GLOBAL HEALTH CENTRE | 2021
A GUIDE TO GLOBAL
HEALTH DIPLOMACY
Better health – improved global solidarity – more equity
Ilona Kickbusch, Haik Nikogosian,
Michel Kazatchkine, Mihály Kökény
Supported by Ece Karaman
Published on 18 February 2021
Global Health Centre
Graduate Institute of International and Development Studies
Chemin Eugène-Rigot 2 | Case Postale 1672
1211 Geneva 21 | Switzerland
Tel +41 22 908 4558
Fax +41 22 908 4594
Email globalhealth
@
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ä
graduateinstitute.ch/globalhealth
A guide to global health diplomacy 3
ACKNOWLEDGMENTS
With contributions* from: Michele Acuto, University of Melbourne; Paul Bekkers, Ministry of For-
eign Affairs, Netherlands; Gian Luca Burci, Global Health Centre, IHEID; Emanuele Capobianco, In-
ternational Federation of Red Cross and Red Crescent Societies; Marcelo A.C. Costa, United Na-
tions; Roopa Dhatt, Women in Global Health; Erica Di Ruggiero, University of Toronto, Dalla Lana
School of Public Health; Marja Esveld, Ministry of Foreign Affairs, Netherlands; Satoshi Ezoe, Min-
istry of Foreign Affairs, Japan; Lemlem Girmatsion, Global Health Centre, IHEID; Githnji Gitahi, Am-
ref Health Africa; Renzo Guinto, Harvard T.H. Chan School of Public Health; Madeleine Heyward,
Permanent Mission of Australia to the United Nations, Geneva, Switzerland; Roger Kampf, World
Trade Organization; John Kirton, University of Toronto, Munk School of Global Affairs and Public
Policy; Kerstin Kolbe, Gavi, the Vaccine Alliance; Eero Lahtinen, Ministry for Foreign Affairs of Fin-
land; Lindiwe Makubalo, Permanent Mission of South Africa to the United Nations and other Inter-
national Organizations, Geneva, Switzerland; Colin McIff, Office of Global Affairs at the U.S. Depart-
ment of Health and Human Services; Lolem B. Ngong, Amref Health Africa; Miguel Perez La Plante,
Permanent Mission of Switzerland to the United Nations, Geneva, Switzerland; Nathita Premabhuti,
Ministry of Foreign Affairs of Thailand; Catherine Saez, Heath Policy Watch; Flavia Schlegel, Sci-
ence Governance Partnership, Paris, France; Gaudenz Silberschmidt, World Health Organization;
Luis Sundkvist, Editor; Orsolya Süli, NHS Scotland, UK; Zsofia Szilagyi, World Health Organization;
Tamar Tchelidze, Permanent Mission of Georgia to the United Nations; Menno Van Hilten, World
Health Organization.
* Contributors are not responsible for the final version of this publication nor the ideas presented in this guide.
4 Global Health Centre | February 2021
A guide to global health diplomacy 5
PREFACE
The year 2020 marks two important anniversaries: 100 years of multilateralism in Geneva and 75
years of the United Nations. For almost all of that time, Geneva has been the seat of the World
Health Organization (WHO) and the hub of global health diplomacy.
Since then, global health challenges have moved increasingly centre-stage, and the COVID-19 pan-
demic has only underscored the centrality of health to social, economic and political stability, and
to the 2030 Agenda for Sustainable Development. The growing awareness of social, environmental,
commercial, and political determinants of health has also made international health negotiations
increasingly political, diverse, and multi-sectoral.
The COVID-19 pandemic has demonstrated the vital importance of global solidarity to confront
shared public health threats. WHO plays a central role in supporting countries to respond in a coor-
dinated way and to bring together many actors to jointly address the pandemic and its enormous
global impact.
Global health diplomacy is a defining feature of the health "ecosystem" in Geneva, and plays a vital
role in shaping the global health architecture and agenda. Successful global health diplomacy re-
lies on political and diplomatic experience and practice, which must be combined with public
health knowledge and evidence.
This Guide to Global Health Diplomacy is a valuable and practical tool for enabling health diplomats
to be both professional and effective in their work. I am grateful to the authors, the Global Health
Centre at The Graduate Institute of International and Development Studies for its pioneering work,
and the Swiss government for its generous support.
Tedros Adhanom Ghebreyesus
Director-General, World Health Organization
December 2020
6 Global Health Centre | February 2021
A guide to global health diplomacy 7
TABLE OF CONTENTS
INTRODUCTION 13
NOTE TO READERS 15
PART A: THE BASICS 17
CHAPTER 1 | GLOBAL HEALTH DIPLOMACY
IN A CHANGING MULTILATERAL SYSTEM 19
1.1 Diplomacy in a changing world 19
1.2 The increasing politicization of global health 21
1.3 The move towards multi-stakeholder diplomacy 23
1.4 Governance spaces for global health diplomacy 26
1.5 The changing role of diplomats 36
CHAPTER 2 | GLOBAL HEALTH DIPLOMACY: SYSTEM AND METHODS 39
2.1 Defining global health diplomacy 39
2.2 Foundations of the modern understanding of global health diplomacy 42
2.3 The global health diplomacy system 46
2.4 Relationships in the global health diplomacy system 49
2.5 Digital diplomacy 52
CHAPTER 3 | THE DIMENSIONS OF GLOBAL HEALTH DIPLOMACY 55
3.1 Negotiating to promote health and well-being in the face of other interests 55
3.2 Establishing new governance mechanisms in support of health and well-being 57
3.3 Creating alliances in support of health and well-being outcomes 58
3.4 Building and managing donor and stakeholder relations 62
3.5 Responding to public health crises 65
3.6 Improving relations between countries through health and well-being 67
3.7 Contributing to peace and security 69
PART B: NEGOTIATING HEALTH IN A MULTILATERAL SPACE 73
CHAPTER 4 | MANDATES AND LEGITIMACY IN GLOBAL HEALTH DIPLOMACY 75
4.1 Multilateralism and the legitimacy of international organizations 75
4.2 The importance of legitimacy 79
8 Global Health Centre | February 2021
4.3 Legitimacy and sovereignty of States 81
CHAPTER 5 | KEY GLOBAL HEALTH INSTRUMENTS 85
5.1 Introduction to global health instruments 85
5.2 Instruments adopted by the World Health Organization 85
5.3 The legal status of WHO instruments 87
5.4 Entry into force of WHO instruments 87
5.5 Proposals for new WHO conventions 88
5.6 Instruments adopted outside WHO 88
5.7 Steps after the adoption of instruments 94
CHAPTER 6 | KEY GLOBAL VENUES AND ACTORS 95
6.1 The World Health Organization and the changing field of global health 95
6.2 Other international health organizations and entities 97
6.3 Health diplomacy at the United Nations 102
6.4 The central role of States in global health diplomacy 107
6.5 The role of non-State actors in global health diplomacy 109
6.6 Maintaining a balance 111
CHAPTER 7 | THE ROLE OF REGIONAL ORGANIZATIONS 113
7.1 The interface between regional bodies, diplomacy and global health 113
7.2 An overview of regional integration 114
7.3 Regional integration and health 115
7.4 Regional integration and global health diplomacy 117
CHAPTER 8 | POLICY COHERENCE FOR GLOBAL HEALTH 123
8.1 Creating synergies 123
8.2 Using existing mechanisms more effectively for policy coherence 124
8.3 The domestic groundwork for global policy coherence 125
8.4 The importance of a national global health strategy 126
PART C: THE ELEMENTS OF SUCCESSFUL GLOBAL HEALTH DIPLOMACY 133
CHAPTER 9 | ACHIEVEMENTS IN GLOBAL HEALTH DIPLOMACY 135
9.1 Defining success in global health diplomacy 135
9.2 Examining success 137
CHAPTER 10 | ANALYSING NATIONAL AND GEOPOLITICAL INTERESTS 141
10.1 Understanding the complexity of global health issues 141
A guide to global health diplomacy 9
10.2 Building relationships in Geneva and other negotiating hubs 142
10.3 Gathering available information 142
10.4 Understanding positions 143
10.5 Examining negotiation blocs and alliances 144
CHAPTER 11 | COORDINATION WITH NON-HEALTH SECTORS 147
11.1 The interface between health and other sectors at the national level 147
11.2 Emerging linkages to other sectors 150
11.3 The health sector’s role in cross-sectoral cooperation 151
CHAPTER 12 | CONDUCTING GLOBAL HEALTH NEGOTIATIONS 153
12.1 Competencies for global health diplomacy 153
12.2 Understanding values 154
12.3 Negotiation tactics and conflict resolution 155
12.4 Understanding the rules and procedures 159
12.5 Understanding global health actors and partners at home 159
12.6 Understanding the positions of other actors 160
12.7 Chairing negotiations 164
CHAPTER 13 | EXAMPLES OF GLOBAL HEALTH DIPLOMACY 167
13.1 Access to medicines 167
13.2 Vaccine diplomacy 168
13.3 Air pollution 171
13.4 Trade, intellectual property and health 174
13.5 Antimicrobial resistance 175
13.6 Migration and health 176
13.7 Concluding remarks 177
ANNEX 1 | GLOSSARY 181
ANNEX 2 | RESOURCES 187
ANNEX 3 | LIST OF BOXES 209
CASE STUDY 1 | NEGOTIATIONS FOR THE WORLD HEALTH
ASSEMBLY RESOLUTION ON PRICE TRANSPARENCY (2019) 213
CASE STUDY 2 | THE POLITICAL DECLARATION OF THE HIGH-LEVEL
MEETING ON UNIVERSAL HEALTH COVERAGE (2019) 235
10 Global Health Centre | February 2021
Abbreviations
ACT Accelerator Access to COVID-19 Tools Accelerator
AMR antimicrobial resistance
APEC Asia–Pacific Economic Cooperation
ASEAN Association of Southeast Asian Nations
AU African Union
BMGF Bill and Melinda Gates Foundation
BRICS Brazil, Russian Federation, India, China and South Africa
CARICOM Caribbean Community
CEPI Coalition for Epidemic Preparedness Innovations
COMESA Common Market for Eastern and Southern Africa
COVAX COVID-19 Vaccines Global Access Facility
COVID-19 Coronavirus disease 2019
EAC East African Community
EAEU Eurasian Economic Union
ECOWAS Economic Community of West African States
EFTA European Free Trade Association
EMA European Medicines Agency
EU European Union
FAO Food and Agriculture Organization of the United Nations
FCTC WHO Framework Convention on Tobacco Control
FENSA Framework of Engagement with Non-State Actors [WHO]
G7 Group of Seven
G20 Group of 20
A guide to global health diplomacy 11
Abbreviations
GDP gross domestic product
Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria
Graduate Institute Graduate Institute of International and Development Studies, Geneva
ICRC International Committee of the Red Cross
IFPMA International Federation of Pharmaceutical Manufacturers and Associations
IHR International Health Regulations [WHO]
ILO International Labour Organization
IOM International Organization for Migration
MDG Millennium Development Goal
MERCOSUR Southern Common Market
MERS Middle East respiratory syndrome
NCD noncommunicable disease
NGO nongovernmental organization
ODA official development assistance
OECD Organisation for Economic Co-operation and Development
OIE World Organisation for Animal Health
PAHO Pan American Health Organization
PEPFAR United States President’s Emergency Plan for AIDS Relief
R&D research and development
SAARC South Asian Association for Regional Cooperation
SADC Southern African Development Community
SARS severe acute respiratory syndrome
SDG Sustainable Development Goal
12 Global Health Centre | February 2021
Abbreviations
SEEHN South-Eastern Europe Health Network
SICA Central American Integration System
TRIPS Agreement Agreement on Trade-Related Aspects of Intellectual Property Rights
UHC2030 International Health Partnership for Universal Health Coverage 2030
UN United Nations
UNAIDS Joint United Nations Programme on HIV/AIDS
UNASUR Union of South American Nations
UNDP United Nations Development Programme
UNECE United Nations Economic Commission for Europe
UNEP United Nations Environment Programme
UNESCO United Nations Educational, Scientific and Cultural Organization
UNFCCC United Nations Framework Convention on Climate Change
UNHCR Office of the United Nations High Commissioner for Refugees
UNICEF United Nations Children’s Fund
UNODC United Nations Office on Drugs and Crime
UN-Women United Nations Entity for Gender Equality and the Empowerment of Women
V3P Project Vaccine Product, Price and Procurement Project [WHO]
WAHO West African Health Organization
WHO World Health Organization
WIPO World Intellectual Property Organization
WTO World Trade Organization
A guide to global health diplomacy 13
This Guide builds on the extensive experience of all four of its authors in both practising and teach-
ing global health diplomacy. We have conducted courses at the Graduate Institute of International
and Development Studies (hereafter the “Graduate Institute”) in Geneva, Switzerland, and at simi-
lar institutions in many other countries over the past decade. During this period, the world experi-
enced many changes and disruptions, all of which have come to be reflected in the underlying
values, approaches and mechanisms of global health diplomacy. At the time of writing, the
COVID-19 pandemic is having a significant impact on the multilateral system and expanding the
range of actors and venues in global health diplomacy.
In 2013, the Global Health Centre at the Graduate Institute published the first systematic introduc-
tion to the field of global health diplomacy, outlining key concepts, issues, actors, instruments, fo-
rums and cases.
1
The present publication takes the process further, focusing on practical aspects
of global health diplomacy and taking into account new experience and developments in this field.
Case studies are available in the online version of the Guide, which will be updated with additional
ones in due course.
A special focus of this Guide lies on the World Health Organization and negotiations in the Geneva
global health “ecosystem”. In view of the many relevant actors, processes and institutions that
continuously interface with the health sphere, the Guide argues that health diplomats need to
consider carefully the larger ecosystem within which they negotiate – also at the national level,
including the various ministries and groups that are stakeholders. To reinforce this message, we
have included a number of text boxes describing other organizations and the negotiation processes
they follow. We hope that this Guide will soon be joined by other publications providing comple-
mentary perspectives.
Diplomacy is facing immense challenges at a point in time when it is more necessary than ever.
Many analysts of international politics agree that multilateralism has entered a period of crisis.
New political and economic realities, notably geopolitical power shifts, are leading to a questioning
1 Kickbusch I, Lister G, Told M, Drager N, editors. Global health diplomacy: concepts, issues, actors, instruments, fora and cases.
New York: Springer; 2013.
INTRODUCTION
14 Global Health Centre | February 2021
not only of existing institutions but also of the basic tenets on which those institutions were origi-
nally built. The very system of diplomacy is threatened by this “new disorder”, while its methods
are challenged by the ongoing digital transformation. Especially during the COVID-19 pandemic,
complicated negotiations could not be conducted face to face, hampering the informal contacts
that in the past have been so essential for reaching compromises.
As the authors we are convinced that global health diplomacy has never been as important as it is
at present. This already became clear when negotiating the role of health in the Sustainable Devel-
opment Goals, which were adopted in 2015. Now, during the second major pandemic after the in-
fluenza pandemic of 1918–1919, in a climate of growing suspicion, rivalry and infighting among
nations, the need to work together at a multilateral level to ensure health for all countries is at its
most acute. On the other hand, the above-mentioned challenges to multilateralism are making it
more difficult to achieve global cooperation.
No country is safe unless all are safe. Global solidarity – the spirit in which the Constitution of the
World Health Organization was drafted and adopted after the ravages of the Second World War –
must be reinforced repeatedly through the kind of relationship-building and negotiating processes
that are at the heart of global health diplomacy. Health challenges transcend not only borders but
also North–South, East–West and public–private divides, exposing the limitations of segmented
approaches. A more holistic, inclusive, comprehensive and coordinated strategy is required to tack-
le these truly global challenges.
Global health diplomacy is an important component of a multilateral system that seeks to contrib-
ute to a well-functioning global order. It requires the recognition that both science and politics are
essential to inform negotiations. The goal of global health diplomacy is to bring about agreements
that are scientifically credible and politically achievable.
Global health rests on the three pillars explored in this Guide: governance, instruments and diplo-
macy. The growing interconnectedness between these three pillars is an essential driving force of
global health in the 21st century.
The present publication is intended to provide an entry point for readers wishing to gain a better
understanding of the fundamentals of global health diplomacy and the various approaches in-
volved. We hope that it will be useful for those preparing to work in this area for the first time, and
that it will motivate them to undertake further studies and, above all, to acquire further practical
experience. Those already engaged in global health diplomacy should find some useful indications
for their work in this Guide. We also hope that it will be used as a support tool in the teaching of
global health diplomacy at both national and international institutions.
A guide to global health diplomacy 15
NOTE TO READERS
The Guide focuses on basic concepts and practical aspects of conducting global health diplomacy.
We hope that it will help individuals coming to the subject for the first time to better understand
the context and system of global health diplomacy, and to familiarize themselves with relevant
practical approaches.
The text is structured into three parts dealing with: (a) the basics in this field; (b) the features of
negotiating health in a multilateral space; and (c) what makes for successful global health diploma-
cy. Key information is provided in the various chapters under each part. The chapters do not neces-
sarily have to be read consecutively, even though the text’s structure does follow such a logic. As
some aspects (instruments, coherence, the role of key organizations etc.) are relevant to several
parts of the Guide, we have deliberately left certain overlaps in the text and added cross references
where applicable. We have also included text boxes on special topics written by invited contributors.
