Public Health Global Health Diplomacy
by
Ilona Kickbusch, Thorsten Behrendt
  • LAST REVIEWED: 26 January 2021
  • LAST MODIFIED: 27 March 2014
  • DOI: 10.1093/obo/9780199756797-0101

Introduction

Today’s debates on global health diplomacy are characterized by two major governance challenges in the global health domain that reflect a globalized and increasingly interdependent world. First, the last decade has witnessed the uncoordinated proliferation of a wide variety of global health actors with different interests, resource flows, principles and objectives. The exponential increase of actors and initiatives has resulted in a polylateral and fragmented global health domain that falls short in converging strategies and resources in a transparent and effective way. Second, the state of global health is increasingly affected by decisions made in sectors that are not part of the global health governance system. Protecting and promoting health governance processes such as trade, environment, and food security is difficult and has not yet received sufficient attention. This is increasingly referred to as global governance for health. New processes of health diplomacy are required to ensure an increased consideration of health impacts by other sectors. Traditional notions of diplomacy are also changing in response to the growing interdependence and complexity of many current global problems, and a shift to new spaces of negotiation and influence has taken place. This is reflected in a broad literature on international relations that cannot be referenced here. Health has entered the realm of foreign policy due to national security concerns and as a soft power mechanism to serve geopolitical interests. However, the foreign policies of countries also and increasingly serve the goals of health—this is beginning to be more recognized in the literature. For example, to enhance development, diplomats have negotiated international agreements such as the Millennium Development Goals and RIO+20; they have also contributed to the negotiation of major health agreements such as the Framework Convention on Tobacco Control and are instrumental in the creation of many major global health alliances. Today, diplomats play a critical role in the creation and management of global partnerships for health that cover a wide variety of actors. Global health diplomacy builds on this notion of diplomacy as being engaged in the management of globalization and tries to capture multi-level and multi-actor negotiation processes that shape and manage the global policy environment for health. Given the interdisciplinary nature of the young field, a literature review on global health diplomacy requires the consideration of introductions to diplomacy, global health, and global health governance.

General Overviews

Globalization has changed traditional ways of conceptualizing and organizing the medical, economic, political, and technological means to improve health. The rise of health as a foreign policy concern reflects this development and the challenge of moving toward a new global social contract for health. Global health diplomacy can be seen as a process of social involvement of a wide array of actors at different levels of governance. If well conducted, this process leads to better population health outcomes for all countries. For this purpose global health diplomacy seeks to position health in foreign policy negotiations with the aim of creating new forms of governance that either stimulate progress within the global health system (global health governance) or help to improve health through the actions of actors in other global policy-making arenas (global governance for health). The general overviews presented here take this two-fold governance challenge into account when describing the intersectoral and interdisciplinary nature of global health diplomacy as well as discussing its value base. They are only exemplary of the extensive literature that is now available in this field. Harman 2012 explores the various ways in which we can understand global health governance. The author provides an analysis on the most relevant actors in global health governance, their purpose, influence, and impact. Youde 2012 gives a similar overview of the messy landscape of institutions and actors. It describes the shifts implied in moving from international to global health governance and the impact and tensions between framing health as a security or a human rights issue. Parker and Sommer 2011 explores key public health challenges, conceptualizes the notion of global health, and highlights critical priorities in the rapidly evolving field. Schrecker 2012 provides a more political viewpoint and specifically analyses health as an element of many nations’ foreign policies. While some aspects of health, like the spread of easily transmitted communicable diseases, are self-evidently global in an age of rapid, low-cost air travel, others reflect the political and economic impact of globalization and its effects on national economies, societies, and health systems. Kickbusch, et al. 2013 describes global health diplomacy as a discipline with transformative potential that furthers the human rights dialogue and provides a framework for understanding global health issues and their negotiation in many different venues of global governance. According to Novotny, et al. 2013, the success of global health diplomacy efforts strongly depends on the recognition of the interplay of globalization, economic interdependence, social justice, and the self-interests of nations.

  • Harman, Sophie. 2012. Global health governance. Routledge Series on Global Institutions. London and New York: Routledge.

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    Highlighting the wide variety of actors, issues, and approaches involved, this work shows the complex nature of global health governance and concludes that it is still highly hierarchical and highly conflictive. It does not yet function as an agreed regime for common action and agreement; the political will is still lacking.

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  • Kickbusch, Ilona, Graham Lister, Michaela Told, and Nick Drager, eds. 2013. Global health diplomacy: Concepts, issues, actors, instruments, fora and cases. New York: Springer.

    DOI: 10.1007/978-1-4614-5401-4Save Citation »Export Citation »

    This very first handbook on global health diplomacy sets out defining principles, presents the current agenda of the field, and examines the many venues and actors of global health diplomacy. In particular, it highlights the need for a value base of global health diplomacy and sees this in the provision of global public goods and a human rights perspective.

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  • Novotny, Thomas E., Ilona Kickbusch, and Michaela Told, eds. 2013. 21st Century global health diplomacy. Global Health Diplomacy 3. Hackensack, NJ: World Scientific.

    DOI: 10.1142/8178Save Citation »Export Citation »

    The contributions to this volume explore the challenges that emerge as health diplomacy enters a range of new arenas; chapters explore health diplomacy in the context of foreign policy, security, humanitarian action, as well as the military. It provides insights into the historical trajectory of global health diplomacy and proposes ways to strengthen global health diplomacy.

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  • Parker, Richard Guy, and Marni Sommer. 2011. Routledge handbook of global public health. London: Routledge.

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    The handbook describes global health within the context of a rapidly changing political and institutional landscape shaped by globalization. It gives an overview on contemporary global public health challenges, highlights critical priorities for action, and argues that today’s health threats require the attention not only of governments but also of a range of non-state institutions and actors.

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  • Schrecker, Ted, ed. 2012. The Ashgate research companion to the globalization of health. Farnham, UK, and Burlington, VT: Ashgate.

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    This volume of original contributed papers provides an excellent overview of the state of current global health scholarship, the multidisciplinary nature of the field, and the most significant issues for research and policy. It identifies two key challenges: the issue of resources and changing approaches to financing and development aid and the issue of institutions that can respond to the dynamics of globalization.

