two  main  aims  drove  the  UK  to  develop  its  global  health 
strategy: “to use health as an agent for good in foreign policy” and to ensure more 
transparency and clarity on the impact of foreign and domestic policies on global 
health  (Sridhar  2009).  Switzerland,  which  hosts  the  WHO  in  Geneva, recognized 
that  internationally  coordinated  responses  were  required  in  health;  these  two 
factors  drove  it  to  develop  a  global  health  strategy  (Sridhar  2009).  Others  have 
suggested  that  the  search  for  effective  ways  to  use  scarce  resources  was  a  key 
driver. New research and evidence that highlighted the effectiveness and benefits 
of  more  integrated  and  focused  global  health  approaches  also  had  an  impact.  A 
clear understanding of the reasons behind Canada’s desire for a strategy will help 
to frame the context and narrative of the overall policy. 
Third, the main aims of the global health strategy must be identified. The UK’s 
“stability  first”  strategy  targeted  five  actions:  enhance  global  health  security  to 
improve economic and political stability; create stronger, fairer and safer systems 
to  deliver  health;  make  international  organizations  including  the  WHO  and  the 
EU more effective; engage in stronger, freer and fairer trade for better health; and 
strengthen  the  way  the  UK  develops  and  uses  evidence  to  improve  policy  and 
practice  (HM  Government  2008).  The  EU  identified  three  main  objectives: 
fostering  good  health  in  an  aging  Europe,  protecting  citizens  from  health  threats 
and supporting dynamic health systems and new technologies (Commission of the 
European Communities 2007). The  five main  priorities of the  Swiss government’s 
global  health  strategy  are  to  protect  national  health  interests  from  global  health 
threats,  including  influenza  pandemics,  consumer  health  threats  and  non‐
communicable  disease;  harmonize  national  and  international  health  policies; 
improve  the  effectiveness  of  international  collaboration  in  the  area  of  health; 
improve  the  global  health  situation;  and  safeguard  Switzerland’s  role  as  host 
country  to  international  organizations  and  major  companies  working  in  health 
(FDHA/FDFA 2006). Canada can look to all these areas and objectives to see which 
should  be  adopted  in  a  Canadian  global  health  strategy.  Certain  ones,  such  a 
strengthening  health  systems,  protecting  citizens  from  global  health  threats  and 
harmonizing  national  and  international  health  policies,  stand  out  as  worthy 
candidates.  Canada’s  global  health  strategy  should  consider  aims  that  are  best 
suited to Canadian values and interests.  
Fourth, the resources necessary for developing and executing the global health 
strategy  must  be  determined.  As  with the  EU  and  Switzerland,  Canada  need not 
necessarily  find new resources at the outset.  Funds could be  drawn from existing 
individual  global health initiatives. The  global health strategy would therefore be 
reinforce  the  goals  already  targeted  (Sridhar  2009).  However,  allocating  new 
resources, as the UK did, would signal that Canada is serious about implementing 
its  strategy  and  committed  to  seeing  it  through.  It  could  also  help  catalyze  or 
mobilize funding from other sources. 
Fifth, a global health strategy should identify one‐year, five‐year and 10‐ to 15‐
year  initiatives.  The  strategy  should  be  reviewed  after  each  period  with  reports 
published  publicly,  including  recommendations  for  future  actions  and  changes. 
There  should  be  a  balance  of  specified  and  flexible  initiatives,  so  that  clear  goals 
can  be  set.  At  the  same  time  there  should  be  room  to  adjust  to  any  crises  that 
might arise, such as the 2010 earthquakes in Haiti and Chile or a future influenza 
pandemic.  A  five‐year  approach  as  an  initial  base  would  be  a  suitable  timeline, 
following  the  example  of  the  UK,  the  EU  and  Switzerland.  Starting  in  2010/11,  it 
would also fit within the MDG timeframe. It could also include shorter plans and 
longer plans, as in the U.S. strategy (Fallon and Gayle 2010). 
Sixth,  the  strategy  should  build  on  Canada’s  strengths  in  the  academic,  civil 
society,  business  and  government  sectors.  It  should  also  identify  areas  where 
Canada  can  improve  and  close  critical  gaps.  It  should  specify  what  departments 
and  agencies  should  be  responsible  for  each  initiative.  It  should  also  focus  on 
merging  non‐health  actors,  such  as  those  in  trade,  agriculture  and  the 
environment,  and  match  them  with  those  with  relevant  technical  capacity, 
understanding and expertise in health. 
Seventh, Canada should consider collaborating with other key actors, including 
those countries that have developed or are developing health strategies. It should 
continue to collaborate with long‐standing partners starting with the WHO as the 
lead intergovernmental organization, and also with the UK, the U.S. and the EU. 
Canada should also encourage other countries to develop their own global health 
strategies, as part of a broad, globally coordinated approach. 
Eighth, following the UK, Canada should consider appointing an independent, 
third‐party  body  or  office  to  review  the  success  and  effectiveness  of  a  Canadian 
global  health  strategy.  This  same independent  body  should  produce  the  progress 
reports and provide constructive advice on the next steps to ensure the strategy is 
implemented effectively. 
Ninth,  Canada  should  ensure  that  it  remains  open  and  transparent  about 
conflicting  interests  that  exist  between  departments  and  agencies,  such  as  trade 
and  development  or  environment  and  health.  It  should  make  it  clear  that  it  is 
ready to resolve discrepancies, or at least reduce differences, by clarifying roles and 
highlighting  synergies.  With  the  Canadian  government  already  focused  on 
accountability, this approach would strengthen its commitment to transparency.  
Tenth, as with Switzerland’s strategy and its federal sensibilities, the Canadian 
government  should  use  its  global  health  strategy  to  improve  the  integration  and 
synergies  among  provincial,  national  and  international  health  policies.  It  should 
clearly  specify  which  actor  or  actors  should  lead  and  which  should  play  a 
supporting role on each initiative for better clarity, cooperation, coordination and 
cost effectiveness. 
Specific steps for delivering a strategy following these guidelines are identified 
in Appendix J. 
A more systematic survey should be undertaken to explore the potential impact 
of  a  Canadian  global  health  strategy.  Cross‐Canada  consultations  should  be 
undertaken  with  academics,  NGOs,  politicians,  bureaucrats  and  members  of  the 
business  and  industry  communities.  New  public  opinion  polls  should  be 
conducted.  Interdepartmental  workshops  should  be  convened.  International 
stakeholders,  particularly  those  from  consequential  countries  that  have  already 
developed global health strategies, should be included in these processes.  
References 
Ali, Mohammed K. and K.M. Venkat Narayan (2009). “The United States and 
Global Health: Inseparable and Synergistic? The Institute of Medicine’s Report 
on Global Health.” Global Health Action 2. <www.globalhealthaction.net/ 
index.php/gha/article/viewArticle/2035/2488> (March 2010). 
Association of Faculties of Medicine of Canada, BIOTECanada, Canada’s Research‐
Based Pharmaceutical Companies, Canadian Healthcare Association, Canada’s 
Medical Technology Companies and Research Canada (2010). “Canada Speaks! 