For those who wish to delve deeper, we provide an annex listing various publications and other re-
sources (the citations in the main text, presented using the Harvard system, refer to this annex).
We also hope that the Guide and the way it is structured will make it a useful resource for those
engaged in teaching global health diplomacy. We have drawn on our own experience in teaching
this subject for over a decade in many different contexts and settings and have been able to include
many insightful comments provided by the reviewers. It should be possible to cover all of the subject
matter in a one-week course while allowing enough time for students to look at specific case studies
in greater depth, especially those relevant to the context in which the course is taking place. One day
of the course could usefully be dedicated to the simulation of a global health negotiation by students.
16 Global Health Centre | February 2021
A guide to global health diplomacy 17
PA RT A:
THE BASICS
18 Global Health Centre | February 2021
A guide to global health diplomacy 19
CHAPTER 1 | GLOBAL HEALTH
DIPLOMACY IN A CHANGING
MULTILATERAL SYSTEM
1.1 Diplomacy in a changing world
Diplomacy has been practised for centuries, during which it has undergone many significant chang-
es, some concerning its very nature. Over the past decade in particular, diplomacy has become a
constitutive part of the system of global governance, which involves many different venues and
actors. This development has been reinforced by the fundamental changes arising from the nego-
tiation of the Sustainable Development Goals (SDGs) and by the increasing need for global crisis
diplomacy. The most important shift has been that away from a mindset centred on development
assistance towards acknowledgement of common global goals that can only be achieved if all
countries work together – the COVID-19 pandemic has made that even clearer.
Despite these changes, three key defining features of diplomacy remain intact: representation,
communication and negotiation.
Multilateral diplomacy as we know it began with the ad hoc congresses convened in Europe in the
17th century to negotiate war and peace between sovereign States. In 1919 it led to the creation of
the first collective security organization: the League of Nations. At the end of the Second World
War, multilateral diplomacy was institutionalized more robustly with the establishment of the Unit-
ed Nations (UN). One of the UN system organizations created shortly afterwards was the World
Health Organization (WHO), which took up its work in 1948 in Geneva, Switzerland. Over time,
many other multilateral venues for health were established but WHO remains the norm-setting
organization for health. The WHO Constitution defines health as a human right and this is a guiding
principle for all other health organizations (see Box 7).
The significant cross-border economic and security impact of developments in such areas as the
natural environment and human health made it clear that the issues in question could no longer be
resolved at the national level only. As these areas, previously treated under “soft policy” in foreign
affairs and diplomacy, gained in importance, new types of international agreements, instruments
and organizations were created in response – for example, the Paris Agreement on Climate Change
(2015), the revised International Health Regulations (2005), the Global Fund to Fight AIDS, Tubercu-
losis and Malaria (2002) and, most recently in 2020, the COVAX Facility, a global risk-sharing mech-
20 Global Health Centre | February 2021
anism for pooled procurement and equitable distribution of eventual COVID-19 vaccines.
Multilateralism has many definitions – in essence it is governance by the many to address shared
problems. It rests on a set of common principles guiding relations among the parties, including
agreed rules of behaviour. Multilateralism often takes the form of membership in international or-
ganizations, but that is not the only form. Among the various types of multilateralism are universal
multilateralism including all States, for example as members of the UN; regional multilateralism,
which brings together States in specific geographical regions; values-based multilateralism as ex-
emplified by organizations such as NATO or the European Union and the suggestions to create new
bodies that include democracies only; and “minilateralism”, which brings together small groups of
States (or “clubs” such as the G20 and the BRICS countries) to tackle specific problems. Multilater-
alism stands in contrast to bilateralism and unilateralism, and governments have to decide which
of these strategies they will adopt in their foreign policy to deal with a particular challenge. Bilat-
eralism means engaging with just one other country, while unilateralism implies acting on one’s
own without regard for other countries.
Other terms are also in use. In trade negotiations, plurilateral agreements – meaning, for example,
a treaty between a limited number of States with a particular interest in the subject of the treaty –
have become more prominent. Finally, “polylateral diplomacy” refers to the involvement of many
non-State actors in diplomatic processes – something that makes the contemporary diplomatic
arena pluralistic, dynamic and complex. This is also referred to as multi-stakeholder diplomacy –
the term used in this Guide.
A guide to global health diplomacy 21
This Guide focuses on the global health diplomacy practised at international organizations and in
other multilateral venues that aim to resolve global health challenges. However, multilateralism
also denotes what is often referred to as the liberal international order, enshrined in the Charter of
the United Nations, which was signed by 50 States in 1945. The values, norms and principles un-
derpinning this order have been defined as: economic openness, rule-based international relations,
security cooperation, openness to reform and change, and solidarity based on the model of liberal
democracy (Ikenberry, 2018).
The UN today encompasses 193 countries. A new and growing set of actors at the national, region-
al and global level have emerged and are now part of global decision-making. The past decade in
particular has seen major geopolitical power shifts, while new parallel multilateral institutions have
been created. Another important development is that new communication technologies are now
omnipresent across the globe and significantly influence negotiations.
While there is an increasing number of interrelated global challenges that need to be resolved, the
present multilateral system is in flux. Some criticize its ideological premises, its power imbalances
and lack of inclusiveness; others demand greater transparency and accountability to the general
public; while yet others decry the system’s failure to deliver decisive action in response to such
major crises as poverty, migration and climate change. Most alarmingly, though, a new wave of
nationalism is challenging its very nature and necessity. The United States of America, which con-
tributed so much to establishing the multilateral system after the Second World War, has during
the Trump administration distanced itself from a number of organizations in the UN family, multilat-
eral processes and international agreements. Possibly this will be reversed by the new Biden ad-
ministration. All these developments have had an impact on the system of multilateral diplomacy,
on relations between the actors involved and on the role of diplomats. The COVID-19 pandemic has
highlighted both the mounting challenges faced by multilateral institutions and the central role of
these institutions in finding joint solutions to shared problems.
1.2 The increasing politicization of global health
In 2007, a group of foreign ministers from seven countries agreed “to make impact on health a point
of departure and a defining lens that each of our countries will use to examine key elements of
foreign policy and development strategies, and to engage in a dialogue on how to deal with policy
options from this perspective”.
2
2 The Oslo Ministerial Declaration, entitled “Global health: a pressing foreign policy issue of our time”, was issued on 20 March
2007 by the Ministers for Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa and Thailand.
22 Global Health Centre | February 2021
More than 10 years later, the interface between global health and foreign policy has become in-
creasingly dynamic, with both positive and negative implications for health. Global health is now
integral to the foreign policy agendas of many countries, notably in relation to economic and social
development, security, humanitarian affairs, social justice and human rights, and global crisis man-
agement. The number of multilateral health negotiations, instruments, organizations, and venues
has increased significantly. Health is now part and parcel of global negotiations related to food,
climate, energy and water, and is discussed at major global and regional summits. This is largely
thanks to the adoption of the SDGs in September 2015 and to the inclusion of health in the deliber-
ations of both the Group of Seven (G7) and the Group of 20 (G20). Health diplomats must therefore
be able to negotiate in contexts and institutions that are very diverse and require quite different
approaches. These developments have highlighted that global health diplomacy, like all diplomacy,
is always political. Global health professionals are wary of what they consider a politicization of
global health, but it is an illusion to think it can be avoided. The increasing involvement of political
leaders and actors in health matters can indeed work in two directions: it can be the decisive factor
in rallying political support for global health, or it can undermine global health if narrow geopolitical
or ideological agendas prevail. Both types of effect could be observed during the COVID-19 pan-
demic. The erosion of shared norms can also lead to very difficult negotiations, and disagreement
on other areas of national policy – for example, a liberal versus a restrictive position on immigration
or on women’s rights – often has a strong impact on health negotiations at the global level and
makes it difficult to reach consensus.
Recent examples that serve to illustrate both the positive and the negative impact of the politiciza-
tion of health include a series of recent G20 and G7 meetings (see Box 2); the negotiations on pri-
mary health care at WHO,
3
on universal health coverage at the UN,
4
and on the health rights of
refugees at the International Organization for Migration; and, more recently, the negotiations at the
UN Security Council leading to the adoption of a new resolution on sexual violence in conflict.
5
In
all these cases, health objectives were diluted because of national political positions.
The specific national and geopolitical context has always been important in global health diplomacy.
During the Cold War between the former Soviet Union and the United States (and their allies), ideo-
logical conflict was inseparable from the negotiations conducted at the UN and WHO, especially
negotiations concerning the role of the State or the private sector in the provision of health care.
Since the 1990s, positions detrimental to the advancement of global health have been closely tied to
3 Specifically, the negotiations that resulted in the adoption of the Declaration of Astana in October 2018 (WHO & UNICEF, 2018).
4 Specifically, the negotiations during the High-Level Meeting on Universal Health Coverage held at the General Assembly on 23
September 2019, which resulted in the adoption of a political declaration (UN, 2019).
5 Resolution 2467 (2019), adopted by the Security Council on 23 April 2019.
A guide to global health diplomacy 23
the protection of economic interests and industries (for example, tobacco and pharmaceuticals), in-
cluding patents and intellectual property rights. Almost all Member States use health negotiations to
promote their industrial policy or their perceived economic interests, but they rarely do so openly in
the context of health organisations, preferring instead to invoke health or humanitarian arguments.
Since early 2020, the geopolitical tensions between China and the United States have become a
determining factor in global health diplomacy, with wide-ranging implications. These tensions
came to a head during the COVID-19 pandemic, when the United States declared its intention to
withdraw from WHO. On the other hand, the threat posed by COVID-19 has generally accelerated
multilateralism and cooperation in Europe – even though the closing of borders, protectionist poli-
cies and trade restrictions dominated the early response to the pandemic. New opportunities
emerge to strengthen multilateralism now that the USA has rescinded its withdrawal and con-
formed its commitment to a strong WHO.
It is clear that because of shifts in ideology and geopolitical power, the agreements, declarations,
positions and approaches adopted through multilateral negotiations in the past can no longer be
taken for granted. The constant conflicts on human rights matters are a case in point. Representa-
tives of civil society and local communities expect their positions and concerns to be taken into
account in formal negotiations. Social media have also encouraged a wider debate on, and greater
public involvement in, global affairs, but in some cases, they have contributed to an erosion of trust
in the international system or reinforced conspiracy theories about who sets global priorities. This
can create considerable difficulties for the technical and evidence-based work of health organiza-
tions and for the consensus-oriented approach to global health diplomacy in the governing bodies
of the UN and WHO. Social media therefore need to be factored in as a potentially critical new el-
ement in both diplomacy and policy-making.
The challenges for global health diplomacy in a divided world are intensifying because, as a result
of the COVID-19 crisis, it is very unlikely that the health-related SDGs can be achieved by 2030. In-
deed, the main task for the near future is to make up for the development losses caused by the
devastating impact of COVID-19 and by some of the measures taken to combat the pandemic.
1.3 The move towards multi-stakeholder diplomacy
The SDG negotiation process was a conceptual and political breakthrough, leading to a significant
expansion in multilateral diplomacy focused on global challenges within the UN framework. In
adopting the 2030 Agenda for Sustainable Development in September 2015, the UN Member
States agreed on a set of 17 interdependent goals that would apply to the entire world community.
24 Global Health Centre | February 2021
Goal 17 in particular highlighted the need for strong global partnerships to achieve the SDGs.
Health has proved to be an integral component and outcome of every SDG that was negotiated.
This explains the continuing central role of global health diplomacy in practically every subsequent
round of SDG-related negotiations, a recent example being the negotiations at the UN Climate
Change Conference in December 2019 or the annual meetings of the High-level Political Forum on
Sustainable Development, which assesses progress on the SDGs. As a result, the global health
agenda is now approached as a common challenge for all countries – not simply as a matter of
development cooperation.
The dynamics of the SDG negotiations were quite different from the closed decision-making pro-
cess conducted in the late 1990s that resulted in the adoption of the Millennium Development
Goals (MDGs) in 2000. From the very start, the SDG negotiations transformed the role of diplomats
at the UN. A novel negotiation process based on open working groups was established; seats were
assigned on the basis of regions and had to be shared among several countries; a group of co facil-
itators was established. All this fundamentally changed the power dynamics and gave the develop-
ing countries a much stronger voice: they were able to lead the way in shaping agendas for the
future (Dodds, Donoghue & Roesch, 2016).
Civil society, academia, policy networks, think tanks, the private sector and many newly formed
alliances participated in an inclusive process entirely without precedent, which has been referred
to as the “new multilateralism”, or multi-stakeholder diplomacy. This move towards multi-stake-
holder diplomacy within a multilateral system that was at first geared almost exclusively towards
countries has accelerated in most areas of international policy-making, including global health. The
accompanying changes in the power balance and in the roles of diplomats and other players have
been reinforced by the multiplicity of outreach processes made possible by new technologies.
The UN Charter from 1945 had already recognized that the Economic and Social Council should
consider consulting with nongovernmental organizations (NGOs). The number of such actors and
the degree of their involvement have increased with the years. The involvement of non-State actors
now extends far beyond consultation – as originally envisaged in the UN Charter – and includes the
setting of agendas, participation in negotiations and collaboration in the development of standards.
The inclusive and comprehensive SDG negotiation process has become the yardstick of multi-stake-
holder involvement and continues to be emulated throughout the UN system. Indeed, such broad
inclusivity is now expected of all multilateral processes – also in global health diplomacy. The SDGs
have, moreover, introduced a new strong interface between multilateral objectives and processes
on the one hand, and national implementation on the other. They have underlined – especially
through Goal 17 – that partnerships need to drive implementation at all levels of governance. Pub-
A guide to global health diplomacy 25
lic engagement and innovative partnerships, facilitated by a whole-of-government and whole-of-so-
ciety approach and supported by the enhancement of digital means of communication, continue to
be an essential component of multi-stakeholder diplomacy as established through the SDGs.
All major UN high-level meetings now include multi-stakeholder forums in the preparatory process
to provide input for the subsequent negotiations between governments. Civil society and commu-
nity representatives have been provided with many new opportunities to participate and be heard.
Despite some attempts at improvement, WHO still lags behind most of the rest of the UN system in
terms of civil society involvement in its governing body processes. Even so, some Member States
now include civil society representatives and youth delegates in their WHO delegations. In some
instances, though, State–civil society relations have worsened, prompting some commentators to
speak of a “shrinking space” for civil society organizations. The pressure exerted on such organiza-
tions includes restrictions on foreign funding, barriers to registration, intervention in their internal
affairs, and other forms of harassment.
The multi-stakeholder approach to diplomacy supported by the UN has given the private sector
unprecedented access to the UN and its deliberations. This is viewed with certain suspicion among
some members of civil society, who are concerned about the possibility of undue influence by
business and commercial interests. Yet, in global health the private sector has also become part of
the new governance mechanisms of international organizations such as Gavi, the Vaccine Alliance
or the Global Fund to Fight AIDS, Tuberculosis and Malaria (hereafter “the Global Fund”) (see Box
10 and Box 11).
26 Global Health Centre | February 2021
A new development is the expansion in the global activity of cities and their authorities (see Box
16). Mayors are increasingly representing their cities on the world stage, and international organi-
zations are reaching out to them. While city diplomacy was initially about the promotion of cities, it
now includes involvement in the shaping and implementation of international agreements, the
most important being the Paris Agreement to Combat Climate Change. Municipal authorities now
also engage with WHO on health matters – for example, in combating tobacco use. The role of
cities as global hubs was highlighted further by the COVID-19 pandemic.
1.4 Governance spaces for global health diplomacy
The World Health Organization plays a central role in the governance of global health: it is the
leading authority for international health work. However, in recent decades, other organizations
and bodies have begun to engage substantially – either directly or indirectly – in global health
matters, resulting in greater complexity and even competition. The venue for negotiations may in-
fluence the composition of national delegations and, to some extent, also their position. At WHO,
health ministries are at the forefront of most countries’ delegations, at the UN it is foreign minis-
tries, at development organizations it is development ministries and agencies (where these exist)
and at the World Trade Organization (WTO) it is trade ministries. At the same time, WHO has itself
expanded its participation in a wide range of venues for health negotiations and increased the
number of actors it works with and the issues it addresses. This complex field can be broken down
into three overlapping “governance spaces”:
The global health system: the governance interface
Global Governance for Health
Health in the context of global organizations
in other sectors
Global Health Governance
Governance of the dedicaced health
organizations and their interface
Governance for Global Health
Governance at national and regional level
in support of global health agendas
Network and Negotiation hubs
Governance
for Global
Health
Global Heath
Governance
Global
Governance
for Heath
A guide to global health diplomacy 27
Global health governance refers mainly to those institutions and governance processes that are
based on an explicit health mandate: WHO first and foremost, along with a few others with narrow-
er – though still explicit – health mandates, such as the Joint United Nations Programme on HIV/
AIDS (UNAIDS), the Global Fund and the Gavi Alliance. An often-neglected aspect is the key role
played by the secretariats of these organizations, whose staff members are part of a well-estab-
lished international civil service system. A wide range of other global health actors are active, many
of them working from Geneva, which is generally considered to be the global health capital. Addi-
tionally, in response to emerging challenges, several new research-based organizations have been
created, such as the Coalition for Epidemic Preparedness Innovations, a global partnership
launched in 2017 to develop vaccines aimed at preventing future epidemics. New governance
structures have similarly been set up in response to the COVID-19 pandemic, such as the Access to
COVID-19 Tools Accelerator, a G20 initiative that brings together many of the actors in the global
health governance space with a view to overcoming the pandemic more quickly by supporting the
development and equitable distribution of testing facilities, treatments and vaccines.