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  • Youde, Jeremy R. 2012. Global health governance. Cambridge, UK, and Malden, MA: Polity.

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    The comprehensive overview offers an introduction to the changing international legal environment, the governmental and non-governmental actors involved with health issues, and the current regime’s ability to adapt to new crises. It explains both the trajectory of global health institutions over the past century and their current operations and influence.

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Introductory Works

To comprehensively describe today’s global health diplomacy, an understanding for the overall evolution of diplomacy is needed. Diplomacy after the Peace of Westphalia in 1648 was, for a long time, focused on bilateral negotiations between two states. This system was transformed in 1814, when the Congress of Vienna introduced multilateral club diplomacy as a way to achieve a long-lasting peace among European states. New multilateral universal diplomatic platforms were established with the League of Nations after the First World War and with the United Nations System after the Second World War. While these new forums aimed to increase participation, transparency, and accountability by working to the principle of “one country–one vote” the limits of a system based on nation states has become glaringly obvious. Global interdependence and the plurality of objectives have transformed the very essence of diplomacy and paved the way for today’s polylateral multi-stakeholder diplomacy. Today, the solution of national problems often requires collective global action that includes not only states but also a whole variety of other actors. Particularly in relation to the so-called “softer” global problems such as health, non-state actors have obtained significant power. This transformation of the general patterns of diplomacy has a fundamental impact on global health diplomacy. Therefore, a literature review on global health diplomacy requires an introduction to the recent literature on diplomacy as well. One helpful introduction is Kerr and Wiseman 2013, which provides a theoretical understanding of the field as well as examples from the practice of diplomacy, to show how increasingly complex it has become. Nowotny 2011 argues that traditional diplomacy has become redundant and sometimes counterproductive. Diplomats are trained to transform differences into consensus and to navigate conflicts. But to do so effectively, and to meet today’s challenges, they will have to adjust both their ways of working and the relevant institutions. McInnes and Lee 2012 contend that the long separation of health and international relations has now dramatically changed. Since the 1990s, the two fields increasingly overlap, and the questions to be answered are how this shift can be explained and what implications this may have for the future. Finally, for those who come to global health diplomacy from other fields, it can be helpful to study one of the introductions to global health, such as DeLaet and De Laet 2012. It provides a helpful overview of global health concepts, the medical aspects of global health, and the interface of global health with international relations.

  • DeLaet, Debra L., and David E. DeLaet. 2012. Global health in the 21st century: The globalization of disease and wellness. Boulder, CO: Paradigm.

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    This comprehensive introduction to global health emphasizes the potential of public health intervention to improve the longevity and quality of human life across the globe. The authors offer an up-to-date picture of the field and discuss the promotion of global health from both the top down, through states, and the bottom up, through civil society organizations.

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  • Kerr, Pauline, and Geoffrey Wiseman. 2013. Diplomacy in a globalizing world: Theories and practices. New York: Oxford Univ. Press.

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    Within this introductory work, twenty-three well-known scholars contribute to the debate about the changing nature of diplomacy and its future theoretical and practical directions. The book’s premise is that diplomacy is becoming more rather than less important. It is an essential instrument for managing the differences between countries in the face of major power shifts and new types of global challenges.

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  • McInnes, Colin, and Kelley Lee. 2012. Global health and international relations. Malden, MA: Polity.

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    The book examines key intersections between health and international relations such as global health security. The authors illustrate how global health has been socially constructed, shaped in theory and practice by particular interests and normative frameworks, and how the wide range of new social actors in global health has contributed to shaping the global agenda.

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  • Nowotny, Thomas. 2011. Diplomacy and global governance: The diplomatic service in an age of worldwide interdependence. New Brunswick, NJ: Transaction.

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    The book is based on unique experiences in bilateral and multilateral international diplomacy. Nowotny argues that diplomacy has to build bridges between the realm of the political unit of ever-smaller states and the realm of global regimes, rules, and institutions. Modern diplomacy is defined by its function to engage in the web of mutual dependence and to actively shape it.

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Reference Works

The new field of global health diplomacy is embedded within the context of international relations and diplomacy. Diplomacy is the art and practice of conducting negotiations. It describes specific methods for reaching compromise and consensus as well as a system of organization for the negotiating process. Moreover, diplomacy is a highly political activity oriented toward achieving a specific outcome, i.e. foreign policy goals of a nation state. This has not changed for centuries. What has changed, however, is the way and scope of negotiating. Health diplomats need to understand the complex, historically grown dynamics of international relations and develop general diplomatic skills in order to move health into the diplomatic sphere. Evans and Newnham 1998 as well as Berridge and James 2003 provide comprehensive dictionaries that offer overviews on this broader environment in which global health diplomacy takes place. The World Health Organization (WHO) and the World Health Assembly are the major forums a for global health diplomacy. Lee and Fang 2013 is an outstanding reference work that covers all six decades of WHO’s existence. The more than 1,000 entries also reflect the organization’s institutional and programmatic adaptation to important changes in its operating environment. Burci and Vignes 2004 have particularly covered the last twenty years and WHO’s development, given the transition from international to global health cooperation. The book is especially interesting to those not coming from a medical background and provides a thorough analysis of the role of WHO, both within and outside of the global health system. A crucial reference work is Amorim, et al. 2007, the Oslo Ministerial Declaration, in which the involved Ministers of Foreign Affairs from seven countries agreed to make the impact on health a point of departure and a defining lens that each of their countries would use to examine key elements of foreign policy and development strategies. The statement has been quoted as a paradigm shift in many key articles on global health diplomacy since.

  • Amorim, Celso, Phillippe Douste-Blazy, Hasan Wirayuda, Jonas Gahr Støre, Cheikh Tidiane Gadio, and Nkosazana Dlamini-Zuma. 2007. Oslo Ministerial Declaration. Global health: a pressing foreign policy issue of our time. The Lancet 369.9570: 1373–1378.

    DOI: 10.1016/S0140-6736(07)60498-XSave Citation »Export Citation »

    Under their initiative on Global Health and Foreign Policy, the Ministers of Foreign Affairs of seven countries issued the Oslo Declaration on March 20, 2007. It recognizes that, in today’s era of globalization and interdependence, there is an urgent need to broaden the scope of foreign policy, and it argues that health is one of the most important, yet still broadly neglected, long-term foreign policy issues of our time.