2010: Canadians Go for Gold in Health and Medical Research.” January. 
<www.csbmcb.ca/Downloads/18‐ResearchCanada‐pollEng.pdf> (March 2010). 
Bennett, Carolyn (2009). “Lessons from SARS: Past Practice, Future Innovation.” In 
Andrew F. Cooper and John J. Kirton, eds., Innovation in Global Health 
Governance: Critical Cases. Farnham: Ashgate. 
Berrang‐Ford, L., J.D. Maclean, Theresa Gyorkos, J.D. Ford and N.H. Ogden (2009). 
“Climate Change and Malaria in Canada: A Systems Approach.” 
Interdisciplinary Perspective on Infectious Disease (2009). <www.hindawi.com/ 
journals/ipid/2009/385487.html> (March 2010). 
Bildook, Kelly (2008). “Media, Public Opinion and Health Care in Canada: How 
the Media Affect ‘The Way Things Are’.” Canadian Journal of Political Science 
41(2): 355–374. 
Canada. Citizenship and Immigration Canada (2009). “Facts and Figures 2008 — 
Immigration Overview: Permanent and Temporary Residents.” <www.cic.gc. 
ca/english/resources/statistics/facts2008/permanent/index.asp> (March 
2010). 
Canada. Department of Finance (2006). “The Budget Plan 2006: Focusing on 
Priorities.” May 2. <www.collectionscanada.gc.ca/webarchives/20061129173143/ 
www.fin.gc.ca/budget06/pdf/bp2006e.pdf> (March 2010). 
Canada. Department of Foreign Affairs and International Trade (2010a). 
“Negotiations and Agreements.” <www.international.gc.ca/trade‐agreements‐
accords‐commerciaux/agr‐acc/index.aspx> (March 2010). 
Canada. Department of Foreign Affairs and International Trade (2010b). “Trade 
and Intellectual Property: WTO Trade‐Related Aspects of Intellectual 
Property Rights.” <www.international.gc.ca/trade‐agreements‐accords‐
commerciaux/fo/trips_agree.aspx?menu_id=2&menu=R> (March 2010). 
Canadian Institutes of Health Research (2002). “A First‐Time Collaborative Effort 
in Canada Will Address Global Health Through Research: Joint Press Release.” 
January 11. <www.cihr‐irsc.gc.ca/e/8077.html> (March 2010). 
Canadian Institutes of Health Research (2008). “Japan‐Canada Joint Health 
Research Program.” <www.cihr‐irsc.gc.ca/e/35595.html> (March 2010). 
Canadian International Development Agency (2009a). “Canada Moves on Another 
Element of Its Aid Effectiveness Agenda. News release, February 23. 
<www.acdi‐cida.gc.ca/acdi‐cida/ACDI‐CIDA.nsf/eng/NAT‐223132931‐PPH> 
(March 2010). 
Canadian International Development Agency (2009b). “Catalytic Initiative to  
Save a Million Lives.” <www.acdi‐cida.gc.ca/acdi‐cida/acdi‐cida.nsf/eng/ 
NAD‐1249841‐JLG> (March 2010). 
Canadian International Development Agency (2009c). “Countries of Focus.” 
<www.acdi‐cida.gc.ca/acdi‐cida/ACDI‐CIDA.nsf/eng/JUD‐51895926‐JEP> 
(March 2010). 
Canadian International Development Agency (2010). “Project Browser.” Database. 
<www.acdi‐cida.gc.ca> (March 2010). 
Canadian Medical Association (2007). “Health of One‐in‐Four Canadians Hurt  
by the Environment.” August 17. <www.cma.ca/multimedia/cma/ 
Content_images/Inside_cma/Annual_Meeting/2007/GC_page/ 
Report_Card_Release_e.pdf> (March 2010). 
Canadians for Health Research (2008). “Public Health Researcher Extraordinaire: 
Meet Dr. Frank Plummer.” Future Health. <www.chrcrm.org/main/modules/ 
pageworks/index.php?page=018&id=1253> (March 2010). 
Cannon, Lawrence (2010). “Address by Minister Cannon to the Economic Club of 
Canada Concerning the G8 Foreign Ministers Meeting.” Toronto, March 22. 
<www.international.gc.ca/media/aff/speeches‐discours/2010/2010‐11.aspx> 
(March 2010). 
Chan, Margaret (2009a). “Influenza A (H1N1).” Statement, April 29. <www.who.int/ 
mediacentre/news/statements/2009/h1n1_20090429/en> (March 2010). 
Chan, Margaret (2009b). “Influenza A (H1N1): Lessons Learned and Preparedness.” 
July 2, Cancún. <www.who.int/dg/speeches/2009/influenza_h1n1_lessons_ 
20090702/en> (March 2010). 
Clinton, Hillary (2010). “Development in the 21st Century.” Prepared text of speech 
delivered to the Center for Global Development, Washington DC, January 6. 
Foreign Policy. <www.foreignpolicy.com/articles/2010/01/06/ 
hillary_clinton_on_development_in_the_21st_century> (March 2010). 
CNW Group (2009a). “JDRF launches Clinical Trial Network Centre at University 
of Waterloo.” Press release, March 8. <www.newswire.ca/en/releases/archive/ 
March2010/08/c7713.html> (March 2010). 
CNW Group (2009b). “On Eve of Medical Association’s Annual Meeting: New Poll 
Shows Overwhelming Support for Public Health Care; CMA President Out of 
Touch with Most Canadians.” August. <www.nanosresearch.com/news/ 
in_the_news/CNW August 12 2009.pdf> (March 2010). 
Commission of the European Communities (2007). “Together for Health: A 
Strategic Approach for the EU 2008–2013.” White Paper. <ec.europa.eu/ 
health/ph_overview/strategy/health_strategy_en.htm> (March 2010). 
Community and Hospital Infection Control Association – Canada (2009). 
“Information about West Nile Virus.” <www.chica.org/links_wnv.html> 
(March 2010). 
Community and Hospital Infection Control Association – Canada (2010a). 
“Influenza, Avian Influenza and Pandemic Influenza.” <www.chica.org/ 
links_flu.html> (March 2010). 
Community and Hospital Infection Control Association – Canada (2010b). 
“Pandemic (H1N1) 2009 Virus.” <www.chica.org/links_swineflu.html>  
(March 2010). 
Cooper, Andrew F., John J. Kirton and Ted Schrecker (2007). “Governing Global 
Health in the Twenty‐First Century.” In Andrew F. Cooper, John J. Kirton and 
Ted Schrecker, eds., Governing Global Health: Challenge, Response, 
Innovation. Aldershot: Ashgate. 
Fallon, William J. and Helene D. Gayle (2010). A Healthier, Safer and More 
Prosperous World. Report of the CSIS Commission on Smart Global Health. 
<csis.org/files/publication/100318_Fallon_SmartGlobalHealth.pdf> (March 
2010). 
Fidler, David (2004). SARS, Governance and the Globalization of Disease. London: 
Palgrave Macmillan. 
Fischer, Julie E. (2009). “Global Health Security: A Long‐Term Perspective.”  
Henry L. Stimson Center. <www.stimson.org/Presidential_Inbox_2009/ 
JFischer_Final.pdf> (March 2010). 
G8 (2003). “Health — A G8 Action Plan.” Evian, June 2. <www.g8.utoronto.ca/ 
summit/2003evian/health_en.html> (March 2010). 
GAVI Alliance (2010). “Donor Contributions and Commitments.” 
<www.gavialliance.org/support/donors/index.php> (March 2010). 
Global Fund to Fight AIDS, Tuberculosis and Malaria (2010). “Pledges and 
Contributions.” <www.theglobalfund.org/documents/pledges_ 
contributions.xls> (March 2010). 
Global Health Security Initiative (2009). “Special Ministerial Meeting on Pandemic 
(H1N1) 2009. September 11. <www.ghsi.ca/english/statementbrussels2009.asp> 
(December 2009). 
Global Polio Eradication Initiative (2010). “Historical Contributions Since 1985.” 
<www.polioeradication.org/content/general/HistContributionWeb28.January.
2010.pdf> (March 2010). 
Government of Canada (2008a). “Canada’s Investments in Global Health.”  
<camr‐rcam.hc‐sc.gc.ca/doc/invest‐contrib/index‐eng.php> (March 2010). 
Government of Canada (2008b). “National Animal Health Strategy.” 
<www.healthyanimals.ca/english/index_e.shtml> (March 2010). 
Government of Canada (2010). “A Stronger Canada. A Stronger Economy. Now and 
for the Future.” Speech from the Throne, March 3. <www.sft‐ddt.gc.ca/grfx/ 
docs/sft‐ddt‐2010_e.pdf> (March 2010). 
Guebert, Jenilee (2009). “G8 Commitments on Health.” G8 Research Group. 
<www.g8.utoronto.ca/evaluations/g8‐commitments‐health‐to‐2009.html> 
(March 2010). 
Harper, Stephen (2009). “The 2010 Muskoka Summit.” In John Kirton and 
Madeline Koch, eds., The G8 2009: From La Maddalena to L’Aquila. London: 
Newsdesk Media. <www.g8.utoronto.ca/newsdesk/harper‐2009.html> (March 
2010). 
Harper, Stephen (2010a). Canada’s G8 Priorities. January 26. Ottawa: Office of the 
Prime Minister of Canada. 
Harper, Stephen (2010b). “Statement by the Prime Minister of Canada.” Address to 
the World Economic Forum, Davos, 28 January. <www.pm.gc.ca/eng/ 
media.asp?id=3096> (March 2010). 