Box 1: Negotiating at the World Health Organization
Negotiations and decision-making at the World Health Organization (WHO) continue very much
to be intergovernmental processes complemented by multi-stakeholder diplomacy. While the
Sustainable Development Goals call for broader participation by non State actors, the majority of
Member States support the exclusive role of nation States in WHO decision making, especially in
view of the Organization’s normative and treaty-making powers.
28 Global Health Centre | February 2021
What are the core functions of WHO?
The main negotiating forum for health diplomats at WHO comprises the two governing bodies –
the World Health Assembly and the Executive Board – and the many formal and informal plat-
forms that provide inputs to their work. Since WHO deals with many different areas, it is import-
ant to be aware of the Organization’s core functions. Article 2 of the WHO Constitution lists 22
functions, which may be summarized as follows:
Æ
Providing leadership on matters critical to health, and engaging in partnerships when joint
action is needed;
Æ
Proposing conventions, agreements and regulations, and making recommendations on
international health matters;
Æ
Setting norms and standards, and promoting and monitoring their implementation;
Æ
Shaping the research agenda and stimulating the generation, transfer and dissemination of
valuable knowledge;
Æ
Articulating ethical and evidence-based policy options;
Æ
Providing technical support, catalysing change and building sustainable institutional
capacity;
Æ
Monitoring the global health situation and assessing health trends; and
Æ
Responding to health emergencies.
Decision-making at WHO
Decision-making is formally governed by the principle of one vote per Member State. The Rules
of Procedure of the World Health Assembly and those of the Executive Board provide for decision
making by a simple majority except for decisions on important questions, such as the adoption of
conventions or agreements, amendments to the Constitution and suspension of the voting privi-
leges of Member States, for which a two-thirds majority of the Member States present and voting
is required. However, virtually all negotiations are conducted with the goal of reaching consen-
sus, and almost all decisions are indeed adopted by consensus. In WHO practice this means the
adoption of decisions without a formal vote. Consensus does not imply unanimity, that is, a situ-
ation in which all Member States have formally accepted a decision, but, rather, that no Member
State actively opposes the decision.
The adoption of new policies often requires a difficult and long process of consensus building. It
may be necessary to drop strong wording from the draft text or to abandon certain policy options
in order to secure the adoption of a resolution that proves acceptable to all 194 Member States.
Briefings and consultation sessions are held to support the consensus-building process – these
are often for Member States only.
A guide to global health diplomacy 29
World
Health Assembly
Executive Board
Secretariat
Regions (6)
Members Countries (193)
Organizational Structure
Negotiations take time. In that respect, setting priorities when drawing up the agenda for meet-
ings of the governing bodies has been a major challenge because of the growing number of items
to be covered, reluctance to allow issues to be taken off the agenda even if no new action is
needed, and the limited time available for discussion. In recent years, more and more resolutions
have been negotiated informally at intersessional meetings conducted mostly among the Geneva
based missions.
Where are the WHO negotiating rules to be found?
The most important statutes can be found in the WHO book entitled Basic documents (the latest
version was published in 2020). This regularly updated compendium contains all the statutory
documents of the Organization, such as the WHO Constitution, agreements with other intergov-
ernmental organizations, the Financial Regulations, the Framework of Engagement with Non-
State Actors and, most importantly, the Rules of Procedure of the World Health Assembly and the
Executive Board, whose regular sessions are the main venues for negotiations at WHO. The two
sets of Rules of Procedure lay down, among other things:
Æ
how the agenda is set;
Æ
the role of officers;
Æ
the functions of the WHO Secretariat;
Æ
the conduct of business at plenary meetings and in committees; and
Æ
the voting regulations.
These statutory documents are difficult to amend, especially the Constitution, because Member
States, for various reasons, are reluctant to forsake the status quo – in particular, the intergov-
ernmental nature of WHO governance. New challenges have emerged in the context of the
COVID-19 pandemic, as an increasing number of meetings – including meetings of the World
Health Assembly and the Executive Board – have had to be conducted remotely.
30 Global Health Centre | February 2021
What do the WHO negotiating rules reflect?
The operating rules of the WHO governing bodies establish the Organization’s room for manoeu-
vre in complying with its constitutional obligation, namely, “to act as the directing and coordinat-
ing authority on international health work” (Article 2(a)).
Examples of unresolved issues
The founding fathers’ vision was for WHO to be an organization embodying excellence in public
health. They therefore wanted the members of the Executive Board to serve in their personal
capacity, despite being designated by a Member State. The increasing politicization of debates
within and around WHO finally led to a motion at the Fifty-first session of the World Health As-
sembly in 1998 calling for Article 24 of the Constitution to be interpreted (though not amended as
such) to mean that members of the Executive Board act as government representatives.
The above development illustrates the fluctuation between political (social-medical) and techni-
cal aspirations that has characterized the Organization’s history. WHO is torn between different
demands by Member States, which expect it to be normative, technical and operational – as well
as politically astute. These often-conflicting demands are particularly noticeable when the Orga-
nization seeks to address the root causes of health problems, such as the social and commercial
determinants of health. It must also take extreme care not to become embroiled in conflicts be-
tween member states as – for example – during the COVID19 crisis.
The Framework of Engagement with Non-State Actors (FENSA), adopted by the World Health
Assembly at its Sixty-sixth session in May 2016, is the first such framework to have been negoti-
ated intergovernmentally within the United Nations (UN) system. FENSA codified and adjusted
the observer status of non State actors in official relations, though without fundamentally chang-
ing the rules applied since the Third World Health Assembly, which have allowed nongovernmen-
tal organizations to participate as observers and deliver statements at meetings of the WHO
governing bodies. A dedicated manual providing guidance on the application of FENSA is avail-
able (WHO, 2018a). A number of non-State actors are not satisfied with the Framework and wish
to see it reformed.
There are a number of problems with the existing decision-making process. For example, there
have been calls for meetings of the governing bodies to be scheduled for different periods of the
year, mainly so as to separate meetings of the Executive Board’s Programme, Budget and Admin-
istration Committee from meetings of the Board proper. This would give the Executive Board
more time to react to issues arising at the Committee’s meetings. However, this proposal has yet
to be put into practice.
A guide to global health diplomacy 31
The effectiveness of decision-making at WHO depends on the political will of Member States to
find a common solution. Fundamental disagreements between Member States, especially be-
tween powerful ones, can block political decision-making at WHO, although the Organization is
often able to preserve its normative function (that is, the setting of technical norms and standards).
When WHO was set up, it was necessary to find a way of integrating the existing Pan American
Health Organization (PAHO) into the new entity. This resulted in WHO having the most federalis-
tic structure of any UN agency, with the regional directors being selected directly by the Member
States in the respective regions. The six regional committees are therefore also important deci-
sion making bodies. During periods in the Organization’s history when WHO headquarters was
perceived as weak, this proved to be an asset. However, concerns have been raised over the in-
efficiency of WHO’s regional structure, particularly with regard to emergency response. Follow-
ing the Ebola outbreak in 2014–2016, the Director-General’s leadership was reasserted in some
areas, such as preparing for and responding to outbreaks and emergencies, but in many others
the decision making process remains highly complicated.
Global governance for health refers to those institutions and processes of global governance that
do not necessarily have an exclusive or explicit health mandate but nevertheless influence health
through the work carried out under their core mandates. They include – but are not limited to – the
Bretton Woods institutions, the WTO (see Box 9), the Food and Agriculture Organization of the
United Nations (FAO), the United Nations Children’s Fund (UNICEF), the United Nations Develop-
ment Programme (UNDP), the United Nations Environment Programme (UNEP), the United Nations
Entity for Gender Equality and the Empowerment of Women (UN-Women) and the United Nations
Office on Drugs and Crime (UNODC). In 2018, many of these organizations came together to imple-
ment the Global Action Plan for Healthy Lives and Well-being for All, which seeks to remedy the
fragmentation in global health. In recent years, several important health topics have been promot-
ed to the UN stage by being addressed at high-level meetings of the General Assembly and at the
Security Council. Moreover, the centrality of health to the 2030 Agenda means that health matters
feature prominently in the regular discussions at the Economic and Social Council on progress on
the SDGs. Health is also a recurring subject of discussion at the Human Rights Council. (For further
information, see Chapter 12.)
Governance for global health refers to institutions and mechanisms that contribute to global
health established at the national level (that is, strategies on global health and health in foreign
policy adopted by some national governments) and the regional level (for example, the European
Union, the West African Health Organization (WAHO) and the Association of Southeast Asian Na-
tions (ASEAN)). This governance space also includes political clubs and cross-regional actors, such
32 Global Health Centre | February 2021
as the G7, the G20 and the BRICS grouping of countries. Moreover, through the Inter Parliamentary
Union, the role of parliamentarians in global health has increased in recent years. (Chapter 7 ex-
plains in more detail how regional organizations are engaged in global health diplomacy.)
This increase in the number and diversity of venues means that significant administrative and hu-
man resources are necessary to be able to deal continuously with existing and emerging multilat-
eral diplomacy challenges. Among the resources required are dedicated departments within na-
tional ministries and regional organizations, along with representations (referred to as permanent
missions) and specialized staff at the main offices of international organizations. This inevitably
gives rise to inequalities between the countries that have such resources in abundance and those
that do not. Such inequalities are a major challenge and can themselves act as a barrier to consen-
sus at times.
Dedicated resources to manage multilateral affairs – not only donor relations – are also increasing-
ly required within the international organizations themselves.
In line with the growth of multi-stakeholder diplomacy, a wide range of civil society and private
sector non-State actors (global, regional and national) participate in, and exert their influence on, all
three governance spaces. Cities and local governments are also playing an increasingly prominent role.
Box 2: Negotiating health at the G7 and G20
Introduction
The Group of Seven (G7) and the Group of 20 (G20) are multi-stakeholder summit institutions that
are playing an increasingly prominent role in the governance of global health.
The Group of Seven
The G7 – which comprises Canada, France, Germany, Italy, Japan, the United Kingdom and the
United States (and the European Union as a non-enumerated member) – began convening at annu-
al summits in 1975 for the stated purpose of promoting democracy and individual liberty worldwide.
How does the G7 contribute to global health governance?
As an informal international institution, with no charter or permanent secretariat, the G7 has
mainly a deliberative role. Discussions among its members are conducted at the Group’s annual
summits, which are usually held in late spring or early summer. Its key functions in relation to
health are:
A guide to global health diplomacy 33
Æ
Discussing key health issues and publicly recording conclusions in the summit communiqués.
The health agenda of the G7 has expanded over the years. From 1979 to 1995 the Group dealt
with a few selective issues. From 1996 to 2009 it focused on HIV/AIDS, tuberculosis and
malaria, and then on severe acute respiratory syndrome and avian flu. Maternal, newborn
and child health dominated the agenda in 2010 and a few years later Ebola was the principal
item. Most recently, on 16 March 2020, the G7 held an emergency summit (via videoconfer-
ence) on COVID-19.
Æ
Direction-setting by affirming principles and norms to guide members and others in their
approach to health policy and its determinants. Thus, the G7 upheld the importance of hu-
man rights from 1985 to 1987, and it has been standing up for democracy from 1997 onwards.
The Group focused on women’s health rights in 2016 and 2017. There were no references to
democracy in the summit communiqués of 2018 and 2019, but the G7 once again upheld that
concept at the emergency summit of 16 March 2020. The Group has increasingly addressed
health matters in connection with hunger, poverty, nuclear safety and proliferation, biotech-
nology, the natural environment, drugs, ethics, gender equality and climate change. There
are now plans to expand the G7 into a D10.
Æ
Decision-making through specific, future-oriented and politically binding public commit-
ments that oblige all or some members to act at home and abroad by changing or introducing
policies, supporting outside actors and mobilizing funds to achieve key health goals. From
1979 to 2020 the G7 adopted 435 core health commitments, averaging 10 a year, with peaks
of 69 at St. Petersburg, Russian Federation, in 2006; 61 at Schloss Elmau, Germany, in 2015;
85 at Ise Shima, Japan, in 2016; and 21 out of a total of 33 commitments at the emergency
summit on COVID-19 on 16 March 2020.
Æ
Developing global health governance by shaping the evolution and work of international in-
stitutions. From 1987 to 2020, G7 summits made 330 references to such institutions, led by
the World Health Organization (WHO) with 110 references, the United Nations with 65 and
the Global Fund to Fight AIDS, Tuberculosis and Malaria with 61.
Decision-making at the G7
Decision-making at the G7 depends largely on the outcomes that the summit’s host and the other
members wish to see emerging from the annual summit. Up to two years in advance, the desig-
nated host country privately shares with the other members its priorities for the year of its G7
presidency. Every year, from 1 January, the leaders’ personal representatives, called “sherpas”,
meet several times. The first meeting is often held to discuss a thematic paper from the host,
which gradually develops into a draft communiqué that can be agreed on by the eve of the sum-
34 Global Health Centre | February 2021
mit. During the summit itself, the sherpas assist their leaders in resolving any outstanding issues
and working out the definitive text of the communiqué. The G7 leaders discuss and negotiate over
two or three days; there are also some sessions at which they meet alone without the sherpas
and other advisers. At the end of the summit, the agreed communiqué is released and each
leader gives a news conference to explain what has been achieved.
Decisions are reached by consensus, with no formal votes. While the host country’s preferences and
the ability of its leader obviously influence the final result, the norms of equality and collegial con-
sensus prevail throughout. The host country’s leader will not propose an agenda item or text that he
or she knows will be adamantly opposed by another G7 member. Moreover, the host will withdraw
proposals at the end if two or more members are in opposition. If only one leader is opposed, he or
she will usually acquiesce, though in recent years leaders in such a situation have explicitly not
agreed to the commitment in question. The necessity, born out of domestic political considerations,
to display leadership on a particular initiative often results in lengthy and multiple communiqués.
At the summit itself, leaders often introduce new issues and initiatives spontaneously. In the case
of controversial texts, they usually adopt the alternative wording presented by their sherpas, po-
litical directors and finance deputies.
Throughout the year, an increasing number of G7 ministerial meetings are held to iron out differ-
ences among countries and ease the leaders’ task, or to decide on specialized, non contentious
issues. The G7 health ministers, for instance, first met in this format in 2006, when they made 14
commitments, to which were added 36 in 2015, 40 in 2016, 101 in 2017 and 13 in 2019.
Outstanding issues
The G7 faces several outstanding issues or questions. For example, how can the Group return to
the continuously high level of performance that it showed from 2000 to 2010? How should it re-
late to civil society, WHO and the G20? Should it focus on mobilizing funds for poor countries (first
and foremost in Africa), as it has done in the case of the Global Fund, or should it move to a
broader array of instruments and also deal with issues that affect developed countries, such as
road accidents, “diseases of despair” and universal health coverage? Finally, taking its cue from
the Sustainable Development Goals, should the G7 explicitly address the determinants of health,
including health as a cause and consequence of gender equality; the natural environment; and
climate change?
The Group of 20
The G20 is made up of the G7 member countries, the BRICS countries (Brazil, Russian Federation,
India, China, South Africa), the MIKTA countries (Mexico, Indonesia, Republic of Korea, Turkey,
Australia), Argentina, Saudi Arabia and the European Union. The International Monetary Fund
A guide to global health diplomacy 35
and the World Bank Group participate in the G20’s deliberations but are not members. Since it
started convening as a meeting of finance ministers and central bank governors in 1999, and as
a leaders’ summit in 2008, the Group’s main objective has been to promote financial stability and
make globalization work for all.
The G20 countries, drawn from a diverse array of developed, emerging and developing economies,
represent a large majority of the global population, economy and health-generating capabilities.
Their leaders are now supported by many ministerial meetings, international organizations and
civil society engagement groups. They can thus shape the health agenda in a uniquely inclusive,
comprehensive and synergistic manner.
As an informal international institution, the G20’s functions are similar to those of the G7.
The scope of G20 summit deliberations on health has expanded considerably since 2008, in par-
ticular in 2013 and 2014, and then in 2017 and 2019 and at the emergency summit on COVID-19
held (via videoconference) on 26 March 2020.
From 2011 to 2019, the G20 leaders adopted a total of 75 commitments on health, with peaks of
33 (all on the Ebola outbreak) at Brisbane, Australia, in 2014, and 19 (on antimicrobial resistance,
strengthening of health systems and polio) at Hamburg, Germany, in 2017. In March 2020, 22
further commitments were added (all on COVID-19).