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  • Berridge, Geoff, and Alan James. 2003. A dictionary of diplomacy. 2d ed. Basingstoke, UK, and New York: Palgrave Macmillan.

    DOI: 10.1057/9780230501348Save Citation »Export Citation »

    Like all professions, diplomacy has developed its own specialized terminology, and the lexicon is a comprehensive collection of relevant terms. It also includes entries on legal terms, political events, international organizations, and major diplomatic figures. The book is particularly useful for students of diplomacy and related subjects as well as for members of diplomatic services worldwide.

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  • Burci, Gian Luca, and Claude-Henri Vignes. 2004. World Health Organization. The Hague: Kluwer Law International.

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    The World Health Organization (WHO) was established in 1946. Since then, WHO has used its authority and constitutional mandate in many different and sometimes innovative ways, at the normative, policy-making, and technical levels alike. The authors have written a systematic review of WHO in its changing historical and political context, aiming in particular at practitioners and scholars without a specific medical background.

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  • Evans, Graham, and Jeffrey Newnham. 1998. The Penguin dictionary of international relations. London: Penguin.

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    The dictionary provides an overview of the complex and constantly shifting dynamics of international relations. The book is a central and comprehensive guide to the events, organizations, theories, and concepts that are shaping today’s global community.

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  • Lee, Kelley, and Jennifer Fang. 2013. Historical dictionary of the World Health Organization. 2d ed. Historical dictionaries of international organizations. Lanham, MD: Scarecrow.

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    The dictionary covers the history of the World Health Organization through a chronology, an introductory essay, appendices, and an extensive bibliography. The dictionary section has over one thousand cross-referenced entries on key bodies, programs, events, and people. This book is an excellent access point for students, researchers, and anyone that would like to learn more about the organization.

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Key Journal Articles

Diplomacy opened in the 1950s to economy and trade, enlarged in the 1980s to the environment, and has begun the 21st century with a focus on health. Chan, et al. 2008 argues that public health has often been placed in a reactive role in dealing with the consequences of policies it had no influence in shaping. With the emergence of global health diplomacy and foreign policies that serve the goals of health, this role has changed. In this context, Møgedal and Alveberg 2010 identifies policy coherence as being a necessary undertaking for all countries. Foreign policy practitioners need to become more aware of the impact of their decisions on health outcomes. Lee and Smith 2011 provides a conceptual review on global health diplomacy, the definition of which recognizes the duality of the relationship between health and foreign policy, and the centrality of negotiation in achieving goals within each policy sphere. Katz, et al. 2011 proposes a taxonomy for global health diplomacy that reflects the increasing diversity of the field and argues that multi-stakeholder diplomacy in global health requires a new combination of technical expertise, legal knowledge, and diplomatic skills. Scholars differ in their argumentation as to whether global health diplomacy is driven by foreign policy interests or not. In April 2010, PLoS Medicine launched a six-part series on global health diplomacy. The introductory article, Feldbaum and Michaud 2010, argues that despite recent suggestions to the contrary, foreign policy interests play a critical role in determining which global health issues achieve political priority and attract funding. The United States debate on winning the hearts and minds of people in poor countries by exporting medical care, expertise, and personnel reflects this notion. Labonté and Gagnon 2010 argues along the same line. The findings indicate that most states still make decisions primarily on the basis of the “high politics” of national security and economic development. Development, human rights, and ethical and moral arguments for global health assistance, the traditional “low politics” of foreign policy are present in discourse but do not appear to dominate practice. Kickbusch 2011 claims that, while in relation to national security and economic development, countries tend to use health as an instrument or integral part of foreign policies to achieve other more traditional foreign policy objectives, the creation of global public goods based on health as a social value and human right implies that the foreign policies of countries serve the goals of health. In this article, the author gives several examples in which this has been the case.

  • Chan, Margaret, Jonas Gahr Støre, and Bernard Kouchner. 2008. Foreign policy and global public health: Working together towards common goals. Bulletin of the World Health Organization 86.7: 1–2.

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    An important article on the interface between foreign policy and health written by three of the most respected figures in the field. The authors argue that the current interest in global health as a foreign policy concern offers a window of opportunity to embed the use of the health lens in foreign policy.

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  • Feldbaum, Harley, and Joshua Michaud. 2010. Health diplomacy and the enduring relevance of foreign policy interests. PLoS Medicine 7.4: 1–5.

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    The text describes health interventions that were conducted by states to achieve foreign policy goals related to national security and economic development. It shows convincingly that foreign policy interests are critical for understanding today’s global health diplomacy.

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  • Katz, Rebecca, Sarah Kornblet, Grace Arnold, Eric Lief, and Julie E. Fischer. 2011. Defining health diplomacy: Changing demands in the era of globalization. The Milbank Quarterly 89.3: 503–523.

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    The authors examine the foundations of various approaches to global health diplomacy and their implications for the policies that shape the international public health and foreign policy environments. It is clearly demonstrated that the deepening links between health and foreign policy require both the diplomatic and global health communities to re-examine the skills, comprehension, and resources necessary to achieve their mutual objectives.

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  • Kickbusch, Ilona. 2011. Global health diplomacy: How foreign policy can influence health. British Medical Journal 342:d3154.

    DOI: 10.1136/bmj.d3154Save Citation »Export Citation »

    The article provides an innovative continuum of the relationship between health and foreign policy. Foreign policy can have a negative impact on health, use health as an instrument, integrate health, or serve the goals of health. It is argued that public health experts need to work with diplomats to achieve global health goals.

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  • Labonté, Ronald, and Michelle L. Gagnon. 2010. Framing health and foreign policy: Lessons for global health diplomacy. Globalization and Health 6.1: 1–19.

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    This interesting analysis of the arguments for health in foreign policy may prove helpful to those engaged in global health diplomacy. The authors indicate that the framing of health as a possibility for enhancement of national security and economic development may increase the political leverage of global health diplomats.

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  • Lee, Kelley, and Richard Smith. 2011. What is “global health diplomacy?” A conceptual review. Global Health Governance 5.1: 1–12.

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    The conceptual review provides a convincing definition of global health diplomacy, which can be seen as a good starting point for a more focused research agenda to strengthen the understanding of health negotiations and to investigate how global health diplomacy can contribute to achieving more effective collective action.