Health Canada (1999). “Women’s Health Strategy.” <www.hc‐sc.gc.ca/ahc‐asc/ 
pubs/strateg‐women‐femmes/strateg‐eng.php> (March 2010). 
Health Canada (2009). “Canadian Tobacco Use Monitoring Survey.” <www.hc‐sc. 
gc.ca/hc‐ps/tobac‐tabac/research‐recherche/stat/_ctums‐esutc_prevalence/ 
prevalence‐eng.php#wave1_09> (March 2010). 
Health Research Council of New Zealand (2009). “Indigenous Health Research.” 
<www.hrc.govt.nz/root/pages_maori_health/Indigenous_health_research. 
html> (March 2010). 
Intergovernmental Panel on Climate Change (2007a). “Climate Change 2007: 
Synthesis Report.” <www.ipcc.ch/pdf/assessment‐report/ar4/syr/ar4_syr.pdf> 
(March 2010).  
Intergovernmental Panel on Climate Change (2007b). “Working Group II Report: 
Impacts, Adaptation and Vulnerability.” <www.ipcc.ch/ipccreports/ 
ar4‐wg2.htm> (March 2010).  
International Development Research Council (2008). “Global Health Research 
Initiative.” <www.idrc.ca/en/ev‐114548‐201‐1‐DO_TOPIC.html> (March 2010). 
Ipsos Reid (2006). “Majority (54%) Feel P.M. Was Wrong Not to Attend Recent 
International AIDS Conference.” September. <www.ipsos‐na.com/news‐polls/ 
pressrelease.aspx?id=3176> (March 2009). 
Ipsos Reid (2007). “2007 Report Card on the Health Care System in Canada: Health 
of One in Four Canadians Hurt by the Environment.” August. <www.ipsos‐na. 
com/news‐polls/pressrelease.aspx?id=3604> (March 2009). 
Ipsos Reid (2008). “Not a Great First Impression: Only One in Three (34%) 
Canadians Claim to Know Anything about Dion’s ‘Green Shift’ Plan.” July. 
<www.ipsos‐na.com/news‐polls/pressrelease.aspx?id=4000> (March 2010). 
Ipsos Reid (2009). “Most (85%) Want Canada to Be Known as a Global Leader in 
Finding Solutions to Poverty and Protecting the World’s Children.” 
November. <www.ipsos‐na.com/news‐polls/pressrelease.aspx?id=4611> 
(March 2010). 
Kates, Jen, Julie Fischer and Eric Lief (2009). “The U.S. Government’s Global 
Health Policy Architecture: Structure, Programs and Funding.” April. Henry J. 
Kaiser Family Foundation. <www.stimson.org/globalhealth/pdf/ 
GlobalHealth_KFF.pdf> (March 2010). 
Kickbusch, Ilona (1989). “Healthy Cities: A Working Project and a Growing 
Movement.” Health Promotion. 4(2): 77–82. 
Kickbusch, Ilona and Christian Erk (2009). “Global Health Diplomacy: The New 
Recognition of Health in Foreign Policy.” In Andrew Clapham and Mary 
Robinson, eds., Realizing the Right to Health. Zurich: Rüffer and Rub. 
Kickbusch, Ilona, Gaudenz Silberschmidt and Paulo Buss (2007). “Global Health 
Diplomacy: The Need for New Perspectives, Strategic Approaches and Skills in 
Global Health.” Bulletin of the World Health Organization 85(3): 230–232. 
<www.who.int/bulletin/volumes/85/3/06‐039222/en/> (March 2010). 
Kirton, John (2007). Canadian Foreign Policy in A Changing World. Toronto: 
Thomson‐Nelson.  
Kirton, John, ed. (2009). Global Health. Farnham: Ashgate. 
Kirton, John and Jenilee Guebert (2010a). “Canada’s G8 Global Health Diplomacy: 
Lessons for 2010.” Canadian Foreign Policy 15(3). In press. 
Kirton, John and Jenilee Guebert (2010b). “The Climate Change‐Health 
Connection: Compounding Challenges for Scholars and Practitioners.”  
Paper presented at the International Studies Association convention,  
New Orleans, February 17. <www.g8.utoronto.ca/scholar/ 
kirton‐guebert‐isa‐100217.pdf> (March 2010). 
Kirton, John and Jenilee Guebert (2010c forthcoming). “North American Health 
Governance: Shocks, Summitry and Society Support.” Norteamerica. In press. 
Kirton, John and Jenilee Guebert (2010d). “Soft Law Regulation Coordination and 
Convergence in North America.” In Monica Gattinger and Geoffrey Hale, eds., 
Borders and Bridges: Canada’s Policy Relations in North America. Toronto: 
Oxford University Press. 
Maioni, Antonia (2008). “The Media and Public Opinion about Health Care.” 
Health Innovation Forum. <www.healthinnovationforum.org/2008/may/01/ 
media‐public‐opinion> (March 2010). 
Mental Health Commission of Canada (undated‐a). “Evergreen: Child and Youth 
Mental Health.” <www.mentalhealthcommission.ca/English/Pages/ 
evergreen.aspx> (March 2010). 
Mental Health Commission of Canada (undated‐b). “Mental Health Strategy for 
Canada.” <www.mentalhealthcommission.ca/English/Pages/Strategy.aspx> 
(March 2010). 
Labonté, Ronald, and Michelle Gagnon (2010). “What Is the Case for a Canadian 
Global Health Strategy?” Paper commissioned by the Strategic Policy Branch 
of the International Affairs Directorate of Health Canada. Draft of March 15. 
Orbinski, James (2007). “Global Health, Social Movements, and Governance.” In 
Andrew F. Cooper, John Kirton and Ted Schrecker, eds., Governing Global 
Health: Challenge, Response, Innovation. Aldershot: Ashgate. 
Organisation for Economic Co‐operation and Development (2009a). “Measuring 
Aid to Health.” November. <www.oecd.org/dataoecd/44/35/44070071.pdf> 
(March 2010). 
Organisation for Economic Co‐operation and Development (2009b). “OECD 
Health at a Glance 2009: Key findings for Canada.” <www.oecd.org/ 
documentprint/0,3455,en_2649_33929_44220787_1_1_1_1,00.html> (March 
2010). 
Phillips, Anne (2001). “Canada Leads the Way in Diabetes Research.” GSK News 
(November) <www.gsk.ca/english/docs‐pdf/PPNov01ENG.pdf> (March 2010). 
Price‐Smith (2009). Contagion and Chaos: Disease, Ecology, and National Security 
in the Era of Globalization. Cambridge: MIT Press. 
Public Health Agency of Canada (2005). “The Integrated Pan‐Canadian Healthy 
Living Strategy.” <www.phac‐aspc.gc.ca/hl‐vs‐strat/pdf/hls_e.pdf> (March 
2010). 
Public Health Agency of Canada (2006a). “Canada’s New Government to Develop a 
New Heart Healthy Strategy.” Press release, October 23. <www.phac‐aspc. 
gc.ca/media/nr‐rp/2006/2006_09‐eng.php> (March 2010). 
Public Health Agency of Canada (2006b). “Diabetes Facts and Figures.” <www. 
phac‐aspc.gc.ca/ccdpc‐cpcmc/ndss‐snsd/english/facts_figures‐eng.php> 
(March 2010). 
Public Health Agency of Canada (2007). “Centre for Chronic Disease Prevention 
and Control.” <www.phac‐aspc.gc.ca/ccdpc‐cpcmc/cancer/cpac‐accc_e.html> 
(March 2010). 
Public Health Agency of Canada (2008a). “Canadian Diabetes Strategy.” <www. 
phac‐aspc.gc.ca/cd‐mc/diabetes‐diabete/diabetes_strategy‐diabete_ 
strategie‐eng.php> (March 2010). 
Public Health Agency of Canada (2008b). “Diabetes in Canada: Highlights from the 
National Diabetes Surveillance System, 2004–2005.” <www.phac‐aspc.gc.ca/ 
publicat/2008/dicndss‐dacsnsd‐04‐05/pdf/dicndss‐04‐05‐eng.pdf> (March 
2010). 
Public Health Agency of Canada (2008c). “Report from the National Diabetes 
Surveillance System, Diabetes in Canada 2008.” <www.phac‐aspc.gc.ca/ 
publicat/2008/ndssdic‐snsddac‐08/index‐eng.php> (March 2010). 
Public Health Agency of Canada (2008d). “Vaccine‐Preventable Diseases Measles.” 
<www.phac‐aspc.gc.ca/im/vpd‐mev/measles‐eng.php> (March 2010). 
Public Health Agency of Canada (2009a). “HIV and AIDS in Canada: Surveillance 
Report to December 31, 2008.” <www.phac‐aspc.gc.ca/aids‐sida/publication/ 
survreport/2008/dec/pdf/survrepdec08.pdf> (March 2010). 
Public Health Agency of Canada (2009b). “Obesity in Canada: Snapshot.” 
<www.phac‐aspc.gc.ca/publicat/2009/oc/pdf/oc‐eng.pdf> (March 2010). 
Public Health Agency of Canada (2009c). “Report from the National Diabetes 
Surveillance System, Diabetes in Canada 2008.” <www.phac‐aspc.gc.ca/ 
publicat/2008/ndssdic‐snsddac‐08/index‐eng.php> (March 2010). 
Public Health Agency of Canada (2009d). “West Nile Virus Monitor.” <www. 
phac‐aspc.gc.ca/wnv‐vwn/index‐eng.php> (March 2010).  
Public Health Agency of Canada (2009e). “West Nile Virus Monitor: Human 
Surveillance.” <www.phac‐aspc.gc.ca/wnv‐vwn/mon‐hmnsurv‐archive‐eng. 
php> (March 2010).  
Public Health Agency of Canada (2010a). “The Canadian Pandemic Influenza Plan 
for the Health Sector.” <www.phac‐aspc.gc.ca/cpip‐pclcpi> (March 2010). 
Public Health Agency of Canada (2010b). “Government of Canada Announces 