From 2008 to 2019, the G20 leaders made 11 health-related references to entities within the G20
countries and 56 to external actors. The latter were led by WHO with 17 references and the
United Nations with 15, the remaining entities receiving far fewer mentions.
Decision-making at the G20
Decision-making at the G20 is much like that at the G7. However, members must choose which
of the 19 country members is to host the annual summit. Each country thus hosts summits far less
frequently than at the G7. The leaders’ G20 sherpas are sometimes the same as their G7 ones.
Since 2017, annual meetings of the G20 health ministers have helped to prepare and implement
their leaders’ decisions. The inherited agenda, which has branched out from economics to cover
social, environmental and security issues as well, gives hosts less flexibility to discard old agenda
items in favour of new ones that they may consider to be more relevant.
36 Global Health Centre | February 2021
1.5 The changing role of diplomats
Bilateral and multilateral diplomatic structures are embedded in the international order, but the
negotiation and subsequent adoption of the SDGs have led to important changes in how multilat-
eral diplomacy is practised. Instead of being concerned mainly with representation, diplomacy has
now become, together with communication, a key tool for the management of transformational
global change and social engagement, including the handling of complex relationships.
Diplomacy is now a critical element of global governance. Diplomats must connect both issues and
actors, at the national and global level alike. The function of a foreign ministry has shifted from that
of a gatekeeper overseeing all official contacts at the international level towards being the coordina-
tor and enabler of a whole-of-government and whole-of-society approach, as more and more of a
country’s ministries engage in international affairs and its civil society organizations become ever
more internationally minded. This also means that many more individuals are engaged in diplomacy
outside the circle of professional diplomats. As one saying puts it, “Nowadays everyone is a diplomat”.
Embassies and other diplomatic missions engage to a much greater extent than before in outreach,
dialogue and relationship building, and diplomats must be able to interact with a wide range of
traditionally non diplomatic actors at home and abroad, practising bilateral, multilateral and
multi-stakeholder diplomacy – often at the same time and on the same issues. Foreign ministry
officials must keep abreast with national policy developments and with the increasingly global ac-
tivities of other ministries, many of which now have their own international departments and are
expanding the scope of their activities – for example, to participate in the SDG implementation
process. In many cases, the health ministries have had to expand their departments for internation-
al or global health. In the Geneva context, it is worth noting that governments may send different
types of representatives to WHO and for the conduct of health negotiations: foreign ministry repre-
sentatives in some cases, health ministry representatives in others, or from both ministries in yet
other cases. The composition of a Member State’s delegation ultimately determines whether diplo-
macy is being practised to advance health objectives, or vice versa. Finding the right balance is
essential for national delegations and institutions such as WHO.
A further important representation and negotiation mechanism has emerged through the establish-
ment of the G7 and the G20, namely the “sherpa” system. Sherpas are the personal representatives
of the Heads of State or Government of the countries in these two groupings — career diplomats
or senior government officials appointed by each leader to represent their country’s interests and
participate in the extensive series of consultations needed to prepare all summits. There is only one
sherpa per G7 or G20 member. Sherpas are in turn supported by “sous sherpas”: diplomats and
experts from the same country who have been assigned to work on specific agenda items (now also
A guide to global health diplomacy 37
including health) as part of the working groups established for the various preparatory meetings.
The SDG process and the global challenges of our times require diplomats to assume a dual respon-
sibility: to promote their country’s interest and to advance the interests of the global community. As
has repeatedly become clear in such areas as health and the environment, there is a need to devel-
op an approach that safeguards certain “global public goods”, or “global commons”. This applies,
for example, to the climate agenda or to the call for COVID-19 vaccines to be available to all people.
Such common goods need to be protected jointly and managed in a manner that enables them to
benefit everyone and make sustainable development a reality, despite the unilateral approaches
chosen by some States. During the COVID-19 pandemic, this has been exemplified by what is often
referred to as “vaccine diplomacy”, which seeks to establish a mechanism that will ensure equita-
ble access to a COVID-19 vaccine on a global scale, as opposed to “vaccine nationalism”. (See
Chapter 13 for further examples of global health diplomacy.)
Heads of State and Government are acquiring higher visibility in relation to key global issues. In-
creasingly, they are using summitry to shape agendas and prestige diplomacy to underscore their
engagement. For example, the Chancellor of Germany, Angela Merkel, and the former Prime Min-
ister of Japan, Shinzo Abe, have both distinguished themselves by raising global health issues at
many high-level political forums, such as G20 and G7 summits. Japan played a key role in this re-
spect by using its G20 presidency in 2019 to promote universal health coverage.
Diplomacy is increasingly expected to be more citizen-centric and to deliver value not only to a
country’s citizens at home but also to the global community through the country’s efforts abroad
and in international organizations. Heads of State and Government are more frequently making use
of social media for outreach purposes, with some relying on “Twitter diplomacy” not only to posi-
tion themselves vis-à-vis their electorate but also to secure an international audience and be able
to move agendas forward. More recently, the President of China, Xi Jinping, the President of the
Islamic Republic of Iran, Hassan Rouhani, The President of the Russian Federation, Vladimir Putin
and the President of the Republic of Korea, Moon Jae in, have all practised “corona diplomacy”,
reaching out to a wide range of countries by providing them with support in the form of medical
supplies. They have effectively been engaging in what has been termed a “soft-power race”.
All this implies a changing role – indeed sometimes a weaker role – for foreign ministries and dip-
lomats. At the same time, most foreign ministers, ambassadors and representations (missions to
the UN in New York or Geneva) now have their own social media accounts and are thereby able to
communicate their intentions, policies and outcomes more widely. This type of engagement is a
new form of public diplomacy.
38 Global Health Centre | February 2021
A guide to global health diplomacy 39
CHAPTER 2 | GLOBAL
HEALTH DIPLOMACY:
SYSTEM AND METHODS
2.1 Defining global health diplomacy
Global Health Diplomacy refers to the multi-level and multi-actor negotiation processes that shape
and manage the global policy environment for health in health and non-health fora. Diplomacy is
both a system of organization and a method of work. It is always political and is carried out through
many different channels. Diplomats seek to achieve the objectives of their country’s foreign policy
and, more generally, to protect its interests abroad. Nowadays diplomacy is no longer conducted
exclusively by accredited diplomats but by an increasingly wide array of actors, often through
multi-stakeholder diplomacy. All this is also true of global health diplomacy.
Over the past decades, a very complex, dynamic and diversified “ecosystem” of global health has
emerged, which global health diplomats have to be able to navigate. It is based on rules, processes
and institutions that operate at the global level but remain highly dependent on the willingness of
States to cooperate with one another, despite the fact that other strong actors have entered the
diplomatic health arena. In the context of multilateralism, global health diplomacy can both en-
hance and restrain the power of the players involved. Leadership in global health is always influ-
enced by the prevailing power relations, as witnessed, for example, by the rules on intellectual
property or by vaccine nationalism during the COVID-19 pandemic.
Power not only shapes relations between countries within WHO: it is also wielded by other key
actors, such as large foundations, which are able to set global health agendas because of the sig-
nificant funding that they provide for global health programmes and by virtue of their ready access
to decision makers around the world.
Diplomacy is often defined as the art and practice of conducting negotiations – within a range of
settings and on many different subjects. This is no less true of global health diplomacy, which is
concerned with a very wide spectrum of issues and conducted within the governance spaces de-
scribed in Section 1.4 However, it is much more than just negotiations, as will be explained in
Chapter 3, which discusses global health diplomacy in terms of seven dimensions. It includes the
building and maintaining of relationships, the gathering of information, the establishment of good-
will and the use of health as “soft power”. The latter refers to influencing public opinion through
40 Global Health Centre | February 2021
health, for example by establishing major health programmes such as the United States President’s
Emergency Plan for AIDS Relief (PEPFAR), launched in 2003, or through the “mask diplomacy” prac-
tised by China during the COVID-19 pandemic in 2020. These actions are often bilateral, but they
are fully calculated to influence global opinion.
Global health diplomacy is a manifestation of the increased importance of issue diplomacy. It re-
fers first and foremost to the negotiation processes in the multilateral system that address collec-
tive challenges relating to health. At the core of global health diplomacy are health issues that
transcend national boundaries and require global agreements, instruments and alliances if they are
to be tackled successfully and sustainably through joint action. However, as indicated above, it also
covers many other diplomatic processes: for example, bilateral health diplomacy as manifested in
donor relations (though these are not the focus of this Guide). There are also bilateral negotiation
processes between agencies and countries, for example between the Global Fund or the World
Bank and low- and middle-income countries. In some cases, WHO has special agreements with
individual countries.
Global health diplomacy is not only conducted between accredited diplomats and health officials
representing nation States but also involves many other major actors in the global arena, as is always
the case with multi-stakeholder diplomacy. With health moving beyond the purely medical and tech-
nical realm to become an ever more critical element in foreign, security and trade policy, new skills
are required to negotiate global regimes and international agreements and treaties, and to maintain
good relations with a wide range of actors from other sectors in order to advance global health.
Most diplomats are generalists. When engaging in global health diplomacy, their familiarity with
the international context and diplomatic processes is critical to the negotiations, but because of the
special nature of the field of health, their general knowledge and experience often need to be
complemented by the specific medical and scientific expertise of health professionals, usually from
the health ministries. Tensions can arise – also within national delegations – between the national
interest that diplomats are expected to uphold and the solidarity at the heart of the concept of
“common goods for health”, which should be the prime concern of global public health action.
With WHO as the directing and coordinating agency for global health, the bulk of global health di-
plomacy still consists of formal negotiations between States within its governing bodies, especially
when the goal is to reach agreement on international instruments. Yet, as indicated in Section 1.4,
all three governance spaces contain critical venues where global health diplomacy is practised.
This proliferation of venues is proving to be a great strain on the departments responsible for inter-
national and global health within health ministries, which are often not equipped to deal with the
growing number of negotiations and negotiating partners or with the increasing need for coordina-
A guide to global health diplomacy 41
tion between ministries. This is especially the case in small States and in low- and middle-income
countries. Because of the ever-greater complexity of health negotiations, many permanent mis-
sions in Geneva now have dedicated “health attachés”. There has also been a tendency in some
foreign ministries to increase the number of subject-matter experts among their staff as issue diplo-
macy – such as on health – continues to gain in prominence.
However, it is important not to underestimate the role of informal health diplomacy, conducted
between health diplomats but also with non-State actors, such as NGOs, academia, foundations
and the private sector. Informal multi-stakeholder diplomacy can – and often does – influence the
outcomes of formal global health diplomacy. Relationship-building is a critical skill in multi-stake-
holder diplomacy. It plays a particularly important role in negotiation hubs such as Geneva and
New York, where a large number of events and diplomatic receptions provide plenty of opportuni-
ties for informal diplomacy and information-gathering. Chapter 6 examines the role of non-State
actors in more detail.
Example: The COVID-19 pandemic has posed a number of challenges to global health diplomacy,
as outlined below:
The challenges faced by global health diplomacy during the COVID-19 pandemic reflect to a great
extent the difficulties that the multilateral system has experienced over the past decade. Thus,
the system’s fragility manifested itself in the initial lack of global cooperation on the response to
the pandemic. In particular, the geopolitical stand-off between China and the United States has
hampered progress on multilateral approaches not only at WHO but also at the G7, the G20 and
the United Nations Security Council. This negative trend was reinforced by the announcement of
the United States that it intended to withdraw from WHO.
The challenges in question are considerable even as a new US President takes office: they include
the future of WHO, the development of a new legal basis for pandemic preparedness and re-
sponse, possibly a further revision of the International Health Regulations, and identifying new
approaches to financing common goods in order to keep the world safe and to make a potential
COVID-19 vaccine available to all.
New mechanisms have been created to address these challenges – a WHO committee to review
the functioning of the International Health Regulations during the COVID-19 response; the Ac-
cess to COVID-19 Tools Accelerator, a new type of global collaboration to speed up development,
production and equitable access to COVID-19 tests, treatments and vaccines; the COVAX Facility,
a global risk-sharing mechanism for pooled procurement and equitable distribution of eventual
42 Global Health Centre | February 2021
2.2 Foundations of the modern understanding
of global health diplomacy
The global health architecture, institutions and processes rest on three key pillars: governance, in-
struments and diplomacy. The growing interconnectedness between these three pillars is an es-
sential driving force of global health in the 21st century.
The historical foundations of global health lie in the second half of the 19th century, with the first
of a series of international sanitary conferences taking place in Paris in 1851. The very first human-
itarian health organization – the International Committee of the Red Cross (ICRC) – was founded in
1863, while international health conventions began to be adopted from 1892 onwards.
Two pioneering institutions in the field of international health were established in the first half of the
20th century: the International Office of Public Health (1907) and the League of Nations Health Or-
ganization (1923). Just over a year after the conclusion of the Second World War, the WHO Consti-
COVID-19 vaccines; and new political alliances and fundraising initiatives. The European Union in
particular has played an important role in promoting solidarity.
A guide to global health diplomacy 43
tution was adopted in New York on 22 July 1946, the first statutory function of the new Organization
being “to act as the directing and co-ordinating authority on international health work”. The
Constitution came into force in 1948, when WHO was able to take up its work in Geneva.
However, it was during the latter decades of the 20th century that the present understanding of
global health began to take shape. Heightened demand and expectations for global cooperation on
health were triggered by several external factors, including globalization; transnational commercial
interests; the cross-border nature of health determinants; global epidemics such as HIV/AIDS and
tobacco use; the rising political profile of health; and the multiplication of international actors en-
gaged in health issues.
The end of the 20th and the beginning of the 21st centuries saw a new two-way dynamic emerge
in global health. On the one hand, the world witnessed a rapid rise in the number and intensity of
transnational factors influencing health. Growing international trade, transnational companies,
global tourism, transport and communications have significantly accelerated the cross-border
movement of people, goods, services, information and lifestyles. New global threats, such as in-
equality, climate change, food insecurity, resurging infectious diseases and mass migration, are
having a significant impact on health and well-being. The benefits of globalization have not been
equally distributed, and inequality has increased in the wake of the 2008 financial crisis and the
austerity policies subsequently adopted by many countries.
On the other hand, it is now understood more clearly that health makes a considerable direct and
indirect contribution to economic growth and sustainable development, and to international secu-
rity, stability and peace. The wide-ranging economic impact of the COVID-19 crisis has highlighted
this once again. Furthermore, the health sector has now become one of the largest industries.
Global annual health spending reached US$ 7.1 trillion in 2015 – a figure that was expected to
balloon to US$ 8.7 trillion by 2020. Health is also a key sector in public finance and a major area of
household spending (Deloitte, 2019a). Accordingly, health has acquired a prominent place on both
the domestic and foreign policy agendas of most countries.
At the same time, two distinct approaches to global health have emerged. One is more focused on
improving health in developing countries; it is based on the SDGs, financed by development aid and
increasingly supported by large philanthropic organizations. The other – reinforced by the COVID-19
pandemic – is concerned with all countries, the health inequalities within and between these, and
with health issues that transcend national boundaries and call for responses taking into account
the global forces that determine the health of people. This dynamic interface between health and
economic and societal factors cannot be tackled within national or regional boundaries alone: the
challenges it poses require global solutions based on both multilateral and multi-stakeholder coor-
44 Global Health Centre | February 2021
dination and action, especially during global health crises and outbreaks.
Today there is a lively ongoing debate on how global health should be understood. Governments and
communities in the Global South, in particular, are no longer willing to accept approaches to global
health in which they have not been involved from the start, or to adopt programmes developed “for”
them by others. Many global health professionals and organizations are still concentrated in the
Global North: there have consequently been calls for a “decolonization” of global health (see Box 3).
Box 3: Decolonizing global health diplomacy
In recent years, there have been calls to “decolonize” global health, which some have described
as an inherently “colonialist” field. University students have organized conferences to question
the ahistorical and depoliticized teaching of global health. Journal articles have criticized the lack
of inclusivity in the conduct and publication of research; for instance, African researchers were
found to be grossly underrepresented in scientific papers about health issues in Africa. Some
commentators have discerned “colonial” attitudes and practices in the global response to the
COVID-19 pandemic – from early suggestions to use Africa as a “testing ground” for a potential
vaccine to expert recommendations on handwashing and social distancing that do not take into
account the local context in poor countries.
But what does it mean to decolonize? There are at least two major interpretations of the term
“decolonization”. The traditional view is that it refers to the end of one country’s territorial domi-
nation of another. In this regard, most countries – especially in the “Global South”* – would al-
ready count as “decolonized”. In an influential paper, however, the term was defined as “the re-
versal of the process of European imperial expansion with all its political, economic, social,
cultural and linguistic consequences” (Bismarck, 2012) – in short, a return to a people’s indige-
nous roots. While many remnants of the colonial past, such as language and culture, are difficult,
if not impossible, to purge, this does not mean that the legacy of colonialism as reflected in
modern-day capitalism, sexism, racism and globalization cannot be explicitly acknowledged and
constantly challenged.