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  • Møgedal, Sigrun, and Benedikte Louise Alveberg. 2010. Can foreign policy make a difference to health? PLoS Medicine 7.5: e1000274.

    DOI: 10.1371/journal.pmed.1000274Save Citation »Export Citation »

    This comprehensive discussion on the requirements needed for the improvement of health through foreign policy argues for better coordination at all levels in order to create an improved global policy environment for health.

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Literature Reviews and Bibliographies

Existing literature reviews and bibliographies reflect the interdisciplinary and multi-sectoral nature of global health diplomacy. The literature can be divided into two broad categories. First, publications seek to document how health has been used by national governments to achieve strategic, economic or ideological objectives. Second, the literature describes the global discussions around collective action problems and how complex health problems can be solved by working together across sectors and at different levels of governance. Blouin, et al. 2012, the annotated literature review by the Regional Network for Equity on Health in East and Southern Africa examines the role of global health diplomacy in addressing selected key challenges to health and strengthening health systems. By bringing together the central works from different disciplines, Kirton 2009 gives a comprehensive overview of articles on global health challenges that require foreign policy to serve the goals of health. Diplomacy lies at the core of any attempts to tackle issues such as the shortage of health workers, the access to medicines and technologies, as well as the spread of communicable and non-communicable diseases.

  • Blouin, Chantal, Bente Molenaar, and Mark Pearcey. 2012. Annotated literature review: Conceptual frameworks and strategies for research on global health diplomacy. EQUINET Discussion Paper 92. Harare, Zimbabwe: EQUINET.

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    This literature review particularly focuses on the cooperation between developing countries (south-south cooperation) as an important emerging phenomenon within the global health diplomacy field. Besides the general annotated bibliography, it provides a summary of key features of articles, books, book chapters and academic reports on three case study areas: research on global health diplomacy, access to drugs through south-south partnerships, and involvement of African actors in global health governance.

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  • Kirton, John J., ed. 2009. Global health. Library of essays in global governance. Farnham, UK: Ashgate.

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    This book is part of a series of five volumes that analyze the theory and practice of global governance from a multi-disciplinary perspective. It has reprinted the most influential articles and papers in English on global health and global health diplomacy covering the foundations and evolution of global health, globalization and global health, communicable diseases, health and trade, and global health governance.

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Negotiation

Diplomacy is the art and practice of conducting negotiations. Multi-stakeholder diplomacy refers to international negotiations and interaction in which various state, non-state, and multilateral actors work together to address common issues. This cross-sector engagement with other actors is particularly important for global health diplomacy. Skilled and experienced health diplomats can build broad coalitions on different levels of governance that together can significantly improve health. Literature on how to conduct multi-stakeholder negotiations effectively needs to be taken into account. Starkey, et al. 2010, shows that the process of negotiation has never been a more vital process to understand than in today’s rapidly changing international system. Students of negotiation must understand key concepts of international relations to understand the dynamics of the many new actors that interact with conventional state agents in the diplomatic arena. Hamilton and Langhorne 2011 analyzes the evolution of negotiation processes over the last centuries. The book also refers to the fact that diplomats no longer interact only with other diplomats, but must work together with the private sector, nongovernmental organizations (NGOs), scientists, activists, and the media. By providing case studies from the business, political, NGOs, and international organization arenas, Saner 2008 demonstrates that negotiation practice in these new spheres can be learned. Smith 2009 highlights the shift in diplomatic focus over the past twenty five years from security-related agreements to international and trans-boundary agreements that address global environmental threats and promote cooperative approaches in science and technology. Global health diplomacy clearly can learn from the experiences made in the environment policy arena.

  • Hamilton, Keith, and Richard Langhorne. 2011. The practice of diplomacy: Its evolution, theory, and administration. 2d ed. London and New York: Routledge.

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    Practice of Diplomacy has become established as a classic text in the study of diplomacy. This second edition builds on the strengths of the original text with a strong empirical and historical focus. It also has an entirely new chapter discussing core issues such as NGOs, trans-national corporations, and the revolution in electronic communications.

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  • Saner, Raymond. 2008. The expert negotiator: Strategy, tactics, motivation, behaviour, leadership. 3d ed. Leiden, The Netherlands, and Boston: Martinus Nijhoff.

    DOI: 10.1163/ej.9789004165021.1-292Save Citation »Export Citation »

    In this book, the author draws on his long years of experience as a negotiation adviser, teacher, trainer, researcher, and university lecturer to show that two-thirds of negotiation practice is learnable. Yet very few people are specifically trained in this task. Without sacrificing scientific accuracy, the book offers a highly readable and fascinating guide to the subject.

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  • Smith, Richard J. 2009. Negotiating environment and science: An insider’s view of international agreements, from driftnets to the space station. Washington, DC: Resources for the Future.

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    In this thought-provoking book, the author presents in-depth accounts of eight high-profile negotiations. Smith explains the development of these negotiations, the challenges that emerged, and the strategies that led to treaties. The book was written for an audience with a general interest in international relations and the environment, but many lessons can also be applied to health diplomacy.

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  • Starkey, Brigid, Mark A. Boyer, and Jonathan Wilkenfeld. 2010. International negotiation in a complex world. 3d ed. New Millennium Books in International Studies. Lanham, MD: Rowman & Littlefield.

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    This book explores new complexities in international negotiation processes. The authors have included many real-world cases and examples to illustrate key themes, the role of culture in communication, and the impact of domestic-level politics on international negotiations. This innovative text also presents effective exercises and learning approaches that enable students to understand the complexities of negotiation.

