Introduction: The Art and Practice of Conducting Global Health

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Negotiating and Navigating Global Health
Introduction: The Art and Practice of
Conducting Global Health Negotiations
in the 21st Century
Ilona Kickbuschi and Ellen Rosskamii
Diplomacy is the art and practice of conducting negotiations. It is a
specific method for reaching compromise and consensus, as well as a
system of organisation within which states — and increasingly non-state
actors — pursue their interests. Diplomacy is an essentially political
activity oriented towards achieving a specific outcome. States set the
goals for negotiation in their foreign policies, and — as globalisation
proceeds to deepen — both the private sector and civil society organisations have “foreign policies” of their own. Because of the many
actors on the global stage observers increasingly comment on the need
for new forms of global dialogue and decision-making that move
beyond the traditional state-centred bilateral and multilateral diplomatic
concepts and practices that have been the focus of 19th and 20th century
Professor Dr. h.c. Ilona Kickbusch is the Director of the Global Health Programme at the
Graduate Institute for International and Development Studies, Geneva.
Professor Dr. Ellen Rosskam is Senior Advisor and Consultant to the Global Health
Programme, Graduate Institute for International and Development Studies, Geneva, and
Professor at Webster University, Geneva.
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A range of features characterise 21st century diplomacy:
It needs to function within a multi-polar world and within a multilevel and multi-dimensional global governance structure, which
increasingly includes the regional level.
It is no longer conducted only by professional diplomats; diplomats
today need to interact with many different actors, not only with other
diplomats as they did in the past.
It is characterised by polylateral layers of diplomatic interaction and
relationships and is challenged to manage not only the relations
between states (bi- and multi-lateral) but also the relations between
states and other actors.
It manages these relationships in various diplomatic venues and with
a wide range of instruments.
It is increasingly engaged in public diplomacy vis à vis an informed
public and many actors at home and in the host country.
It is involved with and contributes to a whole host of issues which are
on the international agenda and which require global coordination,
such as security, health, the environment, global finance, climate
change, and the like.
It needs to consider a much closer interface between domestic and international policies and cooperate with other national ministries.1–7
But even as one considers these features one still has not captured the
full essence of the transition: the very goals of foreign policy are changing. Foreign policy is no longer only about the “relation with external
entities”8 it is about achieving security, creating economic wealth, supporting development in low income countries, and protecting human
dignity” both at home and abroad.9 As a consequence, diplomats now
have a double responsibility: to represent the interests of a country as well
as the interests of the global community.10 This “double responsibility”
implies recognition that increasingly global public goods need to be negotiated, managed, and ensured. It also means that regimes in the area of
trade and economic development need to be complemented by agreements in areas of social development and on critical global trans-boundary
issues, such as the environment and health. This complementarity of the
national and the global interest has been expressed for example by
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President Lula de Silva of Brazil in his 2003 inauguration speech: “an
international order guided by values is the one which offers the broadest
possibilities not just for promoting the national interests … but also for
systemic stability itself.”11 This means that the dynamics between health
and foreign policy have changed fundamentally in the 21st century.
As health becomes politically more relevant — in both domestic and
foreign policy — it becomes a feature of the foreign policy of states and
enters the realm of diplomacy. In two consecutive years, UN General
Assembly Resolutions entitled “Global Health and Foreign Policy” recognize their “close relationship […] and their interdependence.”12,13
Health diplomacy as a profoundly political process is conducted at many
different levels of governance; it includes various types of diplomacy
ranging from the bilateral, to the multilateral, and polylateral, and it
moves in different geo-political directions: North-South, South-North,
South-South. The relationship can be illustrated by a continuum with two
endpoints — one endpoint in which (A) foreign policy neglects or even
hinders health, and the other where (D) foreign policy serves health as
presented by the Oslo Declaration on health and foreign policy.14 Along
the continuum we can define a number of different relationships between
health and foreign policy, two of which are of particular importance: (B)
health as an instrument of foreign policy, and (C) health as an integral part
of foreign policy.15 This continuum is presented visually in Fig. 1 below.
At the multilateral level health diplomacy relates in particular to points
C and D. Global Health Diplomacy — that part of health diplomacy which
Fig. 1.
The continuum of the relationship between health and foreign policy. Adapted
from Kickbusch I. (2011) 21st Century Global Health Diplomacy.
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I. Kickbusch and E. Rosskam
deals with the negotiation processes that shape and manage the global policy environment for health — can be considered as a method for reaching
compromise and consensus particularly within the context of international
organisations. It relates in particular to health issues that cross national
boundaries, are global in nature, and require global agreements to address
them both in health and non-health forums. Because of their political relevance these negotiations at the global level are conducted not only between
public health experts representing health ministries of nation states but also
include representatives from foreign policy, security policy, development
and trade, as well philanthropists, civil society, and private players.