When examining the field of global health, the related concept of “decoloniality” is also import-
ant. Originating in Latin American scholarship, it refers to questioning the perceived universality
and superiority of Western knowledge and culture. Much of centuries-old human medicine and
contemporary global health has been shaped by Western thought, which largely ignored other
systems of knowledge production. Therefore, decoloniality in global health is an invitation to a
A guide to global health diplomacy 45
more pluralistic vision of health that also considers non-Western and indigenous perspectives. It
is hoped that such a dismantling of Eurocentric notions will give rise to health interventions,
policies, practices and research arrangements that are inclusive and respectful of different peo-
ples and their cultures. Some have argued, for example, that a lack of such respect led to a
“narrative of mistrust” in the international response to the Ebola outbreak in West Africa in 2014
(Richardson, McGinnis & Frankfurter, 2019).
How, then, is global health diplomacy to be “decolonized”? While the geopolitical colonization of
the Global South by Western countries is largely over, colonial legacies still very much prevail in
the form of neoliberal policies, gender discrimination, white supremacy and ecological destruc-
tion, all of which to this day continue to drive health inequalities within and between countries.
If pressing global health issues, such as noncommunicable diseases, sexual and reproductive
health, and the long-term health impacts of climate change, are to be seriously addressed, mul-
tilateral and bilateral negotiations for health among countries must acknowledge and actively
challenge these long-standing causes of power imbalances.
In addition, the platforms for health diplomacy must be made more inclusive and egalitarian.
Developing countries are still generally unable to transition from unequal relationships with their
former colonizers (and now development aid donors), which dominate decision-making on global
health (whether in United Nations agencies or public–private partnerships, such as the Global
Fund to Fight AIDS, Tuberculosis and Malaria). Much-needed reforms must therefore be institut-
ed to give equal voice to all countries – rich and poor. The shift in 2017 to having the WHO Direc-
tor-General elected by the World Health Assembly (that is, by all countries), rather than by the
Executive Board, was an essential step in that direction. However, additional measures will need
to be adopted to accelerate progress towards greater inclusivity and diversity in global health
leadership, governance and diplomacy.
Finally, applying the decolonial lens to health diplomacy helps in uncovering voices that are either
“too loud” or “not heard at all” at the negotiating table. Beyond national governments, there are
myriad actors who can be seen to be engaging in “neocolonial” behaviour and are exerting un-
due and disproportionate influence in global health policy – from multilateral banks and transna-
tional corporations to philanthropic foundations and elite think tanks. On the other hand, there
are the “silenced voices” in global health – women, members of the LGBT community, ethnic
minorities and indigenous communities, social movements from the Global South, among others.
In order to decolonize global health diplomacy, it has been argued that it is necessary to protect
the negotiating space against “neocolonizers” and create more opportunities for the “colonized”
and oppressed to become involved in negotiations – an important first step towards making
global health truly global.
46 Global Health Centre | February 2021
2.3 The global health diplomacy system
The unique institutional mechanisms and instruments of global health diplomacy are part of a
larger system of diplomacy, with which they intersect and on which they are partly dependent.
Section 1.4 described three governance spaces within which actors negotiate and take decisions,
and sought to give a general idea of the complex and dynamic ecosystem of global health.
Despite a weakening of multilateralism in recent years, the primary channel of global health diplo-
macy remains negotiation between States within the framework of the UN system. WHO remains
the key conduit for global health diplomacy by virtue of its constitutional mandate to coordinate
international health work and to establish norms and standards, its high level of legitimacy stem-
ming from the representation of States, and its treaty making power. However, it has also become
an indispensable platform for multi-stakeholder health diplomacy. The annual World Health As-
sembly, for example, brings together up to 4000 participants from all around the world: on such
occasions one can truly say that “everyone is a health diplomat”.
Global health diplomacy at WHO follows the general system of diplomatic representation and com-
munication practices. The Organization currently has 194 Member States and works according to
the UN principle of universal representation with one vote for each country, irrespective of size or
level of development. Unlike many other venues for diplomacy, the negotiations at WHO are
aimed at reaching consensus, even though in principle it is possible to call for a vote.
Tensions can often emerge at WHO between the value-driven and evidence-based proposals made
by the Secretariat, the foreign policy interests of Member States and the specific national interests
of the health ministries representing their countries in the WHO governing bodies. In most cases,
the day-to-day negotiations are conducted by health attachés, who are based at the diplomatic
representations in Geneva, with higher-level representatives such as ambassadors or ministers
joining them at major meetings or when key decisions are to be adopted. The permanent mission
of a State – for example in Geneva – or the negotiators from the capital receive instructions from
the national government and seek to ensure that the State’s national position and interests are
* The terms “Global South” and “Global North” were introduced in 1980 by the Brandt Report, which was written by
an independent commission chaired by Willy Brandt, former Chancellor of West Germany.
Resources
See the section entitled “Publications on decolonizing global health diplomacy” in Annex 2
A guide to global health diplomacy 47
reflected in the outcome of the negotiations. The effectiveness of smaller missions may depend to
a great extent on the personality and contacts of the health attaché, while larger missions operate
more through their diplomatic machinery.
Responsibility for the success of negotiations also lies with the secretariats of organizations such as
WHO. The way in which proposals are developed does make a difference: if they are handled in a
transparent way that elicits support and includes dialogue and consultations with Member States,
civil society and the private sector, the proposals are likely to make swifter progress within the gov-
erning bodies. Knowing when and how to put forward proposals is an important skill that needs to
be honed within the secretariats of such organizations so as to ensure success in health diplomacy.
Appropriate mechanisms, procedures and strategies developed at the national level are critical for
the success of global negotiations. Good global health begins at home. National policy frameworks
on global health can serve as a compass for negotiations at other levels and can be supported
through strong departments and focal points responsible for global health within national minis-
tries (see Section 8.4).
These policy frameworks can deal with global health generally, or they may be national strategies
on specific issues such as antimicrobial resistance which underline the need for both domestic and
international cooperation. The success of international negotiations also depends on the trust that
countries have in individual organizations, the level of such trust often being informed by the find-
ings of official reviews. Examples include the Multilateral Aid Review in the United Kingdom of
48 Global Health Centre | February 2021
Great Britain and Northern Ireland, and the Multilateral Organisation Performance Assessment
Network, both of which review the performance of multilateral organizations and assess national
plans and strategies.
Since health negotiations often require interaction between health and foreign policy (and other
policy areas), the role of health attachés has become increasingly important. These diplomats are
expected to brief officials in the capitals, prepare negotiations and in many cases to conduct them
directly, both in Geneva and New York.
Geneva, the headquarters of many global health organizations, is considered to be the global
health capital, and most countries and many other key global health actors are represented there.
The city provides an environment in which it is easy to establish relations and use both formal and
informal channels to prepare for negotiations. However, global health negotiations are increasing-
ly also taking place at the United Nations in New York, especially given that health is an essential
component of the SDGs (notably Goal 3). In some cases, health issues acquire such relevance that
they are discussed at the General Assembly, the Security Council or at special high-level summits.
Other important venues are the regular G7 and G20 meetings and special summits. Some commen-
tators have criticized the fact that most major health organizations are based in Geneva, that is, in
the Global North, whereas many of the challenges they are called upon to tackle are in low- and
middle-income countries in the Global South. It should also be noted that some low income coun-
tries do not have their own representation in Geneva.
6
Like other areas of diplomacy, the system of global health diplomacy has evolved to manage not
only the relations between States (bilateral and multilateral) but also those between States and
other actors. The importance of multi-stakeholder diplomacy has increased exponentially. Civil so-
ciety organizations, in particular, expect a high level of involvement, transparency and accountabil-
ity. This is not always forthcoming from large donors and foundations. Many of the more recently
established global health organizations in Geneva are defined by a multi-stakeholder and constitu-
ency-based governance. For example, the Board of the Global Fund comprises 28 seats, of which
10 represent donor constituencies and 10 represent implementer constituencies; the remaining
eight seats are for non voting members of the Board, including a broad range of global health ac-
tors, also from among civil society.
While there is often competition between global health actors, including WHO, for scarce donor
resources, all of them rely on WHO for key aspects of their successful mission delivery, be it the
6 The Swiss Federation provides a regularly updated overview of all organizations and representations in Geneva: https://www.
eda.admin.ch/dam/mission-onu-omc-aele-geneve/en/documents/GI--en-chiffres_EN.pdf
A guide to global health diplomacy 49
norms and standards underpinning their work, technical support at the national level through the
numerous WHO country offices, or even just the legitimacy conveyed by WHO’s support and its
universal membership and consensus-based approach. As the directing and coordinating authority
in global health, WHO has responded to the increase in the number of players in the global health
arena: it engages with non-State actors by recognizing their contributions to global health and by
encouraging them to develop their own activities to protect and promote public health at home and
abroad. Their relations with WHO are governed by the Framework of Engagement with Non-State
Actors. The Framework is intended to strengthen WHO engagement with non-State actors (NGOs,
private sector entities, philanthropic foundations and academic institutions) while protecting the
Organization’s work from potential conflicts of interest, reputational risks and undue influence.
(More details on the venues and actors in global health diplomacy can be found in Chapter 6.)
2.4 Relationships in the global health diplomacy system
Countries engage in both formal and informal global health diplomacy in a variety of ways. Indeed,
the many different forms of conducting diplomacy in general also apply to health diplomacy. The
uneven power dynamics among States, and between States and other actors that want to influ-
ence negotiations, always have an impact on and often even decide the outcome of negotiations.
Despite the many difficulties over the past decades, a willingness to engage in negotiations and
reach an outcome has generally always been forthcoming. However, the weakening commitment
to multilateralism is now making it more difficult to use different forms of diplomacy to move agen-
das forward. One telling sign is that major meetings are increasingly unable to reach an agreed
conclusion. The well-established system of global health diplomacy has been disrupted, with the
leadership void recently created by the United States not yet filled, even though new alliances of
States are forming.
In the majority of cases, different channels of diplomacy are used simultaneously to move an agen-
da forward. As already indicated, formal and informal negotiations (“track-one” and “track-two”
diplomacy) will usually take place in parallel. In order to advance their positions and test possible
alliances, countries (and other stakeholders) sometimes engage in “forum-shopping” – that is,
launching an issue of importance to them in different negotiation venues and at different levels.
(This process of course depends on the influence they have in the various venues.) If well conduct-
ed, the negotiations can reinforce one another and may even facilitate diplomatic breakthroughs,
but they can also fail, as was the case with the global health negotiations at the G7 and G20 in 2020.
Most countries are engaged at the multilateral level with UN system entities (see the chart in
Section 6.3).
50 Global Health Centre | February 2021
The World Health Organization is the key entity when it comes to negotiations on global health
norms and standards. The priorities for such negotiations are usually set by governments, which
participate as nominal equals (according to the principle of one vote per country) within the UN
framework. Before proceeding to the WHO stage there are normally preparatory negotiations at the
bilateral and regional level. Alliances are created at all these levels to move an agenda forward.
Global health diplomacy is also conducted at the Bretton Woods institutions, such as the World
Bank, especially on matters of health financing, and at specific health organizations such as the
Gavi Alliance, the Global Fund and the International Drug Purchase Facility (UNITAID).
The Joint United Nations Programme on HIV/AIDS (UNAIDS) was established by the United Nations
Economic and Social Council and remains the only co-sponsored joint programme in the UN system.
UNAIDS is steered by its Programme Coordinating Board, a governance structure unique in its small
size and level of inclusiveness: it comprises Member States, Cosponsors, civil society representa-
tives and specifically also people living with and affected by HIV. Significantly, the NGO delegation
to the Programme Coordinating Board has co-equal status with Member States and UNAIDS spon-
sors. Such arrangements could help to promote the decolonization of global health governance.
The Global Fund is a private foundation under Swiss law, albeit with quasi-intergovernmental sta-
tus conferred by the Swiss Government. Set up to accelerate the end of AIDS, tuberculosis and
malaria as epidemics, the Global Fund works in partnership with governments, civil society, techni-
cal agencies, the private sector and people affected by these diseases, who are represented in its
governing bodies.
In such settings as negotiations at the Global Fund or the Gavi Alliance, a country’s level of devel-
opment can determine whether it takes part in the negotiations as a donor, a recipient or as an
implementer. A constituency model of representation is frequently chosen (see Box 10 and Box 11).
Multi-stakeholder diplomacy in all organizations and negotiating venues increasingly involves
bringing in other stakeholders: large foundations, academia, the private sector and NGOs. Such
engagement comprises a wide range of interfaces and is often an essential factor in successful
negotiations, even if the final decisions are taken by States. Multi-stakeholder diplomacy is also
conducted through public–private partnerships and alliances, including new mechanisms such
as the Access to COVID-19 Tools Accelerator, that brings together governments, scientists, busi-
nesses, civil society, philanthropists and global health organizations.
Summits of country groupings, such as the G7, the G20, the BRICS countries and the Common-
wealth, now play a very important role in global health diplomacy. An increasing amount of multi-
lateral negotiations on health issues takes place at the level of Heads of State and Government.
This is often referred to as “club diplomacy”, with membership restricted to a select group of
A guide to global health diplomacy 51
countries and with the rotating presidencies deciding on which other countries should be invited to
join the negotiations. Recent G7 summits have paid considerable attention to health (especially
thanks to the presidencies of France, Germany and Japan). Similarly, meetings of the health minis-
ters of the G20 countries have been taking place regularly since the first such meeting in Berlin in
May 2017. There have also been joint meetings of health and finance ministers. In recent years, the
final communiqués of both G7 and G20 summits have increasingly referred to health issues. Reach-
ing agreement on global health issues at such summits, however, is now more difficult to achieve
because of the politicization of the COVID-19 pandemic.
Most countries are likely to be engaged in negotiating bilateral agreements on health. Bilateral
negotiations are frequently about securing financial support from donors or large funding agencies
such as the World Bank or the International Monetary Fund. However, they may also have to do
with people’s access to health services or issues related to the safety of health products as these
cross-borders. Myriad constellations are possible in such negotiations: not just South–North but
also North–North and South–South. China has developed a new mixed approach, using the Belt
and Road Initiative to build a “Health Silk Road” (see Box 5).
Countries may also be engaged in negotiating regional agreements – for example, within the Eu-
ropean Union (EU), where such agreements are often binding, or between regions, as between the
EU and the African Union. The countries in a regional bloc will frequently need to negotiate and
agree on their positions in a multilateral negotiation, but bilateral trade agreements (often includ-
ing health-related provisions) are on the rise. Since regional trade agreements can have significant
positive and negative health impacts, they often prove difficult to negotiate. Regional groupings
can play a key role in advancing global health, as the Caribbean Community (CARICOM) did with
the noncommunicable diseases agenda or, more recently, as the EU has done with the response to
the COVID-19 pandemic. (See Chapter 7)
All this testifies to the ever more important overlap between health diplomacy and economic and
commercial diplomacy. Economic diplomacy is concerned with many transborder determinants of
health – for example, with how to stimulate economic growth, particularly in the poorest countries.
Commercial diplomacy, on the other hand, consists mainly of assistance with the promotion of ex-
ports, securing foreign direct investment, and access to raw materials. It has become increasingly
relevant to the field of health as access to medicines and global supply chains for health gain in
importance. Analysts have noted how modern diplomacy was influenced by commerce from its
earliest days, and that the priority given to economic as well as commercial diplomacy has risen
more in recent years (Berridge, 2015). Health diplomacy is also strongly integrated with economic
and commercial diplomacy in such diverse areas as intellectual property protection, antimicrobial
resistance, noncommunicable diseases, and nutrition policies and labels. More needs to be done to
52 Global Health Centre | February 2021
proactively bring these work streams together, both within national delegations and among inter-
national organizations, as exemplified by the trilateral cooperation on access to medicines under-
taken by WHO, the WTO and the World Intellectual Property Organization (WIPO).
The trend towards greater integration has been reinforced by increasing calls (for example, at the
G7 and the G20) for joint meetings of health and finance ministers to secure financing for universal
health coverage or for pandemic preparedness and response. Most countries integrate economic
and commercial diplomacy into their health diplomacy at least to a certain extent, but this should
not necessarily be seen as something negative. The issue of global supply chains in the face of
COVID-19 is a case in point. For example, a recent EU veterinary directive has potential far-reaching
implications for the fight against antimicrobial resistance, but it is also creating significant disrup-
tion throughout the Americas and Oceania, since trading partners in those regions do not necessar-
ily categorize some feed additives as antibiotics, while the new EU directive does. In this case a
range of commercial factors come into play, including the protection of domestic producers at the
expense of imports.
Health diplomacy – especially if accompanied by science diplomacy – is a helpful channel for inter-
action between countries that have no or very strained foreign policy relations with one another. In
the United States, the term “track-three diplomacy” is frequently used to refer to approaches that
bring experts, scientists and citizens together; it is also referred to as “people to people diplomacy”.
Operating at the grassroots level, such approaches seek to facilitate a better understanding of
others’ positions. Many global health conferences make space for this kind of diplomacy, which,
like the other types, has also become more difficult in the wake of the COVID-19 pandemic. In crisis
situations and in humanitarian diplomacy, the use of third party diplomacy, where a neutral and
independent actor serves as an intermediary, can be critical.