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Case Studies

The global health diplomacy literature is often practical and based on case studies of recent negotiations, rather than theoretical discussions. Sharing experiences can help to develop new skills needed to negotiate global regimes, international agreements, and treaties, and to maintain relations with a wide range of actors. Rosskam and Kickbusch 2012 have collected a large number of negotiation processes and cases that have shaped and managed the global policy environment for health—many of which have included other major actors at different governance levels, including philanthropists and public-private players. The book discusses the successes, challenges, failures, tools and frameworks for negotiation, mechanisms of policy coherence, ways to achieve global health objectives internationally, and how global health diplomacy used as a foreign policy tool can improve relations between nations. The interconnectedness of national and global challenges thereby contributes to a normative change and new incentives to engage in negotiations. An excellent example of the challenges arising from a key global health issue—the access to medicines—is presented in the in-depth analysis of Hein and Moon 2012 on the changing norms in global health governance. These are critical in the conducting of global health negotiations, as norms become codified into more formal rules, new agreements, and possibly even new institutions. Fairman, et al. 2012 argues that in a new era of global health diplomacy, the most important tool for decision-making is negotiation. In the health policy arena, traditional international concerns like the spread of infectious diseases have been joined by new concerns and challenges in managing the health impacts of trade and intellectual property rights, and by new opportunities to create effective global health agreements and programs. To address the major health crises of today and to prevent or mitigate them in the future, countries must seek collective agreement and action within and across their borders. However, the world of international negotiation is not the world in which health decision makers reside or are most comfortable. Therefore, new skills are needed, and this volume gives advice and presents tools for success. Drager, et al. 2000 also provides useful tools, strategies, and examples for negotiations on health diplomacy in low- and middle-income countries.

  • Drager, Nick, Elizabeth McClintock, and Michael Moffitt. 2000. Negotiating health development: A guide for practitioners. Geneva, Switzerland: World Health Organization.

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    This book can be used at any stage in the health development process. Relevant tools, frameworks, processes, and questions are presented. The approach is based on the training of officials from over forty developing countries and includes examples of their very real experiences that will help readers to deal with their own contexts.

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  • Fairman, David, Diana Chigas, Elizabeth McClintock, and Nick Drager. 2012. Negotiating public health in a globalized world: Global health diplomacy in action. Dordrecht, The Netherlands, and New York: Springer.

    DOI: 10.1007/978-94-007-2780-9Save Citation »Export Citation »

    The goal of this guide is to provide health policy makers with practical information and insights from negotiation processes, to help them create better international health agreements and programs. It helps health diplomats to develop the negotiation skills necessary to meet the challenges of global health diplomacy.

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  • Hein, Wolfgang, and Suerie Moon. 2012. Informal norms in global governance: Human rights, intellectual property rules and access to medicines. Farnham, UK, and Burlington, VT: Ashgate.

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    After a decade of controversial debate, an informal but robust and powerful global norm has emerged that all people should have access to essential medicines. This book recounts the remarkable story of the access to medicines movement and offers an explanation for how the “access norm” emerged as a norm in global health governance against long odds.

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  • Rosskam, Ellen, and Ilona Kickbusch, eds. 2012. Negotiating and navigating global health: Case studies in global health diplomacy. Global Health Diplomacy 2. Singapore and Hackensack, NJ: World Scientific.

    DOI: 10.1142/8273Save Citation »Export Citation »

    The intent of this book is to provide learning tools for today’s broad group of new health diplomats in the landscape of this ever-shifting and complex technical and political arena. The well-selected case studies are told by individuals who participated in the various debates, dialogues, and negotiations, or by experts who have studied them.

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The Promotion of Traditional Foreign Policy Interests

National security threats are identified as main drivers for countries to incorporate health considerations within their foreign policies. Pandemics, emerging infectious diseases, and bioterrorism are understood as direct threats to national security. In a globalized world, dangerous pathogens can easily be transmitted. But just as diseases can cross borders easily, so can solutions. Globalization has facilitated the quick response to health problems and created new opportunities to bring together relevant stakeholders to deal with common problems. Yet challenges to policymaking continue to arise despite forums to address some of these concerns. Drawing from the experiences in Taiwan during the SARS outbreak, Liang and Mackey 2012 uses principles from public policy analysis to provide guidance on how to assist those involved in global health diplomacy to better prepare for negotiations and effectively resolve conflicts. Kamradt-Scott 2010 analyzes the negotiations on a revision of the International Health Regulations (IHR) and provides evidence for the importance of committed leadership and diplomatic skills to achieve norm and institutional change. Kaufmann and Feldbaum 2009 examines the case of polio immunization in Nigeria, where in August 2003, the political leadership of several northern Nigerian states responded to community pressure and banned federally sponsored polio immunization campaigns. The authors examine how global health diplomacy ultimately solved the political crisis. By examining the disease surveillance networks of the Mekong Basin, Middle East, and East Africa, Long 2011 provides evidence on how national security concerns and global health diplomacy made possible the joint working of countries that were historically prone to conflict. Turning to US global health diplomacy, the author contends that this arena presents an opportunity for American leadership that could improve America’s image globally. The securitization of health is also shown by the fact that the U.S. military is now, more and more, incorporating health policy into their operations. Moss and Michaud 2013 shows how the Department of Defense supports activities that address infectious disease efforts to protect personnel, build trust, and prevent conflict. Minear and Smith 2007 gives a comprehensive overview on humanitarian diplomacy—a field that in conflict situations is heavily interrelated with global health diplomacy. Countries have also used global health diplomacy to support economic development in low- and middle-income countries and have thereby increased their own political and economic leverage. For example, China increasingly supports health improvements in African states to gain access to natural resources and markets. Wang, et al. 2012 describes the deployment of Chinese Medical Teams as a health diplomacy strategy in developing countries since 1963.

  • Kamradt-Scott, Adam. 2010. The WHO secretariat, norm entrepreneurship, and global disease outbreak control. Journal of International Organizations Studies 1.1: 72–89.

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    The author examines how the practice of using unofficial sources of information to verify disease outbreaks was advanced within the negotiations on a revision of the International Health Regulations (IHR). It shows the power of individuals in overcoming institutional barriers by analyzing how a small group of individuals used global health diplomacy to embed this norm at the very heart of contemporary global disease outbreak control.

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  • Kaufmann, Judith R., and Harley Feldbaum. 2009. Diplomacy and the polio immunization boycott in northern Nigeria. Health Affairs 28.4: 1091–1101.

    DOI: 10.1377/hlthaff.28.4.1091Save Citation »Export Citation »

    This paper traces the diplomatic actions that were taken by the Global Polio Eradication Initiative, the United Nations, and the US government, to restart polio vaccination and resolve the crisis in Nigeria. The polio vaccination boycott in northern Nigeria provides a useful case study of the practice of global health diplomacy.