Significant Contribution to WHO Global Pandemic Relief Efforts.” News 
release, January 28. <www.phac‐aspc.gc.ca/media/nr‐rp/2010/2010_0128‐eng. 
php> (March 2010). 
Public Health Agency of Canada (2010c). “Tuberculosis Prevention and Control.” 
<www.phac‐aspc.gc.ca/tbpc‐latb/surv‐eng.php> (March 2010). 
Public Works and Government Services Canada (2008). “Annual Report 2003–
2004.” <www.tpsgc‐pwgsc.gc.ca/rop‐por/rapports‐reports/2003‐2004/ 
page‐13‐eng.html> (March 2010). 
Ray, Monali, Abdallah Daar, Peter A. Singer and Halla Thorsteinsdóttir (2009). 
“Globetrotting Firms: Canada’s Health Biotechnology Collaborations with 
Developing Countries.” Nature Biotechnology 27: 806–814. <www.nature.com/ 
nbt/journal/v27/n9/abs/nbt0909‐806.html> (March 2010). 
Robbins SCE Research (2004). “Gay Rights Not Important to Canadians — 
Canadians Want Lower EI Premiums, Proper Military Funding and Health 
Care Resolved.” December 16. <www.robbinssceresearch.com/polls/ 
poll_155.html> (March 2010). 
Sharp, Walter R. (1947). “The New World Health Organization.” American Journal 
of International Law 41(3): 509–530. 
Silberschmidt, Gaudenz (2009). “The European Approach to Global Health: 
Identifying Common Ground for a U.S.‐EU Agenda.” Center for Strategic  
and International Studies. <csis.org/files/publication/091112_Silberschmidt_ 
EuroApproach_Web.pdf> (March 2010). 
Singer, Peter (2009). “Canada’s Strategic Role in Global Health.” Meeting Summary 
of the Canadian Academy of Health Sciences Global Health Symposium. 
<www.cahs‐acss.ca/e/pdfs/CAHS_Global_Health.summary.pdf> (March 2010). 
Singer, Peter (2010). “Innovation and Global Health: Canada’s G8 Opportunity.” 
Speaking notes for a conference on “Accountability, Innovation and 
Coherence in G8 Health Governance: Seizing Canada’s G8 Opportunity,” 
Toronto, January 25. <www.mrcglobal.org/files/ 
PSinger‐InnovationandGlobalHealthCanadasG8OpportunityJanuary252010. 
pdf> (March 2010). 
Smylie, Janet (2004). “Why Canada Should Support an Independent International 
Indigenous Global Health Strategy.” <www.csih.org/en/advocacy/ 
IndigenousGlobalHealth.pdf> (March 2010). 
Sridhar, Devi (2009). “Foreign Policy and Global Health: Country Strategies.” 
Introduction to Health and Foreign Policy. Global Health Governance Project, 
University College, Oxford University. <www.globaleconomicgovernance.org/ 
wp‐content/uploads/Health‐and‐Foreign‐Policy‐Introduction‐28‐May‐2009. 
Starky, Sheena (2005). “The Obesity Epidemic in Canada.” Ottawa: Library of 
Parliament. <www2.parl.gc.ca/Content/LOP/ResearchPublications/prb0511‐e. 
Switzerland. Federal Department of Home Affairs and Federal Department of 
Foreign Affairs (2006). Swiss Health Foreign Policy: Agreement on Health 
Foreign Policy Objectives. Geneva. <www.bag.admin.ch/themen/ 
internationales/index.html?lang=en> (March 2010). 
United Kingdom. HM Government (2008). “Health Is Global: A UK Government 
Strategy 2008–13.” <www.dh.gov.uk/en/Publicationsandstatistics/ 
Publications/PublicationsPolicyAndGuidance/DH_088702> (March 2010). 
United Nations (2010). “Millennium Development Goals.” <www.un.org/ 
millenniumgoals> (March 2009). 
World Health Organization (2004). “Summary of Probable SARS Cases with Onset 
of Illness from 1 November 2002 to 31 July 2003.” 21 April. Geneva. 
<www.who.int/csr/sars/country/table2004_04_21/en> (March 2010). 
World Health Organization (2006). “Obesity and Overweight.” Fact Sheet No. 311, 
September. <www.who.int/mediacentre/factsheets/fs311/en> (March 2010). 
World Health Organization (2007). “New Initiative Seeks Practical Solutions to 
Tackle Health Worker Migration.” May 15. <www.who.int/mediacentre/news/ 
notes/2007/np23/en> (March 2010). 
World Health Organization (2009). “10 Facts on HIV/AIDS.” November. 
<www.who.int/features/factfiles/hiv/en> (March 2010). 
World Vision International (2009). “Global Health and Nutrition Strategy.” 
<www.wvi.org/wvi/wviweb.nsf/11FBDA878493AC7A882574CD0074E7FD/$file/
Quick_Guide_for_Global_Health_and_Nutrition.pdf> (March 2010). 
Appendix A:  
Canada’s Global Health Contributions 
Selected Projects 
Global Polio Eradication Initiative  CA$267 million (1985–2010) 
Global Fund to Fight AIDS, Tuberculosis and Malaria  US$100 million (2002–10) 
Global Alliance Vaccine Initiative (core funding)  US149 million (2002–06) 
Global Alliance Vaccine Initiative (AMC)  US$200 million (2007–10) 
Catalytic Initiative to Save a Million Lives  CA$105 million (2007–12) 
Avian and/or pandemic influenza  CA$1 billion (2006–11) 
Bilateral aid to India for the health sector  US$1 million (2006–07) 
Bilateral aid to Nigeria for the health sector  US$9 million (2006–07) 
Bilateral aid to Kenya for the health sector  US$3 million (2006–07) 
Bilateral aid to South Africa for the health sector  US$6 million (2006–07) 
Bilateral aid to Mozambique for the health sector  US$8 million (2006–07) 
Bilateral aid to Ethiopia for the health sector  US$37 million (2006–07) 
Bilateral aid to Zambia for the health sector  US$15 million (2006–07) 
Bilateral aid to Tanzania for the health sector  US$11 million (2006–07) 
Bilateral aid to Uganda for the health sector   US$1 million (2006–07) 
Bilateral aid to Pakistan for the health sector   US$7 million (2006–07) 
Bilateral aid to unspecified recipients for the health sector  US$358 million (2006–07) 
Funding Recipients 
• Afghanistan  • Honduras  • Peru 
• Bangladesh  • Indonesia  • Sudan 
• Bolivia  • Mali  • Tanzania 
• Ethiopia  • Mozambique  • Ukraine 
• Haiti  • Pakistan  • West Bank and Gaza 
Additional recent and current initiatives include support for: 
• Responding to cholera outbreaks in Angola 
• Community‐based treatment of malaria and pneumonia in all African countries 
• UNICEF’s Recovery of Vital Social Sector program in Iraq 
• Support for the Global Fund to Fight AIDS, Tuberculosis and Malaria, which includes funding to the 
Middle East and Eastern Europe 
• Support for the Pan American Health Organization, which includes the Americas 
• The CARE Canada program, which focuses on HIV/AIDS and assists Cambodia and Nepal, and others 
• Asia‐Pacific Strategy for Emerging Diseases, a component of the Canada‐Asia Regional Emerging 
Infectious Disease Project (CAREID) in South East Asia and China 
• Strengthening Health Systems, a World Health Organization project in Boznia‐Herzegovina  
• HIV/AIDS Harm Reduction, an Open Society Institute project in Russia, Ukraine and Georgia 
• The World Bank’s Montenegro Health System Improvement Project 
• Canadian Society for International Health’s Primary Health Care Policy Reform in the Balkans 
Note: Canada announced in 2009 that it would focus 80% of bilateral resources in 20 countries of focus chosen 
according to real needs, capacity to benefit from aid and alignment with Canadian foreign policy priorities. 
Sources: Global Polio Eradication Initiative (2010); Global Fund to Fight AIDS, Tuberculosis and Malaria (2010); 
GAVI Alliance (2010); Canada International Development Agency (2009b, 2009c, 2010); Organisation for Economic 
Co‐operation and Development (2009a); Canada, Department of Finance (2006). 
Appendix B:  
Global Health Actors in Canada 
• Canadian Food Inspection Agency (CFIA)      
• Canadian Institutes for Health Research (CIHR)  
• Canadian International Development Agency (CIDA)  
• Department of Agriculture and Agri‐Food Canada  
• Department of Foreign Affairs and International Trade (DFAIT)  
(formerly Department of External Affairs) 
• Department of National Defence (DND) 
• Environment Canada  
• Health Canada  
• Health Council of Canada 
• Indian and Northern Affairs (INAC) 
• Industry Canada 
• International Development Research Council (IDRC)  
• Prime Minister’s Office (PMO) 
• Privy Council Office (PCO) 
• Public Health Agency of Canada (PHAC) 
• Public Safety Canada 