As already indicated, other types of diplomacy can be greatly relevant for the advancement of
global health: crisis and emergency diplomacy; humanitarian diplomacy; science diplomacy; and
climate diplomacy. It is important to keep in mind that diplomats are on rotation and gain experi-
ence in many settings. For example, many diplomats serve in Geneva after having been based with
their national delegations to the UN in New York. Many different constellations of experience are
possible and this can be an asset in health negotiations.
2.5 Digital diplomacy
Digital diplomacy is increasingly being used to publicize a country’s position to a broader audience
(a function previously fulfilled by public diplomacy) and to influence negotiations. This includes the
A guide to global health diplomacy 53
use of electronic media (such as websites, podcasts and blogs) and social media (particularly Face-
book and Twitter) to reach out to other negotiators, the public and journalists. Digital diplomacy
comprises such channels as “cyberdiplomacy”
7
, which has mainly to do with security issues; “tech
and science diplomacy”
8
, which covers States’ interactions through innovation hubs; “data diplo-
macy”
9
, which refers to the use and impact of “big data”
10
on diplomacy and international affairs;
and “e-commerce”
11
, which is about economic issues.
Digital diplomacy through social media is often used by non-State actors to persuade or even pres-
sure diplomats into adopting a particular position in negotiations. For example, social media fea-
tured prominently in the “Hands off our medicine!” campaign launched by Médecins sans Fron-
tières in 2010 to dissuade the EU from concluding a trade agreement with India that would have
limited the generic production of medicines for the treatment of tuberculosis and other diseases.
Social media also played an important role in the negotiation of the “transparency resolution” at
the Seventy-second World Health Assembly in 2019 (see Case Study 1). The increased use of new
web-based tools in the practice of diplomacy is set to continue.
7 DiploFoundation on Cyberdiplomacy: https://www.diplomacy.edu/blog/web-discussion-summary-applicability-internation-
al-law-cyberspace-do-we-know-rules-road
8 DiploFoundation on Tech and Science Diplomacy: https://www.diplomacy.edu/innovationhubs
9 DiploFoundation on Data Diplomacy: https://www.diplomacy.edu/datadiplomacy/policyresearch
10 DiploFoundation Website on Data Diplomacy: https://www.diplomacy.edu/blog/impact-big-data-geopolitics-negotia-
tions-and-diplomatic-modus-operandi
11 DiploFoundation Website on E-Commerce: https://www.diplomacy.edu/e-commerce
54 Global Health Centre | February 2021
Twitter diplomacy played a key role in the recent elections of the directors general of WHO and the
United Nations Educational, Scientific and Cultural Organization (UNESCO). Most of the candidates
for high-level UN positions now actively campaign on Twitter. This platform is also used increasing-
ly by Heads of State and Government and by ministers and diplomats to share their views and po-
sitions with a wide audience. Similarly, the heads of international organizations use social media to
present their work and policies – something that the WHO Director-General in particular has fre-
quently done during the COVID-19 pandemic.
Social media are particularly prominent in what has come to be called “global issue diplomacy”.
In the context of global health diplomacy, this refers to efforts to promote a specific health issue –
for example, a certain disease (AIDS) or group of diseases (noncommunicable or neglected tropical
diseases) – to the top of the agenda, to gain acceptance for a specific approach (“One Health”,
universal health coverage), or to draw attention to discrimination (the Women in Global Health
campaign). Social media are also critical for new fundraising approaches, as illustrated by the “One
World: Together At Home” campaign in support of the response to the COVID-19 pandemic.
Global health is an area in which broad societal involvement is clearly meaningful. Civil society or-
ganizations focused on development agendas expect governments to support initiatives on global
health, human development and human rights. The number of NGOs active in the field of global
health has grown significantly over the past few years, and they too now use social media to de-
mand investment, action and accountability. They have also begun to organize novel types of glob-
al fundraising campaigns, such as the “One World: Together At Home” and “Global Citizen” cam-
paigns, which helped to raise over US$ 230 million for the COVID-19 Solidarity Response Fund set
up by WHO together with several philanthropic foundations around the world.
While social media provide a wide cross-section of the public with an opportunity to comment on
foreign policy action (or neglect), they can also result in negotiators being subjected to great moral
pressure, highly emotional responses and even vicious personal attacks. WHO has warned of the
negative health impacts of “infodemics”, that is, where the volume of information associated with
a specific topic grows exponentially in a short period of time. The COVID-19 outbreak and the ensu-
ing response measures were accompanied by a massive infodemic: an overabundance of informa-
tion – some accurate, some not – that made it hard for people to find trustworthy sources and reli-
able guidance when they most needed it. This new information environment poses an increasing
challenge to diplomats. Accordingly, WHO took the critical decision to hold press conferences on
the COVID-19 response three times a week – something that it still continues to do – and combined
these with a strong social media presence and outreach efforts.
A guide to global health diplomacy 55
Efforts in global health diplomacy can be better understood by breaking this field down into seven
dimensions:
CHAPTER 3 | THE DIMENSIONS
OF GLOBAL HEALTH DIPLOMACY
Seven dimensions of global health diplomacy
negotiating to promote health and
well-being in the face of other interests
establishing new governance mechanisms
in support of health and well-being
creating alliances in support of health
and well-being outcomes
building and managing donor
and stakeholder relations
responding to public health crises
improving relations between countries
through health and well-being
contributing to peace and security
3.1 Negotiating to promote health and well-being
in the face of other interests
Global health diplomacy at WHO has particular relevance because it is the only global health orga-
nization that sets norms and standards and can adopt treaties. Upholding health interests in the face
of other interests – as was the case, for example, when negotiating the WHO Framework Conven-
tion on Tobacco Control (adopted in 2003) – is a highly political and sensitive matter requiring
thorough preparation. It is important to apply evidence, foresight and judiciousness so as to ensure
that short term political considerations and commercial interests do not endanger the prioritization
of health aspects in sustainable development. The COVID-19 pandemic has demonstrated that, in
addition to a strong mandate, global institutions such as WHO must also have strong tools to re-
spond to health crises. Otherwise, geopolitical and national interests may stand in the way of solu-
tions that benefit all countries. Before any round of global health negotiations, it is vital that diplo-
mats should assess the interests at stake and prepare well to be able to address these strategically.
56 Global Health Centre | February 2021
Four examples of global health diplomacy negotiations that were challenging because of the inter-
play of political, economic and commercial interests are presented below:
Price transparency for medicines: The adoption, in May 2019, of the landmark World Health
Assembly resolution WHA72.8 on improving the transparency of markets for medicines, vaccines
and other health products was achieved only after a very controversial series of negotiations,
with a group of Member States withdrawing from the final round for reasons of both substance
and process. The resolution tasks Member States and WHO with creating systems to collect and
share information about prices, sales, patents, public and private sector research and develop-
ment (R&D) costs, R&D subsidies and other items (see Case Study 1 by Catherine Saez).
Health of refugees and migrants: Member States at the 72nd World Health Assembly took
note of the document Promoting the health of refugees and migrants: Draft global action plan,
2019–2023. After lengthy debate, which reflected the changed political landscape and the often
emotionally charged tone of current discussions on migration, the opposing views of the delega-
tions could not be reconciled, although the original intention had been to achieve a resolution.
This outcome was the sole acceptable one for some countries that did not feel ready to accept
any obligations under the action plan had it been adopted.
Intellectual property: Much of global health diplomacy in relation to this field takes place in
“non-health” forums such as the WTO, a notable example being those rounds of the negotiations
leading to the 1995 Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS
Agreement) in which public health needs had to be upheld in the face of political, economic and
commercial interests.
Response to the COVID-19 pandemic: It had become increasingly difficult to reach agree-
ment on collective measures in response to the pandemic at political negotiation venues such as
the G7 or G20, in particular because of the geopolitical stand-off between China and the United
States, and also because of the critical attitude of the United States towards WHO.
Resources
Bernes TA. COVID-19: the failure of G20. In: Centre for International Governance Innovation
[website]. Waterloo, Canada: Centre for International Governance Innovation; 2020 (https://
www.cigionline.org/articles/covid-19-failure-g20, accessed 14 September 2020).
Severoni S, Kosinska M, Immordino P, Told M, Kökény M, editors. Health diplomacy: spotlight
on refugees and migrants. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.
A guide to global health diplomacy 57
3.2 Establishing new governance mechanisms
in support of health and well-being
At the turn of the 21st century, new organizations were created in the field of global health, such
as UNAIDS, the Global Fund and the Gavi Alliance, which now enjoy a considerable standing. This
was made possible by negotiations between countries and other partners at WHO, the UN, the G7
and the G20, which led to agreement on the establishment of these organizations and on the fi-
nancing and governance mechanisms. They were often set up because WHO was at the time un-
able or unwilling to fulfil the relevant functions. Yet this has also led inadvertently to the fragmen-
tation of global health governance. For that reason, many in the international community are now
very hesitant about creating additional global health organizations.
Two megatrends have emerged in recent years. First, there has been a shift from the traditional
global health architecture towards new political spaces and mechanisms, such as UN forums, region-
al economic and political blocs, major conferences on other global priorities (climate, urbanization,
humanitarian action), initiatives by the Global South and agenda-setting by global health journals
(see Chapter 2). Secondly, the processes of governance have changed: negotiations on a dynamic
range of political and other issues are conducted by an increasingly flexible network of partnerships,
alliances and coalitions (such as dedicated public–private partnerships and umbrella NGOs).
Within intergovernmental organizations, new governance models are being negotiated by the
member countries. For example, the WHO Member States changed the Rules of Procedure of the
Executive Board and the modalities for the election of the Director General. They also strengthened
the Organization’s operational role through the establishment of a new Health Emergencies Pro-
gramme. These are important global health diplomacy processes on account of their impact on long
term decision making.
Indeed, there have already been many calls for a complete overhaul of the governance mechanisms
euro.who.int/en/publications/abstracts/health-diplomacy-spotlight-on-refugees-and-mi-
grants-2019, accessed 14 September 2020).
Watal J, Taubman A, editors. The making of the TRIPS Agreement: personal insights from the
Uruguay Round negotiations. Geneva: World Trade Organization; 2015 (https://www.wto.org/
english/res_e/publications_e/trips_agree_e.htm, accessed 14 September 2020).
58 Global Health Centre | February 2021
in global health to ensure more effective cooperation and use of funds. Some proposals imply a
strengthening, others a weakening of WHO and of its mandate. Reconciling these often-opposing
tendencies will be a key area of global health diplomacy in the coming years.
3.3 Creating alliances in support of health and well-being outcomes
Alliances are formed for mutual benefit or to achieve some common purpose, whether or not an
explicit agreement has been reached among the individual members. Alliances for global health
may include political alliances. For example, in 2019, France and Germany established the Alliance
for Multilateralism, which seeks to bring together all those who believe that strong and effective
multilateral cooperation, based on the objectives and principles of the UN Charter, international
law and justice, is indispensable to secure peace, stability and prosperity. The Alliance issued a
strong statement in support of WHO in the context of the COVID-19 pandemic. Older alliances can
also help to advance agendas: for example, the Non-Aligned Movement, a group established in
1961 that now consists of over 120 developing countries not formally aligned with or against any
major geopolitical bloc, played a significant role in the negotiations leading to the adoption of the
Pandemic Influenza Preparedness Framework in 2011.
Countries with common interests have used a system of “bloc politics” to organize their efforts
under the UN framework. Member States often come together as a regional group within which
there is consensus on defending a common position when voting at the World Health Assembly or
the UN General Assembly. There are five regional groups at the UN: the Group of African States, the
Group of Asia-Pacific States, the Group of Eastern European States, the Group of Latin American
A guide to global health diplomacy 59
and Caribbean States (GRULAC) and the Group of Western European and Other States. The voting
correlation varies between regions and depends on the type of resolution that comes to a vote. The
EU usually acts as a unified bloc during voting at the World Health Assembly or the General Assem-
bly. Although the EU has no voting right as such, its delegation is authorized to speak on behalf of
the whole bloc at the UN. EU member countries may express their individual views but they strong-
ly align their vote with the consensus EU position.
Health alliances taking many different forms have been set up over the past two decades – often
linked to specific diseases, as in the case of the Global Polio Eradication Initiative launched in 1988,
which currently has six core partners. Alliances offer distinct advantages in terms of the pooling of
resources and capabilities. One of the best known is the Gavi Alliance, established in 2000. Gavi
today helps to vaccinate almost half of the world’s children, which gives it vast power to negotiate
prices for vaccines that are affordable for the poorest countries and to remove the commercial risks
that previously deterred manufacturers from serving those countries.
Alliances are necessary to address public health problems that organizations working alone find it
difficult to tackle. Moreover, the health-related targets under the SDGs offer a unique opportunity
to create alliances that can influence the determinants of health. In particular, the interface be-
tween climate change and health has emerged as a priority area. The Global Climate and Health
Alliance was launched in Durban, South Africa, in 2011 to tackle climate change and protect and
promote public health. It comprises health and development organizations from around the world
that are united by a shared vision of an equitable and sustainable future.
The Global Health Workforce Alliance was created in 2006 to coordinate the engagement of multi-
sectoral stakeholders seeking to tackle the crisis in human resources for health. Bringing together
national governments, civil society, international agencies, finance institutions, researchers, educa-
tors and professional associations, the Alliance was able, over the 10 years of its mandate, to gen-
erate significant political will and action for positive change in this area. After the conclusion of its
mandate in 2016 it transitioned into the Global Health Workforce Network.
Groups of countries or health advocates at the country level have also come together to launch
initiatives such as Friends of WHO or Friends of the Global Fund in order to support the relevant
entities in a variety of ways. An example of an alliance for global health created at the national
level is the German Health Alliance, which consists of more than 100 partners from virtually all
sectors: the private sector and industry, NGOs, civil society and foundations, science and academia.
A recent analysis showed that 80% of global health alliances are successful in their work. A key
factor in this respect is achieving a good balance between participation and effectiveness. Success-
ful alliances tend to encourage input from, and consultation with, all parties, without necessarily
60 Global Health Centre | February 2021
Science plays a critical role in health diplomacy. The close interface between science diplomacy
and health diplomacy is proving ever more important in the promotion of global health. In broad
terms, “science diplomacy” refers to the use of science, including its methods and results, for bi-
lateral or multilateral diplomacy. It means putting science at the centre of diplomatic efforts aimed
at building or maintaining relations and at establishing or achieving foreign or multilateral policy
goals. Science diplomacy should ideally be part of the wider interface between policy, society and
science. This type of diplomacy has gained traction in the past two decades owing to the speed of
technological progress and the importance of science for tackling global challenges such as cli-
mate change, the digital divide or pandemics. The recent COVID-19 outbreak and the ensuing
pressure to develop a vaccine have very much led to science taking centre stage in global affairs.
Foreign policy and science policy have become increasingly intertwined, particularly in connec-
tion with advances in the health and medical sciences. However, other scientific fields, such as
climate change or artificial intelligence, also require attention on the part of those responsible for
foreign policy. Diplomatic skills and scientific literacy (in some cases also expertise) have both
become essential to the design and execution of foreign policy.
The definition of science diplomacy proposed by the American Association for the Advancement
of Science acknowledges the fact that while foreign policy decisions may be informed by scientif-
ic evidence, they are also or even more so driven by values, ethics, economics and aspirations for
leadership. Given the growing diversity of (non-State) actors and the opportunities opened up by
digitalization and social media, the playing field for science diplomacy has become increasingly
complex – just as with global health diplomacy. In view of rising geopolitical tensions and nation-
alistic tendencies, a robust set of overarching values, principles and standards is required if the
full potential of science diplomacy is to be harnessed. The Madrid Declaration on Science Diplo-
macy issued in 2019 is an ambitious response to that need.
A relatively recent development in science diplomacy is the growing number of alliances estab-
lished to promote science and innovation for global health. Two recent examples illustrate the
new types of alliances that are emerging to help the scientific community respond to major
involving them all in lengthy decision-making processes. Many alliances are created for a short
period of time in order to work towards a specific goal; others take the form of loose networks – for
example, the Geneva Global Health Hub was set up in 2016 by a group of international NGOs seek-
ing to achieve a stronger voice by working together.
Box 4: Science diplomacy meets health diplomacy: recent examples
A guide to global health diplomacy 61
health challenges. The premise is that science (like health) should be regarded as a global public
good, with fair and equitable access ensured for everyone. In order to enable all people to share
in scientific advances and their benefits, the concept of open science (open methods, open
source, open access, open data and so on) should be at the centre of diplomacy. Diplomats en-
gaged in negotiations must also respect and uphold the freedom and independence of scientists.
COVID-19: Many new alliances have been created in the wake of the COVID-19 pandemic, espe-
cially to facilitate the development of a vaccine. The Access to COVID-19 Tools (ACT) Accelerator,
for instance, is a global collaboration of organizations and governments working to speed up the
development and production of, and equitable access to, COVID-19 tests, treatments and possible
vaccines. The vaccines pillar of the ACT Accelerator, referred to as COVAX, is jointly led by Gavi,
the Vaccine Alliance; the Coalition for Epidemic Preparedness Innovations (CEPI) and the World
Health Organization (WHO). The aim of COVAX is to speed up the development and manufacture
of COVID-19 vaccines, and to ensure fair and equitable access for every country in the world. It is
a key example of multi-stakeholder diplomacy in which the Gavi Alliance, CEPI and WHO are
working together with industrial manufacturers, including those based in developing countries.