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  • Liang, Bryan A., and Tim Mackey. 2012. Preparing for health diplomacy negotiations: Global governance and the case of Taiwan, WHO, and SARS. In Negotiating and navigating global health: Case studies in global health diplomacy. Edited by Ellen Rosskam and Ilona Kickbusch, 173–202. Global Health Diplomacy. Singapore and Hackensack, NJ: World Scientific.

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    The case study of Taiwan and WHO during the SARS epidemic can provide an illustration and lessons of applying principles from public policy analysis to better obtain positive outcomes in health diplomacy and global governance negotiations.

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  • Long, William J. 2011. Pandemics and peace: Public health cooperation in zones of conflict. Washington, DC: United States Institute of Peace.

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    Drawing on international relations theory, Long presents an integrated explanation that demonstrates the processes by which interests, institutions, and ideas can align to allow for interstate cooperation even in unfavorable environments.

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  • Minear, Larry, and Hazel Smith. 2007. Humanitarian diplomacy: Practitioners and their craft. Tokyo and New York: United Nations Univ. Press.

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    Humanitarian professionals negotiate access to reach civilians in need. The book offers a compendium of humanitarian operations in diverse settings such as the Balkans, Somalia, East Timor, Cambodia, the Lebanon, and more recently Colombia and Iraq. These experiences from the field are framed by essays on the theory and practice of humanitarian diplomacy. This volume provides a unique resource for practitioners, policy communities, and students of humanitarian action.

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  • Moss, Kellie, and Joshua Michaud. 2013. The U.S. Department of Defense and global health: Infectious disease efforts. Menlo Park, CA: Henry J. Kaiser Family Foundation.

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    Within this comprehensive report, the authors examine the work of the U.S. Department of Defense in infectious disease prevention, research, and development. It shows how these activities are organized, funded, and coordinated with other U.S. government and external partners. The efforts in HIV/AIDS and malaria prevention and treatment are especially highlighted.

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  • Wang, Kai, Sarah Gimbel, Elfatih Malik, Sara Hassen, and Amy Hagopian. 2012. The experience of Chinese physicians in the national health diplomacy program deployed to Sudan. Global Public Health 7.2: 196–211.

    DOI: 10.1080/17441692.2011.594450Save Citation »Export Citation »

    The authors conducted a review of Chinese literature and governmental websites to describe the history and current distribution of Chinese medical teams around the world. Interviews with current Chinese health workers in Sudan were conducted and allow a deep insight into their work.

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The Creation of Global Public Goods for Health

The creation of global public goods may be the strongest argument for global health diplomacy. The concept of smart sovereignty claims that, for countries to engage in increased international cooperation and to give a certain degree of sovereignty away, may often be the best strategy to serve national priorities. Whelan 2008 argues that the negotiations on the revision of the International Health Regulations (IHR) allowed the elaboration of a legally binding agreement, which touches very closely on issues of sovereignty. Hence, diplomats now have a dual responsibility to represent both the interests of their countries and the global community. Potential providers, however, may not be adequately compensated and often see no strong incentives for engagement. An example for this problem is the controversy on sharing influenza viruses. Drager and Abbott 2013 describes the Pandemic Influenza Preparedness (PIP) framework as a global public good in the making and argues that the four years of negotiations have led to increased fairness. The starting point of the negotiations came in 2006, when Indonesia decided to withhold samples of the H5N1 avian influenza virus in order to publicize and alter the fact that developing countries were providing crucial information and virus samples to the WHO system without getting access to vaccines. Irwin 2010 examines the Indonesian virus-sharing case as well and discusses to what extent the IHR and other agreements are applicable to this case and why countries have chosen to address this issue through an intergovernmental process instead. Fidler and Lee 2010 analyzes the negotiations to increase equitable access to vaccines for avian influenza A (H5N1) and pandemic 2009 influenza A (H1N1). Written before the agreement on the PIP framework, the article is rather skeptical on the prospects of a framework and its implementation. Regulating health-damaging products also fits within the definition of global public goods. In this context, one of the key moments in global health diplomacy has been the adoption of the Framework Convention of Tobacco Control (FCTC). Lee, et al. 2010 describes the FCTC as a product of multi-level and multi-actor negotiation processes that reflect a multipolar world, in which states and non-state actors came together to design a legally binding tool to govern global health. Lencucha, et al. 2011 analyzes the crucial role of NGOs in the FCTC negotiations. Blouin and Dubé 2010 argues that lessons for global health diplomacy drawn from the negotiations on the FCTC can be useful for future negotiations on frameworks that tackle diet-related chronic diseases and prevent obesity.

  • Blouin, Chantal, and Laurette Dubé. 2010. Global health diplomacy for obesity prevention: Lessons from tobacco control. Journal of Public Health Policy 31.2: 244–255.

    DOI: 10.1057/jphp.2010.4Save Citation »Export Citation »

    This article innovatively discusses lessons to be learned from the negotiations of the Framework Convention on Tobacco Control (FCTC) for potential applicability to diet-related chronic disease prevention, and more specifically, to the rise in obesity prevalence worldwide.

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  • Drager, Nick, and Frederick Abbott. 2013. The “PIP” (Pandemic Influenza Preparedness) framework: Smart sovereignty to improve the sharing of influenza viruses with pandemic potential, while also moving towards more predictable and equitable access to vaccines in future pandemics; Annex 2. In Global public goods: A concept for framing the post-2015 agenda? Edited by Inge Kaul, 43–45. Discussion Paper. Bonn, Germany: Deutsches Institut für Entwicklungspolitik.

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    By using the concept of smart sovereignty, the authors give an explanation of how countries achieved consensus on the establishment of the Pandemic Influenza Preparedness (PIP) Framework. Provides a unique insight and identifies the evidence-based understanding by diplomats and an understanding of the negotiation process by health experts as the key feature of success.

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  • Fidler, David P., and Kelley Lee. 2010. Negotiating equitable access to influenza vaccines: Global health diplomacy and the controversies surrounding avian influenza H5N1 and pandemic influenza H1N1. PLoS Medicine 7.5: e1000247.