Global health diplomacy brings together the disciplines of public
health, international affairs, management, law, and economics. New skills
are needed to negotiate global regimes, international agreements and
treaties, and to maintain relations with a wide range of actors. A number
of factors distinguish 21st century global health diplomacy:
(1) the nature of the subject matter: health is a trans-boundary concern for
all nations, it requires collective action,
(2) the role of science and scientists: the response to the spread of disease
is heavily dependent on understanding the causes and as such the productive interface between diplomats and health experts is critical to
successful health negotiations,
(3) the complexity of the negotiations: the interface between diplomacy
and science, the multi-level, multi-factor, and multi-actor negotiations
and the repercussions for trade and commerce, power relations, and
values make for complicated negotiations,
(4) the unique equity issues involved: equity is a driving force of the
global health agenda since its inception, but has gained force with the
adoption of the Millennium Development Goals. A range of global
health strategies deal with equity issues in specific ways, such as differential pricing for vaccines and other essential drugs,
(5) innovative features and approaches: throughout its history in each
institutional phase health diplomacy has been highly innovative in
developing methods, instruments, and organisational forms.
An additional critical feature of health diplomacy is that international
health negotiations have had an institutionalised mechanism at their
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disposal for over 100 years ever since a permanent international agency
for health was in put in place in 1907 — today this is the World Health
Organization, which was founded in 1948.16
The intent of this book is to present a wide variety of perspectives
and experiences that illustrate the defining features and characteristics
of 21st century health diplomacy. They are presented in case studies
contributed by a range of lead negotiators, health diplomats,
Ambassadors, NGOs, technical experts, private sector, international
organisations, academicians, and donors reflecting the polylateral nature
of the field. The range of topics covered provides a snapshot of the
diversity of levels and issues: such as negotiations in multi-lateral institutions, negotiations at national level, negotiations on specific diseases,
negotiations on treaties and conventions, and multi-lateral negotiations
in individual countries on issues such as health sector reform and
The authors describe with as much objectivity as possible different
types of enabling environments that facilitated successful negotiations,
ways in which political space was captured, created, and used at a particular moment in time, types of leadership needed for successful
negotiating outcomes, challenges and opportunities presented by the
involvement of different actors holding differing degrees of power, creative and standard negotiating tools used, the role of and for policy, and
analyses of why some negotiations were unsuccessful. Detailing different positions taken by individual countries and non state actors during
multiple rounds of negotiations, the authors describe in detail various
angles, perspectives, and postures adopted by the various players in the
respective negotiations.
This is the first book to present case studies about how the different
negotiations took place and it is precisely this angle that makes the book
pioneering, providing learning tools for today’s broad group of “new
health diplomats” in the landscape of this ever-shifting, complex technical and political arena. The collection of case studies fills an important
gap in both knowledge and practice by providing insight on how negotiations on global health issues have transpired, successes, challenges,
failures, tools and frameworks for negotiation, mechanisms of policy
coherence, ways to achieve global health objectives internationally, and
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I. Kickbusch and E. Rosskam
how global health diplomacy used as a foreign policy tool can improve
relations between nations.
The case studies are told as the negotiations were experienced by individuals who participated in the various debates, dialogues, negotiations,
or by experts who have studied them. They highlight the art and the practice of health diplomacy. Today more than ever diplomats and negotiators
need practical and technical information on global health and how to use
global health as part of foreign policy to improve relations between countries. Simultaneously, non state actors need practical information to help
them in negotiating and in the use of diplomacy.
In response to these needs the book is directed at representatives of
ministries of health, foreign affairs, finance, and trade, staff of international organisations, and a wide range of non state actors who engage
in trans-border health negotiations. It aims to increase their understanding of the dynamics as well as the art of global health diplomacy
and to improve their negotiation skills. Schools of public health and
international relations should also find this book highly useful for those
giving more attention to this developing area. The Global Health
Programme at the Graduate Institute for International and Development
Studies will be using it in conducting capacity building in Global
Health Diplomacy.
The editors hope that this unique collection of case studies will be
useful for diplomats and other actors in this field from a wide range of
countries. The diverse collection of topics, regions, and contributing
authors provides a rich palette to springboard debate, which is strongly
encouraged. Reader reflection about how other perspectives might present
the same case study is an example of what might catalyse debate, discussion, or reaction based on the angle from which the case is told, the topic,
or specific content.
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