Antimicrobial resistance (AMR): In 2020, more than 20 leading pharmaceutical companies
launched the AMR Action Fund to bridge the current gap in funding for the development of new
antibiotics. The concept for the Fund was developed by the International Federation of Pharma-
ceutical Manufacturers and Associations (IFPMA), the Biopharmaceutical CEOs Roundtable, and
several major biopharmaceutical companies and foundations, in collaboration with WHO, the
European Investment Bank and the Wellcome Trust. The Fund seeks to forge partnerships with
institutions and philanthropic organizations in order to enhance and accelerate the development
of antibiotics. It will also work with governments to ensure that there is a sustainable supply of
new antibiotics.
Resources
Gavi, the Vaccine Alliance (2020). What is the COVAX pillar, why do we need it and how will it
work? [website]. (https://www.gavi.org/vaccineswork/gavi-ceo-dr-seth-berkley-explains-covax-
pillar, accessed 12 October 2020).
IFPMA (2020). The AMR Action Fund [website]. (https://www.ifpma.org/partners-2/the-amr-ac-
tion-fund/, accessed 12 October 2020).
62 Global Health Centre | February 2021
3.4 Building and managing donor and stakeholder relations
As explained in Chapter 2, much of global health diplomacy is now multi-stakeholder diplomacy. This
means that relationships must be established and maintained with a wide array of different actors
in the global health arena. Many global health organizations have special rules and requirements for
such relationship-building: WHO, for example, has the Framework of Engagement with Non-State
Actors. Multi-stakeholder diplomacy is evolving rapidly, not only as a cross-cutting strategic com-
ponent in international relations, but also in terms of the number of actors involved in global health.
Stakeholders ranging from governments, through civil society organizations and foundations, to the
private sector play an influential part at various stages and levels of global health diplomacy.
This complexity calls for a thorough analysis and assessment of the interests and needs of each
stakeholder, so that diplomats can act effectively in such diverse environments. Attention should be
paid to how the numerous stakeholders interact and manage their roles and responsibilities at the
various stages of the negotiation processes, and how they balance requirements, expectations and
accountability. Conflicts of interest must always be taken into consideration and made transparent.
All global health organizations have a special relationship with key donors, which may be countries,
other organizations or private foundations. Donors increasingly expect a coherent, accountable and
transparent collaboration between the various stakeholders before they are willing to commit any
funding. One key challenge in global health diplomacy is, therefore, explaining the rationale for
potential investments and clarifying the nature and duration of the returns on investment that are
to be expected. Investment cases are increasingly at the start of a funding negotiation. Donors can
of course also attempt to exert pressure on organizations and seek to influence their programmes
or policies. WHO in particular, because of its uneven financing (only 20% of its budget comes from
regular assessed contributions), must be careful to protect its independence. The risk of undue in-
fluence by donors (be they countries or large philanthropic organizations), along with the unpredict-
ability that overreliance can create, remains a major concern in global health.
Negotiations at a series of high-profile international conferences in the first decade of the 21st
century resulted in a significant increase in official development assistance (ODA) flows, which
benefited health funding in particular. In 2002, the International Conference on Financing for De-
velopment, held in Monterrey, Mexico, set firm targets for each donor and heralded an upturn in
ODA flows after a decade of decline. In 2005, at the Group of Eight summit held in Gleneagles,
Scotland (United Kingdom), and the Millennium + 5 Summit held at UN Headquarters, donors
made further commitments to increase the level of assistance provided. Fifteen years on, the weak-
ening of multilateralism is reflected in the greater reluctance of some developed countries to pro-
vide foreign aid (ODA) for health. While there has been a short-term resurgence in response to
A guide to global health diplomacy 63
developing countries’ needs with regard to tackling the COVID-19 pandemic, and also in connec-
tion with the quest for a vaccine, many other areas of health development have suffered a dwin-
dling of support.
Siloed approaches are very attractive to donors, but they can hamper efforts to achieve systemic
goals such as universal health coverage or improved preparedness and response capacities. Parlia-
ments in donor countries prefer to approve funds for aid programmes that pursue very specific ob-
jectives. That is why working with the Inter-Parliamentary Union to alert national parliaments to
global health priorities is a very important new development in global health diplomacy.
The Organisation for Economic Co-operation and Development (OECD) regularly provides an over-
view of government aid that promotes and specifically targets the economic development and
welfare of developing countries. The OECD Development Assistance Committee adopted ODA as
the “gold standard” of foreign aid in 1969, and to this day it remains the main source of financing
for development. The aid provided includes grants, “soft” loans and technical assistance. Soft loans
are those in which the grant element makes up at least 25% of the total. In development cooper-
ation, most ODA negotiations are concerned with bilateral aid, though countries are steadily in-
creasing their contributions to multilateral aid by providing assistance to UN system organizations,
the World Bank and specialized health agencies, such as the Gavi Alliance and the Global Fund.
Certain shifts have occurred in funding priorities: for example, Norway launched a global strategy
in November 2019 to help combat noncommunicable diseases in low-income countries, thereby
reinvigorating a neglected area of funding.
The members of the OECD Development Assistance Committee have generally accepted the target
of 0.7% of a donor’s gross national income being earmarked for ODA, even though very few have
actually achieved that target. The United Kingdom was the only large donor country to have
reached the recommended level of spending alongside a group of smaller countries such as Den-
mark, Luxembourg, Norway and Sweden, which are all fulfilling their obligations. It has though
recently decided to not exceed 0.5. The United States has recently rescinded its decision to with-
hold funding from WHO, it remains to be seen how this is reflected in ODA for health. Germany has
significantly increased its contributions to WHO. Negotiating the funding of WHO is a key area of
global health diplomacy in the years to come.
Negotiations on the funding of global health increasingly cover debt relief, loans and foreign direct
investment. That is one reason why joint meetings of health and finance ministers are critical for
global health diplomacy.
Partnerships are also negotiated with the private sector – for example, by the Gavi Alliance to en-
64 Global Health Centre | February 2021
sure that vaccines are affordable. Gavi’s predictable funding and pooling of demand have created
an incentive for the pharmaceutical industry to set up a tiered pricing policy, whereby low-income
countries are charged less than higher-income ones for the same product. Through COVAX, the
new vaccine pooling mechanism for COVID-19, the Gavi Alliance is now striving to negotiate a new
financial mechanism.
Two areas in which global health diplomacy plays a crucial role in securing funding are described
below:
Universal health coverage: Investment on a vast scale is required from the public and private
sectors to ensure equitable access to health services. On the other hand, “digital health” presents
a major economic opportunity for both sectors. Dealing with the multi-stakeholder opportunities
and risks arising from the attempt to balance economic interests and social (and global) solidarity
is a key challenge in global health diplomacy. The multi-stakeholder hearings at the UN in prepa-
ration for the High-Level Meeting on Universal Health Coverage in 2019 – modelled on the
multi-stakeholder SDG negotiations – are one example. The first-ever meeting between G20
health and finance ministers, which took place on the margins of the G20 summit in Osaka, Japan,
in June 2019, was another significant milestone (see Case Study 2 by Satoshi Ezoe, Tamar Tche-
lidze, Nathita Premabhuti, Marcelo A.C. Costa).
Replenishment of global health funds: Another significant challenge in global health diplo-
macy is the replenishment of the funds of four major financing platforms: the Global Fund to Fight
AIDS, Tuberculosis and Malaria; Gavi, the Vaccine Alliance; the Global Financing Facility for Wom-
en, Children and Adolescents; and the Global Polio Eradication Initiative. Negotiating the replen-
ishment model for financing is a particularly attractive opportunity for Heads of State and Govern-
ment to engage in prestige diplomacy. A notable example is the French campaign to secure the
replenishment of the Global Fund in 2018 and 2019. Becoming involved in such negotiations also
appeals to donors, as it gives them high visibility and enables them to reach out to many different
global health actors, such as governments, foundations, civil society and the private sector.
Resources
Health: launch of the campaign to replenish the Global Fund to Fight HIV/AIDS, Tuberculosis
and Malaria. In: France, Ministry of Europe and Foreign Affairs [website]. Paris: Ministry of
Europe and Foreign Affairs; 2018 (https://www.diplomatie.gouv.fr/en/french-foreign-policy/
development-assistance/news/2018/article/health-launch-of-the-campaign-to-replenish-the-
global-fund-to-fight-hiv-aids, accessed 14 September 2020).
A guide to global health diplomacy 65
3.5 Responding to public health crises
Crisis diplomacy has been defined as the interactions between States (and other actors) under a
heightened threat of systemic change. As global interdependence and integration increase, health
diplomacy is used more and more often in dealing with local, regional and global health crises. In
recent years the international system has been experiencing a range of crises arising mainly from
power politics, economic and strategic interests, and globalization. Global public health crises be-
long to the latter category.
Multilateral health diplomacy has been practised since the 19th century, notably during major chol-
era pandemics. However, “modern” health crisis diplomacy emerged in the early 2000s, when the
HIV epidemic, a global cross-border health threat, was placed on the agenda of the UN General As-
sembly and Security Council, notably in the Declaration of Commitment on HIV/AIDS “Global Crisis –
Global Action”, adopted on 27 June 2001 at the special session of the General Assembly on HIV/AIDS.
Multilateral cooperation and diplomacy have further helped in responding effectively to tuberculosis
and malaria, and they have paved the way for large-scale vaccination campaigns in fragile settings.
Over the past 20 years, outbreaks of avian influenza, severe acute respiratory syndrome (SARS), Mid-
dle East respiratory syndrome (MERS), Ebola and COVID-19 have posed further challenges to the in-
ternational multilateral order, international organizations and to crisis diplomacy in general.
The SARS epidemic that affected over 25 countries in 2003 served as a wake-up call for the interna-
tional system. In view of that epidemic, the revised International Health Regulations (IHR) were
negotiated and finally endorsed in 2005 as an international legally binding framework by all WHO
Member States (see also Chapter 5). In adopting the revised IHR, Member States committed to re-
porting to WHO any disease outbreaks that had the potential to become global public health threats.
Within less than 10 years, health diplomacy was confronted with the failure of countries and inter-
national agencies to respond effectively to the first outbreak of Ebola, which began in West Africa
in early 2014. Among the salient features of that crisis were: the long delay before it was recog-
nized as a public health emergency of international concern and the IHR Emergency Committee
was accordingly convened; the key role played by Médecins Sans Frontières, an NGO, in calling the
world’s attention to the crisis and organizing early interventions in the countries affected by the
epidemic; and the lack of coordination between the affected countries when taking decisions with
economic and political implications, such as the closure of national borders.
Bilateral and multilateral efforts were undertaken to support countries in their fight against the
epidemic in Africa and to prevent it from escalating into a global pandemic. The UN Secretary
General appointed a Special Envoy on Ebola, while ad hoc ambassadors were designated by a
66 Global Health Centre | February 2021
number of countries and the EU to conduct the crisis diplomacy required. The UN Security Council
adopted resolution 2177 (2014) on the Ebola outbreak and its impact in Africa and beyond. Crisis
diplomacy covered issues as diverse as multilateral and bilateral aid, border closures, the pooling
of scientific information, and the design and development of medicines and vaccines. Once the
outbreak was over, health diplomats called for a reinforcement of the IHR, the creation of a contin-
gency fund and the establishment of a global health emergency workforce (World Health Assembly
resolutions A68/22, A68/24, A68/26 and A68/27). A WHO Health Emergencies Programme was
established in 2016 at the request of the World Health Assembly. The most important lessons from
the Ebola epidemic for health crisis management were the need for countries to fulfil their obliga-
tions under the IHR effectively and the urgent necessity of empowering WHO to monitor implemen-
tation of the IHR and promoting health-related data transparency. The recent COVID-19 crisis has
made it clear that these lessons were not fully heeded.
The essential role of global health diplomacy in addressing crises
Destruction of
1. Infrastructure
and health facilities
2. Water, sanitation
and hygiene
Improved access to care
Provision of essential
healthcare through
medical diplomacy
Enhances health security
Addresses aspects of food
security, environmental
security and other aspects
of human security
Mobilizes all the global
stakeholders together
to manage the crisis
and bring peace
Brings in the required
humanitarian assistance
from the multilateral
and bilateral organizations
Increased mortality
and morbidity
(in addition to existing
burden of infectious
and chronic diseases)
Displacement camps,
migration, refugees
Economics crisis and
failure of supply chains
PANDEMICS
(COVID-19,
H1N1, Ebola)
War, Conflicts,
Climate change,
Economics crisis,
Disasters
1. Rise in communicable
and chronic diseases
and mortality
2. Increase in demand
for health services
3. Rise in malnutrition
Need for
1. International
assistance
2. Health intelligence,
real time data sharing
3. Partnerships at local,
national, regional and
global level
Global Health
Diplomacy
(applies International
norms, peace
agreements and seeks
donor assistance)
Source: Chattu & Chami (2020)
A guide to global health diplomacy 67
3.6 Improving relations between countries
through health and well-being
Soft power refers to a country’s ability to influence the actions of others without the use of force or
coercion. The use of health aid in foreign policy is a widely used soft-power strategy through which
the donor country can assert its influence. Thus, Tommy G. Thompson, former US Secretary of
Health and Human Services, argued over 15 years ago that medical diplomacy was “a way to fur-
ther America’s causes around the world” that could accomplish a lot more than the use or projec-
tion of military power (Iglehart, 2004).
Earlier initiatives such as the launching of vaccination programmes (“vaccine diplomacy”) to tack-
le childhood mortality in Central American and African countries won the United States a great deal
of trust and respect worldwide (see also Section 13.2). The United States President’s Emergency
Plan for AIDS Relief (PEPFAR) has invested over US$ 85 billion in the global response to HIV/AIDS
since its launch in 2003, the largest financial commitment by any country to tackle a single disease
in all of history. Similarly, Cuba and China have over many decades strengthened their internation-
al standing through “medical diplomacy” by sending medical personnel to developing countries
and supporting medical education. Under the Belt and Road Initiative, officially launched in 2013,
China is developing an approach referred to as the Health Silk Road (see Box 5). More recently,
China’s “mask diplomacy” in the early period of the COVID-19 pandemic attracted much attention,
especially in Europe and Latin America.
Box 5: China’s Belt and Road Initiative and its relevance to health
The Chinese Belt and Road Initiative (BRI), often also referred to as “the new Silk Road”, has
hitherto been discussed mainly in political and economic terms. Health, however, is an important
additional dimension because of the way it underlies economic development, cross-border deter-
minants and international cooperation. From the viewpoint of health diplomacy and governance,
several aspects of the BRI are noteworthy.
The projects launched under the Initiative are at the intersection of trade, economic, transport
and environmental policies. Furthermore, the overall BRI concept is strongly embedded in the
foreign, development and investment policies of the participating countries. Health has its own
interface with all the above sectors – it may thus potentially serve as a soft-power catalyst for
connecting and engaging countries.
Such important areas as communicable diseases, health security, healthy lifestyles, illegal sub-
68 Global Health Centre | February 2021
stances and road safety are bound to be affected by the increased flow of people, information,
goods and services along the Road. There will also be opportunities for expanding trade in health
products, services and technologies, establishing cross-border laboratories to enhance health
security, and founding health care hubs to attract medical tourism. Increased international coop-
eration, negotiations and diplomacy will be required to manage such emerging pressures on, and
opportunities for, cross-border health and public health in general.
Additionally, new forms of dialogue and cooperation in research and knowledge sharing are be-
ing developed. Cooperation networks for health policy research, public health and human re-
sources have been launched, as have Belt and Road hospital and university alliances. A whole
new “Health Silk Road” concept was introduced in 2017 at a high-level international meeting
with the participation of WHO – a concept that is now even more important because of the
COVID-19 pandemic. Health communication and dialogue are also likely to be enhanced by the
Digital Silk Road strategy that was launched in parallel.
Regional institutions and mechanisms supporting the BRI serve as a further key channel of health
diplomacy. This manifests itself in the public health stance adopted by political and economic
organizations that have overlapping membership with the BRI, such as the Asia Pacific Economic
Cooperation, the Shanghai Cooperation Organisation and the Eurasian Economic Union. Meet-
ings of the health ministers of China and Central and Eastern European countries, along with the
annual high-level Forums on China-Africa Health Cooperation, have further contributed to the
strengthening of health diplomacy.
Diplomacy will also be critical in managing the associated risks. Countries with weaker health
systems may find it difficult to cope with the health effects of a surge in infrastructure projects,
cross-border movement and trade – notably the spread of infectious diseases in areas with low
vaccination rates, readier supply of tobacco and unhealthy food, environmental and road safety
concerns – unless these issues are discussed properly beforehand.
The world’s changing realities – global power shifts, rising geopolitical tensions, weakening of
traditional channels of multilateralism and the COVID-19 crisis – are further accentuating the role
of health diplomacy in connection with major transnational movements such as BRI. The “vaccine
diplomacy” practised by China and other countries is a recent case in point.