Appendix C:  
Canada’s Role in Regional and International  
Health‐Related Organizations  
International – Multilateral  
• Food and Agriculture Organization (FAO) 
• Joint United Nations Programme on HIV/AIDS (UNAIDS) 
• United Nations General Assembly (UNGA) 
• United Nations High Commission for Refugees (UNHCR) 
• World Health Organization (WHO) and the World Health Assembly (WHA)  
• World Intellectual Property Organization (WIPO) 
• World Trade Organization (WTO) 
International – Plurilateral 
• Asia Pacific Economic Cooperation (APEC) 
• Commonwealth  
• Global Health Security Initiative (GHSI) 
• Global Public Health Intelligence Network (GPHIN) 
• Group of Eight (G8) 
• La Francophonie 
• Organisation for Economic Co‐operation and Development (OECD) 
Regional  
• Arctic Council  
• Commission for Environmental Cooperation of North America (CEC) 
• North American Leaders’ Summit 
• Pan American Health Organization (PAHO) 
Appendix D:  
Canadians Affected by Diseases 
West Nile  Seasonal 
Virus  Tuberculosisa  HIVb  AIDSc  SARS  H1N1  Influenza  Measles  Diabetes  Obesitye 
% of 
Year  Cases  Deaths  Cases  Deaths  Cases  Cases  Deaths  Cases  Deaths  Cases  Deaths  Cases  Cases  Cases  Population 
1979            1                   
1980            3  2                 
1981            8  5                 
1982            26  13                 
1983            64  28                 
1984            162  80                 
1985            402  175                 
1986            688  341                 
1987            1,012  528                 
1988            1,180  622                 
1989            1,408  820                 
1990      1,997      1,466  912                 
1991      2,018      1,515  1,105                 
1992      2,109      1,755  1,292                 
1993      2,012      1,829  1,412                 
1994      2,074    32,878f  1,789  1,470                 
1995      1,931    2,948  1,651  1,501                 
1996      1,849  117  2,737  1,189  1,063                 
1997      1,975  120  2,471  725  473                 
1998      1,810  122  2,293  647  282                 
1999      1,821  129  2,191  558  272          7,027    1,200,000   
2000      1,724  111  2,105  500  265          4,154  ~200    14.9 
2001      1,773  126  2,217  426  202          6,771  ~10     
2002  414  14  1,666  115  2,469  410  144          3,517  ~10     
2003  1481  14  1,613  112  2,482  382  153  251  44      11,435  ~10    15.4 
2004  25  0  1,613  105  2,530  324  83          12,879  ~10  1,800,000  23.4 
2005  225  10  1,641  98  2,496  354  66          7,422  ~10  1,900,000  24 
2006  151  2  1,654  111  2,550  311  56          8,133  ~10  2,000,000   
2007  2215  12  1,577  143  2,452  260  48          12,256  101    25 
2008  36  0  1,600  NA  2,623  255  45      12,262  77  23,376       
2009  8  0                33,477  348  39,044       
Notes: 
SARS = severe acute respiratory syndrome. 
a. Incidence rate is per 100,000. Numbers for 2008 are provisional.  
b. The number of positive HIV test reports by year up to February 13, 2009. Annual data are unavailable for 
positive HIV test reports prior to 1995. Positive HIV test reports vary for cases under two years of age.  
c. The number of reported AIDS cases by year of diagnosis goes to February 12, 2009, except for Quebec, for 
which no data are available after June 30, 2003.  
d. In 2008–10 there has been an increase in cases due to pandemic (H1N1) 2009 influenza virus. The 2009–10 
influenza season began on August 30, 2009. Cases include influenza A and B up to February 6, 2010.  
e. Data for 2000–04 include adults ages 20–64. Data for 2005 and 2007 include adults over age 18. 
f. Number of cases reported between 1985 and 1994. 
Sources: Community and Hospital Infection Control Association – Canada (2009, 2010a, 2010b); Public Health 
Agency of Canada (2006b, 2008b, 2008c, 2008d, 2009a, 2009b, 2009c, 2009e, 2010c); Starky (2005); World Health 
Organization 2004.  
Appendix E:  
Canadian Public Opinion on Health Issues 
Date  %  Rank  Statement  Poll 
Canadians believe their member of Parliament should be spending 
Dec 
35  1a  time on discussions of the Canada Health Act and its practical  RSR 
2004 
evolution in maintaining high standards of health care for all Canadians 
2006  67    Canadians approve the overall quality of healthcare services available  IR 
Sep 
54    Harper was wrong not to attend the International AIDS conference  IR 
2006 
Apr  Canadians are not confident that Canada will have enough healthcare 
63    IR 
2006  professionals in 10 years 
Apr  Canadians believe that health services are best improved with 
60    IR 
2006  increased numbers of health professionals 
Aug 
27    Canadians have been affected by an environmental health concern  IR 
2007 
Aug  Canadians have taken action to protect their health from the 
65    IR 
2007  environment 
Aug  Canadians think the federal government is doing enough to address 
36    IR 
2007  environmental and health concerns 
Aug  Canadians are concerned about environmental standards in other 
87    IR 
2007  countries and impact on imported food 
Aug  Canadians are concerned about climate change and its impact on 
82    IR 
2007  health 
Aug  Canadians are concerned about the potential for climate change to 
82    IR 
2007  encourage spread of disease 
Aug 
79    Canadians are concerned about air pollution  IR 
2007 
Aug 
76    Canadians are concerned about heat and sun exposure  IR 
2007 
Aug 
75    Canadians are concerned with the use of herbicides and pesticides  IR 
2007 
Aug  Canadians are concerned with the effects of soil contamination on 
74    IR 
2007  local fruits and vegetables 
Aug 
70    Canadians are concerned with water quality  IR 
2007 
Aug  Canadian approved of the overall quality of healthcare services 
62    IR 
2007  available 
Aug  Canadians believe it is important for government to help increase access 
91    IR 
2007  to treatment for people with HIV/AIDS in developing countries 
Aug  Canadians believe government’s foreign spending on HIV/AIDS is not 
48    IR 
2007  enough 
Nov  Canadians are concerned about HIV/AIDS when they think about global 
77    IR 
2007  issues 
Nov  Canadians believe if they can prevent people from getting infected with 
90    IR 
2007  HIV they have a moral obligation to try 
Nov  Canadians think government should do more to ensure people get 
80    IR 
2007  HIV/AIDS treatment 
May 
86    Canadians think there is a shortage of doctors  IR 
2008 
Date  %  Rank  Statement  Poll 
May  Canadians think the government should address the shortage of 
96    IR 
2008  doctors 
Aug  Canadians strengthening public health care rather than expanding for‐
86    NR 
2009  profit services 
Canadians aged 15 and over reported being “very satisfied” or 
Aug 
85    “somewhat satisfied” with the way overall healthcare services were  NR 
2009 
provided 
Nov  Canadians believe Canada should use its influence in hosting the G8 and 
88    IR 
2009  G20 to reduce global child mortality 
Jan  Canadians believe that Canada should be a global leader in global health 
89    RC 
2010  and medical research 
Jan  Canadians think health and medical research makes an important 
84    RC 
2010  contribution to the economy 
Jan  Canadians believe basic research should be supported by the 
90    RC 
2010  government even if it brings no immediate benefit 
Jan  Canadians think health care is the most important issue facing Canada 
12  3b  RC 
2010  today 
Mar  Canadians think health care should be the top priority for Canadian 
23  2c  IR 
2010  leaders 
Notes:  
IR=Ipsos Reid; NR = Nanos Research; RC = Research Canada; RSR=Robbins SCE Research.  
Italics indicates polls related to international issues. 
a. Canadian were asked to choose between discussions of the Canada Health Act and its practical evolution in 