    DOI: 10.1371/journal.pmed.1000247Save Citation »Export Citation »

    The authors argue that national interests of most developed states vis-à-vis dangerous influenza strains favor retaining the existing imbalanced, reactive, and ad hoc approach to vaccine access. They examine why negotiating equitable access to influenza vaccines in the context of the avian influenza H5N1 and the pandemic influenza H1N1 has been a difficult diplomatic endeavor.

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  • Irwin, Rachel. 2010. Indonesia, H5N1, and global health diplomacy. Global Health Governance 3.2.

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    This article explains why negotiations over virus sharing have taken on for so long. It intends to answer questions about what effective global health diplomacy is and how global health governance architecture should change, including the role of WHO.

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  • Lee, Kelley, Luiz Carlos Chagas, and Thomas E. Novotny. 2010. Brazil and the Framework Convention on Tobacco Control: Global health diplomacy as soft power. PLoS Medicine 7.4: 1–5.

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    This research shows very well how an emerging power such as Brazil used its soft power to negotiate the Framework Convention on Tobacco Control. It is argued that skilled and experienced diplomats who supported the goals of health policy were crucial to counter industry-led arguments and to make the negotiations a success for global health.

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  • Lencucha, Raphael, Anita Kothari, and Ronald Labonté. 2011. The role of non-governmental organizations in global health diplomacy: Negotiating the Framework Convention on Tobacco Control. Health Policy and Planning 26.5: 405–412.

    DOI: 10.1093/heapol/czq072Save Citation »Export Citation »

    Based on the negotiation of the FCTC, the article convincingly argues that NGOs serve a diplomatic role and have become regular, more integrated, and often influential participants during negotiations. It portrays how NGOs monitored, lobbied, offered technical expertise, brokered information, and fostered inclusion during the negotiations. Non-state actors mirror modern multi-stakeholder diplomacy in global health and NGOs.

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  • Whelan, Mary. 2008. Negotiating the International Health Regulations. Global Health Programme Working Paper No. 1. Geneva, Switzerland: Graduate Institute.

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    The author describes her experiences as a diplomat chairing the negotiations to revise the IHR. The working paper outlines the organization of work, the issues at stake, the negotiating actors, as well as the challenges encountered, within a negotiation process, of a legally binding agreement that affects vital interests across a broad range of economic, social, and political policies.

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Achieving Policy Coherence in Health and Trade

Global health can only be improved as long as the global health community does not act in isolation. Arguably the most difficult challenge of global health diplomacy, therefore, is the task to ensure policy coherence. Policy coherence is crucial if foreign policy should serve the goals of health diplomacy. Within crosscutting negotiations, global health diplomacy can ensure that policy coherence takes place at the global level. In particular, a higher priority must be given to health when dealing with trade issues. In this context, Blouin, et al. 2007 seeks to answer the question on how to formulate trade policies that simultaneously achieve both growth and health benefits. Trade particularly affects health in relation to the access to affordable medicines. Roffe, et al. 2006 argues that in many developing countries the treatment of diseases such as AIDS and malaria remains a matter of life or death. Previously, access to essential medicines was made possible by the supply of much cheaper generics, manufactured largely by India; from 2005, however, the availability of these drugs is threatened as new WTO rules take effect. For global health diplomacy to have traction in foreign affairs, it needs a clear articulation of the “why.” Gagnon and Labonté 2011 finds many different motives and drivers for the integration of health into foreign policy. Human rights, however, should be the most important underlying principle of global health diplomacy and a guide in all international health negotiations.

  • Blouin, Chantal, Jody Heymann, and Nick Drager. 2007. Trade and health: Seeking common ground. Montreal: McGill-Queen’s Univ. Press.

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    This important book explores the entire range of avenues through which trade affects health and examines a number of case studies on how best to achieve policies that integrate health objectives. The contributors represent the full range of stakeholders in the trade-health debate—medical professionals, civil society representatives, academics from a range of disciplines, and negotiators and policy-makers at national and global levels.

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  • Gagnon, Michelle, and Ronald Labonté. 2011. Human rights in global health diplomacy: A critical assessment. Journal of Human Rights 10.2: 189–213.

    DOI: 10.1080/14754835.2011.569295Save Citation »Export Citation »

    The authors examine formal and informal statements of countries on health as a foreign policy issue and find many different motives and drivers for the integration of health into foreign policy. They then argue that human rights are the best existing argument for why health should be a prominent foreign policy concern.

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  • Roffe, Pedro, Geoff Tansey, and David Vivas Eugui. 2006: Negotiating health: Intellectual property and access to medicines. London and Sterling, VA: Earthscan.

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    The authors provide an informed analysis by internationally renowned contributors who look at the post-2005 world and discuss how action may be taken to ensure that intellectual property regimes are interpreted and implemented in a manner supportive to the right to protect public health and, in particular, to promote access to medicines for all.

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Soft Power and Power Shift

Global health diplomacy mirrors the evolution of polylateral multi-stakeholder negotiations that take into account the complexities and interdependencies of a globalized world as well as the emergence of new state and non-state actors. Fidler 2011 maps thinking and practice on global health diplomacy and argues that more descriptive, conceptual, analytical, and practical approaches are needed to analyze power shifts and the use of soft power by different actors. The BRICS countries (Brazil, Russia, India, China, and South Africa) are increasingly important in international relations. Within the field of global health diplomacy, Brazil has been particularly successful in using its soft power in foreign policy negotiations in recent years. Its health-related diplomatic activities have for a long time been focused on the access of medicines, particularly for the treatment of HIV/AIDS. Brazil’s normative leadership approach was also critical for the successful conclusion of the FCTC negotiations. However, not only Brazil but also other emerging economies are increasing their efforts in global health. According to Bliss 2010, it depends on each country’s history of international interaction on health, on their continued economic growth, and on the extent to which engaging in foreign activities does not conflict with domestic health and development priorities. Giving advice for global health diplomacy in U.S. President Barack Obama’s second term, Bliss 2013 argues that the world of global health diplomacy is quite dynamic at the moment, with new partners setting trends, while traditional actors are reconfiguring their views and practices. In relation to Africa, regional integration organizations have emerged as significant legal and diplomatic spaces to advance health goals. For Onzivu 2012, this evolving regional health diplomacy contributes to the reinforcement African regionalism and shapes the drivers of health policy at the global, regional, and national levels. Jing, et al. 2011 examines the evolution of health diplomacy in China and distinguishes between five different phases in the period from 1949 to the present. Today, China is actively involved in international health affairs and, given its growing national strength, the country will become even more responsive and active in the global health arena in the future.

  • Bliss, Katherine E. 2010. Key players in global health: How Brazil, Russia, India, China, and South Africa are influencing the game. Washington, DC: Center for Strategic and International Studies.

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    The contributions to this book examine the history of each country’s engagement in the global health area; the philosophy that motivates each nation’s global health outreach and cooperation; the relationship between each country’s domestic health conditions and its international work; the legislation and bureaucracies that support the work of governments on global health; the most relevant international organization; multilateral and bilateral partners; and the implications for the United States and other countries.

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  • Bliss, Katherine E. 2013. The changing landscape of global health diplomacy. Washington, DC: Center for Strategic & International Studies.

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    The papers of this useful volume offer insights regarding the background, experience, and politics that shape the approach of selected middle-income countries to global health diplomacy. At the same time, they highlight opportunities for U.S. engagement through existing bilateral and multilateral channels, while offering suggestions regarding what topics or themes may be most promising for enhanced diplomatic coordination and action.

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  • Fidler, David P. 2011. Navigating the global health terrain: mapping global health diplomacy. Asian Journal of WTO & International Health Law and Policy 6.1: 1–43.

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    This article provides a foundation for further analysis, explores conceptual underpinnings of global health diplomacy, and offers an analytical template for use in mapping different aspects of global health diplomacy. The article concludes with thoughts on the importance of mapping for helping countries, intergovernmental organizations, and non-state actors move toward shaping global health diplomacy in ways that contribute to improvements to humanity’s health.

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  • Jing, Xu, Liu Peilong, and Guo Yan. 2011. Health Diplomacy in China. Global Health Governance 4.2.

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    The paper examines China’s global health diplomacy engagement. The country is actively involved in international health affairs. Activities include working jointly with international health organizations, expanding inter-governmental health cooperation, and non-governmental health diplomacy. Identified shifts indicate that health is occupying an increasingly important role in diplomacy, and that diplomatic tools are being utilized to solve health issues.

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  • Onzivu, William. 2012. Regionalism and the reinvigoration of global health diplomacy: Lessons from Africa. Asian Journal of WTO & International Health Law and Policy 7.1: 49–76.

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    This paper refers to case studies of African regional and sub-regional integration organizations and examines the drivers, nature, and limits of their practice of health diplomacy. The paper identifies the strengths and limits of regionalism for health diplomacy and proposes options to use health diplomacy to further advance health at the domestic, regional, and global levels.

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Outlook

Global health diplomacy is an emerging field. It will continue to be discussed controversially. The tensions between global health and national foreign policy concerns will continue. Aginam 2010, for example, criticizes global health diplomacy as an “omnibus concept” that merely re-invents the wheel of age-old international health cooperation between nation-states. There is also an increasing debate as to whether the rise of emerging economies to political power implies a different approach to global health diplomacy. How will south-south cooperation be practiced? Will it move from its bilateral focus to a concerted action by groups of countries, as recently documented by the BRICS health ministers? Will they shift the paradigm, as Passarelli, et al. 2012 contends? How will global health diplomacy itself be shaped in new ways by the many actors involved? Is there a new diplomacy of diversity emerging as outlined in Low-Beer 2012? How does global health diplomacy play out in the new global health partnerships that have been established? How ready is it to embrace the diversity of voices and actors? Finally what is the role for global health diplomacy in relation to failed states and situations of civil war? The recent resurgence of polio in the conflict-ridden countries of Pakistan, Afghanistan, and Syria call for vaccine diplomacy of the type propagated in Hotez 2001. Such reflections must also include a critical look at the role of sanctions and their effect on the health of a population, as suggested in Baradaran-Seyed and Majdzadeh 2013. These examples indicate the need for many more analytical studies of how global health diplomacy functions and what impact it has.

  • Aginam, Obijiofor V. 2010. Health or trade? A critique of contemporary approaches to global health diplomacy. Asian Journal of WTO & International Health Law and Policy 5.2: 350–388.

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    This article offers a critique of contemporary approaches to global health diplomacy. The author argues that, while related concepts of global health governance capture the dynamic governance landscape of public health, global health diplomacy remains connected to age-old international health cooperation between nation states. In this sense, the developments at the World Trade Organization (WTO) are identified as the actual drivers of global health diplomacy.

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  • Baradaran-Seyed, Zahra, and Reza Majdzadeh. 2013. Economic sanctions strangle Iranians’ health, not just drug supply. The Lancet 381.9878: 1626.

    DOI: 10.1016/S0140-6736(13)61024-7Save Citation »Export Citation »

    This article describes how the health of the Iranian people has been affected by political and economic sanctions. For Iran’s sanctioned financial system, it is currently impossible to transfer money for any kind of trade, such as food and industrial raw materials, including pharmaceuticals. It is argued that the foreign policies of countries must urgently take health into account.

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  • Hotez, Peter J. 2001. Vaccine diplomacy. Foreign Policy, accessed on 31 October 2013.

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    The author describes how vaccination initiatives have contributed to peace in the past and argues that, throughout the developing world, vaccines could be transformed into powerful agents of conflict resolution. Multilateral vaccination programs bear the potential to foster a spirit of regional cooperation by engaging scientists and government health officials for a common cause.

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  • Low-Beer, Daniel. 2012. Innovative health partnerships: The diplomacy of diversity. Singapore: World Scientific.

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    Over the last ten years, the financing and diversity of actors in global health have increased significantly. This volume assesses the range of innovative partnerships that are now near the heart of global health diplomacy and describes the negotiations to integrate new players, a development that has changed health governance at global, regional, and local levels.

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  • Passarelli, Carlos, Cristina Pimenta, Kirill Danishevskiy, et al. 2012. Shifting paradigm: How the BRICS are reshaping global health and development. Global Health Strategies initiatives (GHSi).

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    The GHSi team identifies specific examples in which the BRICS and other emerging powers have independently impacted key health challenges. The report presents the priorities, policies and perspectives of the BRICS and their impact on health outside their borders. The report thereby attempts to look beyond the definitions of development assistance that have been commonly used by traditional donors.

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