maintaining high standards of health care for all Canadians (35%), the role of Canada’s Armed Forces in 
negotiations related to Canadian sovereignty and strategic missile defence with U.S. president George W. Bush 
(32%), the issue of Charter rights and specifically the rights of gay men and women to marry (3%), and the use of 
the employment insurance surplus of $50 billion to reduce negative impact of high employment insurance rates 
on employees and employers (34%). 
b. Of 14 issue areas, health care was ranked third most important after the economy (32%) and the environment 
(13%). 
c. The economy was ranked first (36%), followed by health care (23%), the environment (17%), and jobs and 
unemployment (16%). 
Sources: CNW Group (2009b); Ipsos Reid (2006, 2007, 2008, 2009); Association of Faculties of Medicine of Canada 
et al. (2010); Robbins SCE Research (2004).  
Appendix F:  
Benefits, Costs and Risks of a  
 Global Health Strategy for Canada 
Benefits 
A global health strategy for Canada would:  
• lead to better health in Canada and globally 
• provide added value for each ministry involved 
• improve the understanding of what is being done among Canadian actors and stakeholders 
• improve effectiveness and efficiency, in terms of both financial and human resources 
• provide a clear framework, aim and focus 
• support Canada in meeting its domestic and international heath objectives 
• be an example of cooperation that could be followed in other areas, such as agriculture 
• provide articulated and identifiable goals 
• provide greater transparency on Canada’s global health goals and on actions taken to achieve them 
• determine topics, subjects and research that might be explored 
• address any competing objectives that exist within different departments or agencies 
• coordinate and streamline the health‐related departments and agencies 
• ensure that Canada can respond to unexpected health‐related crises  
• ensure that Canada’s interests and values are reflected in its global health initiatives 
• support Canada’s foreign policy and international economic and development goals  
• strengthen national security through better partnerships at home and abroad 
• respond to the desires of Canadians and stakeholders who want Canada to play a larger role in 
global health 
• mobilize more resources by providing a centralized forum where all actors can identify opportunities 
for cooperation 
• identify activities to be enhanced, eliminated or reformed during resource‐constrained times 
• help Canada coordinate best practices 
• support Canada’s collaboration with partner countries that already have a global health strategy 
Costs 
Costs involved in a global health strategy include:  
• financial and human resources to developing a strategy (staffing, consultations, etc.) 
• diversion of resources and attention from other challenges 
• possible adjustment or modification of missions among actors 
• possible difficulty in agreeing on a comprehensive approach  
• possible factions or divisions among actors involved 
• delays in developing the strategy 
• time‐consuming analysis of existing commitments and component strategies 
• potential requirement or modification of legislation to authorize the involvement of some actors or 
resources 
• possible complications that arise from Canada’s complex federal system 
Risks 
Risks to Canada in having a global health strategy include: 
• dissatisfaction among actors due to conflicting priorities 
• alienation among actors 
• overcrowding of actors 
• possible unintended consequences, such as resources diverted from issues that need more attention 
• negative consequences for other countries (such as seeking health providers from other countries) 
• unwanted debates 
• a strategy that is too rigid to be able to adapt to changing situations and needs 
• a strategy that is under‐ or over‐ambitious 
• a strategy that does not include all the relevant actors 
• a strategy that is too general or insufficiently focused 
• limits to coherence in investments 
• satisficing 
• log rolling 
• failure to achieve declared goals 
• failure to fulfil expectations and satisfy demands for accountability 
• disregard for existing commitments in favour of new priorities or pledges 
• reduced competition among health actors 
Note: This is a compilation of points identified through research of published materials, key interviews and 
brainstorming exercises. 
Appendix G:  
Canada’s Free Trade Agreements 
Canada has free trade agreements with the following: 
• Chile 
• Colombia 
• Costa Rica 
• Iceland (Canada‐European Free Trade Association)  
• Israel  
• Jordan 
• Liechtenstein (Canada‐European Free Trade Association)  
• Mexico (North American Free Trade Agreement)  
• Norway (Canada‐European Free Trade Association)  
• Panama 
• Peru  
• Switzerland (Canada‐European Free Trade Association)  
• United States (North American Free Trade Agreement and previously the Canada‐U.S. Free Trade 
Agreement) 
Canada is negotiating free trade agreements with the following: 
• Americas 
• Andean Community 
• Caribbean Community 
• Centre American Four — El Salvador, Guatemala, Honduras and Nicaragua 
• Dominican Republic 
• European Union 
• India 
• Korea 
• Morocco 
• Singapore 
• Ukraine 
Source: Canada, Department of Foreign Affairs and International Trade (2010b). 
Appendix H:  
Effects of Climate Change on Human Health Identified by 
the Intergovernmental Panel on Climate Change 
Very High Confidence  High Confidence  Medium Confidence  Low Confidence 
Climate change  Emerging evidence shows  Emerging evidence  Projected trends will 
contributes to global  that climate change has  shows climate change  increase number of 
burden of disease and  altered seasonal  has altered distribution  people at risk of 
premature deaths  distribution of some  of some infectious  dengue 
allergenic pollen species  disease vectors 
Projected trends will  Projected trends will  Emerging evidence   
affect malaria: contract  increase malnutrition and  shows that climate 
in some areas and  consequent disorders,  change has increased 
expand in others;  including those relating to  deaths related to heat 
transmission season  child growth and  waves 
may change  development 
Economic development  Projected trends will  Projected trends will   
is component of  increase the number of  increase burden of 
adaptation but cannot  people suffering from  diarrheal diseases 
insulate population  death, disease and injury 
from disease and injury  from heat waves, floods, 
due to climate change  storms, fires and droughts 
  Projected trends will     
change range of some 
infectious disease vectors 
  Projected trends will     
increase cardiorespiratory 
morbidity and mortality 
associated with ground‐
level ozone 
  Projected trends will bring     
some benefits to health, 
fewer deaths from cold, 
but likely outweighed by 
negative effects of rising 
temperatures, especially 
in developing countries 
  Adaptive capacity needs     
to be improved; impacts 
of recent hurricanes and 
heat waves show that 
even high‐income 
countries not well 
prepared for extreme 
weather events 
  Adverse health impacts     
will be greatest in low‐
income countries and, in 
all countries, on urban 
poor, elderly, children, 
traditional societies, 
subsistence farmers and 
coastal populations 
Source: Intergovernmental Panel on Climate Change (2007b). 
Appendix I:  
Comparison of National Global Health Strategies 
Britain  Switzerland  European Union  United States 
Principles 
• Do no harm; evaluate    • Based on shared  • Match ambitions with 
impact of domestic  health values  long‐term 
and foreign policies on  • Consider health the  commitments at the 
global health to ensure  greatest wealth  highest levels of US 
intentions are fulfilled  • Consider Health in All  leadership 
• Base global health  Policies (HIAP)  •  “Trust but verify” 
policies and practice  • Strengthen the EU’s  • Build on existing 
on evidence; develop  voice in global health  successes 
evidence where it does  • Prioritize prevention 
not exist  • Be targeted 
• Use health as agent for  • Embed global health 
good, recognizing it  investments within 
can promote a low‐ larger development 
carbon, high‐growth  enterprise 
global economy 
• Promote global health 
outcomes that support 
the MDGs 
• Promote health equity 
through foreign and 
domestic policies 
• Ensure effects of 
foreign and domestic 
policies on global 
health are explicit; 
ensure transparency 
on conflicts between 
the policy objectives 
• Work for leadership 
through reformed, 
strengthened 
institutions 
• Learn from other 
countries’ policies and 
experience to improve 
population health and 
healthcare delivery 
• Protect health by 
tackling health 
challenges that begin 
abroad 
• Work with other 
governments, 
multilateral agencies, 
civil society and 
business 
Britain  Switzerland  European Union  United States 
Goals 
• Better global health  • Protect health  • Fostering good health  • Maintain commitment 
security  interests of the Swiss  in an aging Europe  to fight against 
• Stronger, fairer and  population  • Protecting citizens  HIV/AIDS, malaria and 
safer systems to  • Harmonize national  from health threats  tuberculosis 
deliver health  and international  • Supporting dynamic  • Prioritize women and 
• More effective  health policies  health systems and  children in US global 
international health  • Improve effectiveness  new technologies  health efforts 
organizations  of international  • Strengthen prevention 
• Stronger, freer and  collaboration in health  and capabilities to 
fairer trade for better  • Improve global health  manage health 
health  situation  emergencies 
• Strengthening of the  • Safeguard role as host  • Ensure the United 
way evidence is  to international  States has capacity to 
developed and used to  organizations and base  match global health 
improve policy and  for companies in  ambitions 
practice  health sector  • Invest in multilateral 
institutions 
Measures 
    • Establish coordinating   
office for health 
foreign policy 
• Create information 
platform for health 
foreign policy 
• Produce policy papers 
on health foreign 
policy and strengthen 
academic competence 
• Harmonize with 
general foreign policy 
and other policies 
• Create 
Interdepartmental 
Conference on Health 
Foreign Policy 
Resources 
• 07% of GNI on  • No additional  • Actions supported by  • $63 billion for Global 
international  resources planned for  existing financial  Health Initiative 
development by 2013  implementation  instruments until end  (2009–14) 
• £6 billion on health  of 2010 financial  • $25 billion annually 
systems and services  framework (2013),  (adjusted for inflation) 
(2008–15)  without additional  (2010–15) 
• £1 billion for the Global  budgetary  • increase multilateral 
Fund  consequences  funding from 15% to 
• £400 million for global  20% 
health research  
(2008–13) 
Notes:  
Bold indicates actions where Canadian priorities and interests overlap.  
Global Fund = Global Fund to Fight AIDS, Tuberculosis and Malaria; GNI = gross national income; MDGs = 
Millennium Development Goals. 
Sources: Switzerland, Federal Department of Home Affairs and Federal Department of Foreign Affairs (2006); 
United Kingdom, HM Government (2008); Commission of the European Communities (2007); Sridhar (2009); 
Fallon and Gayle (2010). 
Appendix J:  
Steps for Creating a Canadian Global Health Strategy 
The next steps to consider when developing a Canadian global health strategy should include the 
following: 
1.  Choose a task team that will be responsible for overseeing and reviewing the process, reporting on 
implementation and suggesting next steps. An independent, third‐party could make up this team or 
it could comprise key officials from Health Canada, Public Health Agency of Canada (PHAC), the 
Canadian International Development Agency (CIDA) and the Department of Foreign Affairs and 
International Trade (DFAIT). The team would be responsible for overseeing the Canadian global 
health strategy and coordinating the additional departments and actors involved. 
2.  Engage in two phases of consultations with all key actors, both within Health Canada and PHAC as 
well as interdepartmentally at the federal level, to include the Prime Minister’s Office, DFAIT, 
Agriculture and Agri‐Food Canada, Environment Canada, Indian and Northern Affairs, Public Safety 
Canada, Department of National Defence, Industry Canada, CIDA and the Canadian Food Inspection 
Agency. Consultations should also include the Health Council of Canada, the Canadian Institutes of 
Health Research, the International Development Research Centre, and provincial and territorial 
governments. They should also draw on expertise that exists in the private sector and in civil 
society, including philanthropic entities, non‐governmental organizations and academia.  
• Phase One: Identify the objectives of the Canadian global health strategy and their underlying 
principles of those objectives. The task team should compile a list of all the objectives and 
principles. Any contradictions that cannot be resolved internally should be addressed with the 
involvement of relevant outside actors. Provincial, international and public objectives and 
principles should be next considered and compared with those identified for a national global 
health strategy.  
• Phase Two: Determine the priorities of the Canadian global health strategy. The specific targets 
should be weighted according to those with the most support among stakeholders and then 
placed within a broader framework. The lead and supporting actors for each action should then 
be identified. 
5.  The task team should choose an appropriate time line that fits with the established priorities. A five‐
year term is consistent with the other countries’ global health strategies and fits well within the 
Millennium Development Goals. However, the priorities chosen should dictate the time frame. The 
schedule for conducting reviews should also be decided so that the strategy can remain relevant 
and effective. 
6.  The task team should identify partners within Canada from outside government, including 
academia, the private sector and civil society, as well as other national governments and 
international organizations. 
7.  The task team should identify necessary resources to develop the global health strategy, including 
financial commitments, human resources and programming costs to implement the global health 
strategy. 
Appendix K:  
Research Methodology 
A team of researchers from the University of Toronto’s Global Health Diplomacy Program and G8 
Research Group compile the appendices from published and public material. The analysis used to 
identify the Canadian principles relevant to global health was based on a systematic analysis of all 
health‐related passages in the Speeches from the Throne and major foreign policy statements since 
1947, including statements by Canadian prime ministers at the United Nations General Assembly and 
statements made by Cabinet ministers. Materials are available upon request. 
Interviews were conducted with key stakeholders and experts in the fields related to Canada and 
global health.  
Deliberations held at the Global Health Diplomacy Program’s conference on “Accountability, 
Innovation and Coherence in G8 Health Governance: Seizing Canada’s G8 Opportunity” in January 2010 
at the Munk Centre for International Studies in Trinity College at the University of Toronto were 
considered.  
The authors’ field experiences and past research were drawn on. 

Translating Idea Into Policy

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Translating Idea Into Policy

Uploaded by

Copyright:

Available Formats

Translating an Idea into a Policy:

March 31, 2009

Copyright © 2009 The President and Fellows of Harvard College

In July 2004, the Institute of Medicine (IOM) Committee on the Economics of

The Problem: Malaria and its Treatment

Copyright © 2009 Harvard 2 March 31, 2009

There are also concerns about emerging resistance to artemisinin. Artemisinin

Copyright © 2009 Harvard 3 March 31, 2009

Designing a Solution: The Institute of Medicine Committee on the Economics of

Copyright © 2009 Harvard 4 March 31, 2009

Copyright © 2009 Harvard 5 March 31, 2009

Gaining Adoption for the Idea within the World Bank

The researchers modeled a number of different scenarios, including no subsidy, partial

Copyright © 2009 Harvard 6 March 31, 2009

Copyright © 2009 Harvard 7 March 31, 2009

Challenges in Translating a Research Report into an Operational Plan

Copyright © 2009 Harvard 8 March 31, 2009

Copyright © 2009 Harvard 9 March 31, 2009

Designing Strategies for Addressing Opposition

Copyright © 2009 Harvard 10 March 31, 2009

1. What were the main barriers to ACT access in poor countries?

3. Conduct a stakeholder analysis to assess the feasibility of the IOM’s

Copyright © 2009 Harvard 11 March 31, 2009

Copyright © 2009 Harvard 12 March 31, 2009

Copyright © 2009 Harvard 13 March 31, 2009

Adopting National Health Insurance in West Africa*

The views expressed in this report are those of the authors

You might also like