Although not at the heart of the BRI, health is nevertheless an important domain that needs to be
taken into account as the Initiative advances. Health diplomacy will therefore be an integral part
of the overall diplomatic framework of the Initiative. A Health Silk Road vision may even help to
reconfigure the BRI as a whole – as may prove necessary because of the significant damage to
A guide to global health diplomacy 69
Countries were in the past often able to work together on global health challenges within the frame-
work of multilateral organizations, a case in point being the eradication of smallpox, jointly achieved
by the Soviet Union and the United States. Similarly, China and the United States both helped, to-
gether with WHO, to combat the Ebola outbreak in western Africa in 2014–2015. To cite an example
from the Middle East: the human stampede resulting in the deaths of over 2000 pilgrims during the
annual hajj to Mecca in 2015 could have escalated into a major political crisis between the Islamic
Republic of Iran and Saudi Arabia had the health ministers of both countries not successfully used
a range of soft power options. Geopolitical tensions are at present making it very difficult to tackle
common challenges through global health diplomacy, as illustrated by the COVID-19 crisis. More-
over, there is growing concern that development aid will no longer be distributed on the basis of the
SDG priorities – especially with regard to eradicating poverty and leaving no one behind – but ac-
cording to foreign policy and economic priorities, as was the case during the Cold War.
3.7 Contributing to peace and security
At the intersection of health and peace, efforts to mitigate the effects of armed conflict on health
include humanitarian ceasefires – for example, to allow immunization campaigns or other health
interventions to take place. A good example is the collaboration of UNICEF, WHO and the Roman
Catholic Church (later joined by Rotary International and the ICRC) to negotiate various ceasefires
in El Salvador from 1985 onwards, which made it possible to immunize around 300 000 children
every year. This example has often been cited in the context of “vaccine diplomacy”.
The work of WHO on health security has expanded, especially of late in the wake of the COVID-19
pandemic. The Organization’s successful efforts to tackle the Ebola epidemic in the Democratic
Republic of the Congo, which began in August 2018, were long hampered by the fact that the
outbreak occurred in a war zone. Several health workers have been killed by rebels in that region,
and health facilities and medical personnel are increasingly subject to attack in other areas of the
country affected by military conflict. Although no sustainable solutions have been found yet, it is
becoming clearer to the global health community that, in some crisis situations, cooperation with
the military can be as important as cooperation with the humanitarian sector. Armed conflicts and
the accompanying human rights abuses pose a significant challenge to both health and humanitar-
ian diplomacy (see Box 6).
economies and to the multilateral climate caused by the COVID-19 pandemic. Vaccine availability
and distribution might play a major role.
70 Global Health Centre | February 2021
A highly contentious issue in global health diplomacy is the use of embargoes and economic
sanctions, which are tools of foreign policy. They not only lead to a decline in economic activity but
often also have a significant health impact, especially on vulnerable population groups and inno-
cent civilians. Proposals have been made to find ways of ensuring that such “economic warfare” is
guided by the principles of humanitarian international law so as to mitigate the effects on civilians.
This involves monitoring the impact of sanctions, particularly with regard to water purity, food
availability and the control of infectious diseases.
Box 6: Humanitarian diplomacy and health
Humanitarian diplomacy aims to mobilize public and governmental support and resources for
humanitarian operations and programmes, and to facilitate effective partnerships for respond-
ing to challenges and meeting the needs of communities in fragile settings.
The International Federation of Red Cross and Red Crescent Societies (IFRC) is the world’s
largest humanitarian network; it helps communities worldwide to be safer and healthier and to
respond to and recover from crises more effectively. Founded in 1919, the IFRC comprises 192
National Red Cross and Red Crescent Societies and is guided by seven Fundamental Princi-
ples: humanity, impartiality, neutrality, independence, voluntary service, unity and universality.
These principles underpin the IFRC’s humanitarian diplomacy at all levels.
By engaging in humanitarian diplomacy, the IFRC is living up to a responsibility emanating
from the important role of Red Cross and Red Crescent National Societies as auxiliaries to the
public authorities in the humanitarian field. This responsibility further reflects the international
status of the IFRC and the global reach of its members’ humanitarian and development activi-
ties, carried out at the community level by over 14 million volunteers.
Humanitarian diplomacy consists of a range of activities designed to change mindsets and ul-
timately to improve the well-being and resilience of individuals and communities, particularly
the most vulnerable living in humanitarian settings. These activities include:
Profile-building: achieving widespread understanding of, and gaining the appreciation and
trust of policy-makers, partners and the public for, the role, achievements and working meth-
ods of Red Cross and Red Crescent National Societies and of the IFRC network as principled
humanitarian actors;
Public diplomacy: influencing public behaviour so that individuals and communities take the
A guide to global health diplomacy 71
steps that are available to them to safeguard their health, strengthen their resilience to crises,
and build peaceful, caring and inclusive communities free from any sort of discrimination; and
Influencing States and other actors: influencing policy-makers at the domestic, regional
and global levels to uphold, adopt or enforce new or updated decisions, laws, policies and
practices that promote the safety, well-being and resilience of vulnerable persons and enable
the work of National Societies, particularly in humanitarian settings.
Humanitarian and health diplomacy often intersect in the work of IFRC at various levels. While
diplomacy at the global level (for example, in multilateral institutions) addresses issues of glob-
al concern (such as advocating universal health coverage), humanitarian diplomacy and health
diplomacy at the national level are critical to the delivery of health programmes for the most
vulnerable through complex partnerships.
Response to the Ebola outbreak in the Democratic Republic of the Congo
Throughout the Ebola crisis in the North Kivu and Ituri provinces of the Democratic Republic of
the Congo from 2018 to 2020, the Red Cross was operating in a highly volatile environment
characterized by mistrust towards health personnel, frequent violence and targeted attacks
against front-line responders, including Red Cross volunteers.
Gaining access to and trust within various communities affected by Ebola was a long-term ef-
fort that involved regular consultations and negotiations with public authorities, local armed
groups, partners and communities.
The Red Cross of the Democratic Republic of the Congo was able to educate communities,
isolate Ebola patients, trace and monitor anyone who had come into contact with an infected
person, and provide safe and dignified burials for those killed by the disease. Many volunteers
risked their lives in the front-line response and faced violence and discrimination within their
communities. It was the trust of local communities, obtained through a combination of human-
itarian and health diplomacy, that ultimately led to the chain of transmission being broken.
72 Global Health Centre | February 2021
A guide to global health diplomacy 73
PART B:
NEGOTIATING
HEALTH IN
A MULTILATERAL
SPACE
74 Global Health Centre | February 2021
A guide to global health diplomacy 75
CHAPTER 4 | MANDATES
AND LEGITIMACY IN GLOBAL
HEALTH DIPLOMACY
4.1 Multilateralism and the legitimacy of international organizations
“Multilateralism” is the term used to describe cooperation among States: it is an approach based on
the premise that, by working together, countries can find solutions to common problems without
renouncing their sovereignty.
It was during the Paris Peace Conference of 1919–1920 that a new type of institutionalized mech-
anism was established for States to interact with one another: the universal membership organi-
zation. The first such organization was the League of Nations (founded in 1920), which was re-
placed in 1945 by the UN. After the Second World War, multilateralism became synonymous with
the liberal international order based on Western concepts of international relations – an order that
is now being increasingly challenged. Multilateralism operates through global and regional institu-
tions, norms, frameworks, summits, self-defined blocs and alliances. The rules and procedures de-
termining which actors have the mandate and legitimacy to conduct negotiations are well estab-
lished. The multilateral system is also shaped by differences between States, which have to do with
power, status, wealth and other characteristics; certain Member States exert greater influence
than others on decision-making.
As the UN celebrated its 75th anniversary in 2020, it could look back on a dramatic increase in
membership and expansion of global diplomacy institutions and activities. Membership has been
stable since 2011 at 193 sovereign States, which have equal representation in the United Nations
General Assembly.
76 Global Health Centre | February 2021
201019651945
5
11
51
5
15 15
118
193
5
Number of UN Members States
Permanent Members Security Council Seats UN Member States
UN Member States nearly quadrupled
while the number of Securit Council
selats remains almost the same.
As of September 2011
The World Health Organization is also a universal membership organization, which, as of November
2020, has 194 Member States. All of the UN Member States except Liechtenstein are WHO mem-
bers, as are the Cook Islands and Niue. A State becomes a full member of WHO by ratifying the
treaty entitled the Constitution of the World Health Organization. Membership is based on the
principle of one vote per country irrespective of a country’s size or wealth. Despite this principle,
significant power differentials do of course exist between countries in universal membership orga-
nizations, with the power balance within these being shaped by geopolitical realities. For example,
WHO’s governance and activities in the field of global health diplomacy were greatly influenced by
the long stand-off between the Soviet Union and the United States during the Cold War; the decol-
onization processes that began in the 1960s and led to the accession of many new Member States
from the Global South; the strengthening of neoliberal globalization after the Berlin Wall fell in
1989; and, most recently, by the geopolitical competition between China and the United States that
has been intensifying over the past decade.
The role played by international organizations depends on the interests and the commitment of
their Member States. However, international organizations have increasingly become actors in
their own right and begun to take the initiative in setting agendas – the MDGs and SDGs being a
prime example. Significantly, the UN’s history as an agent of multilateralism, now spanning more
than 70 years, has been accompanied by an expansion of the global diplomacy agenda beyond
peace and security to cover economic development, trade and a wide range of social issues. Multi-
lateral action has changed dramatically to include tackling poverty reduction, defending human
rights, protecting the environment and promoting health.
A guide to global health diplomacy 77
Such areas as human rights, the environment and health were at first seen as so-called low politics
(in comparison with peace and security), but they and their economic impact are now increasingly
at the forefront of concerns. The prominence of health on the political agenda and in the SDGs rests
on the legitimacy with which it has been invested by key decision-makers – a legitimacy that drives
much of global health action nowadays. This development is part of a long process of transforma-
tion of multilateralism that affects both States and international organizations – even to the extent
of reshaping them – and that has an impact on all other stakeholders, too.
Many analysts agree that the “crisis of the liberal order” has eroded the authority and legitimacy of
international organizations, leading even to outright rejection of international cooperation by some
countries. This is partly the reason why multi-stakeholder diplomacy has so gained in strength: as
States withdraw from the global arena, it becomes important for international organizations to
serve as a platform for a wide range of actors and to no longer presume that a particular area is
more important than others. International organizations are themselves fulfilling multiple functions
as actors in their own right, as platforms and as brokers. In many areas of global policy making,
including global health, diplomats need to be aware of this complex “force field” around interna-
tional organizations.
Box 7: Health and human rights
The right to health is essential to a life in dignity and the enjoyment of all other rights.
The right to health was first enunciated as such in the preamble to the Constitution of the World
Health Organization (WHO), adopted in 1946, which states that “[t]he enjoyment of the highest
attainable standard of health is one of the fundamental rights of every human being without
distinction of race, religion, political belief, economic or social condition”. The Universal Declara-
tion of Human Rights (1948) mentions health as part of the right to an adequate standard of living.
Moreover, the right to health was recognized as a human right in the International Covenant on
Economic, Social and Cultural Rights (1966).
The right to health is inclusive in that it extends to key determinants of health such as access to
safe drinking water, adequate nutrition and housing, and gender equality. It includes entitle-
ments such as the right to a system of health protection, the right to disease prevention and
treatment, and the right to access essential medicines. It also includes freedoms, such as the
right to be free from non-consensual treatment and to be free from torture and other cruel, inhu-
man or degrading treatment or punishment.
78 Global Health Centre | February 2021
The right to health and decent care is closely linked to the rights to equality before the law, priva-
cy, work and education; to the right to live in a society that upholds rights; and to the right to
benefit from the advances of science. Human rights are universal, indivisible and interrelated.
The right to health is also intimately linked to freedom from discrimination. Non-discrimination is
a key principle in human rights. Across the globe, discriminated and marginalized groups are
more likely to suffer from poor health. Discrimination on the grounds of race and ethnicity trans-
lates into people receiving less health information and accessing fewer health services. Women
are more negatively impacted by disease in many societies, because they lack influence on deci-
sion-making, including policy decisions that affect their sexual and reproductive lives, and be-
cause of gender violence and gender biases in the health system.
Stigma and discrimination remain major barriers to achieving universal access to prevention and
treatment. The American physician and WHO official Jonathan Mann (1947–1998) was among
the first to highlight the critical links between human rights and public health in the early years
of the AIDS crisis, demonstrating how gender-based violence puts women and girls at risk of HIV
infection, and how punitive laws deter sex workers, men who have sex with men, people who use
drugs and certain other population groups from accessing the services they need.
In recent years, human rights approaches and voices have become less effective in influencing
many critical debates in health. The fulfilment of the right to health is based on equitable health
systems, which are in turn embedded in social orders that ensure the protection of basic rights
and liberties for all. Such social orders have come under threat recently as there has been a sharp
rise in the manipulation of national, racial and religious identity by those wielding or seeking
political power. At the same time, medical innovation (including the development of vaccines)
and disease prevention and treatment are being increasingly determined by economic, security
and trade agendas in which the public have hardly any say. The right to truth has also been
challenged by the rise of social media platforms and the spread of disinformation. The distortion
of scientific evidence is having a direct impact on health, as may be seen, for example, in the
anti-vaccine movement.
The right to health and other health-related human rights have been enshrined in a number of in-
ternational treaties, regional instruments and national constitutions and laws. The legal empower-
ment of people, even the most marginalized, has been increasingly adopted as a strategy to combat
human rights abuses, to use the law to find concrete solutions, and to hold authorities to account.
The Global Fund to Fight AIDS, Tuberculosis and Malaria is one of several donors that currently
support specific human rights programmes aimed at advancing the sexual and reproductive health
and rights of women and girls, removing barriers to access to treatment and services, promoting
A guide to global health diplomacy 79
the meaningful engagement of vulnerable population groups in decision making, and taking hu-
man rights into account throughout the grant cycle and in policies and policy-making processes.
The most emphatic recent reassertion of the right to a minimum achievable standard of health care
is the global push for universal health coverage. But this must go hand in hand with the human
rights imperative to leave no one behind (that is, focusing on those most likely to be excluded) – a
principle that was echoed in the United Nations 2030 Agenda for Sustainable Development.
A notable recent success of global health diplomacy was the Political Declaration adopted at the
2019 United Nations High-Level Meeting on Universal Health Coverage, in which Member States
committed themselves to the implementation of universal health coverage. The Political Declara-
tion mentions sexual and reproductive rights and various vulnerable groups that should enjoy the
right to health care, namely persons with disabilities, people living with HIV/AIDS, older people,
indigenous people, refugees, internally displaced persons and migrants. The quest for universal
health coverage is a recurring topic of health diplomacy discussions at WHO.
To achieve universal health coverage and win the fight against disease, it is also necessary to win
the fight for human rights.
Resources
United Nations General Assembly (2015). Transforming our world: the 2030 Agenda for
Sustainable Development (A/RES/70/1; https://undocs.org/en/A/RES/70/1, accessed 13
November 2020).
United Nations General Assembly (2019). Political declaration of the high-level meeting on
universal health coverage (A/RES/74/2; https://undocs.org/en/A/RES/74/2, accessed 13
November 2020).
4.2 The importance of legitimacy
Former US Secretary of State Henry Kissinger once defined diplomacy as “a specific method for
compromise and consensus, and a system of organization – within a legitimate international order”.
In both international affairs and domestic politics, a mandate is the authority granted by a constit-
uency to an organization to act as its representative. For example, Member States provide WHO
with the authority to act on their behalf. It is from this mandate that WHO in the first instance de-
80 Global Health Centre | February 2021
rives its legitimacy. However, legitimacy also depends on the perception among both constituents
and observers that this authority is being exercised appropriately. Ever since its inception, multilat-
eral diplomacy has set itself apart from the often-secretive diplomacy of the past through a com-
mitment to transparency, modelled on parliamentary practice.
Formal legitimacy no longer tends to be sufficient to justify a system of governance: moral legitima-
cy and results-based legitimacy are playing an ever more important role, especially in global health.
For multilateral organizations, legitimacy is critical because it:
Æ
determines whether they continue to be the main platform for States’ efforts to coordinate
policies and solve problems;
Æ
affects their capability to develop new rules and norms that are accepted broadly; and
Æ
has a bearing on their ability to ensure compliance with international rules and norms.
Legitimacy is also related to fundamental normative concerns: if international organizations and
their processes lack legitimacy in society, this contributes to a sense of democratic deficit and a lack
of trust in global governance. It is necessary to think about what actually constitutes legitimacy, es-
pecially in the age of social media, in which moral legitimacy is so important. In this context, a new
type of legitimacy is derived from the representation and involvement of a large number of stake-
holders. Legitimacy is undermined if an organization does not reflect the diversity of its constituency
– for example, if it fails to recruit more women and professionals from the Global South, also for senior
positions. Because of the ongoing shifts in global power, fair and just negotiations are now prereq-
uisites for reaching international agreement and ensuring effective follow-up on commitments.
Another key issue is the level of independence and authority granted to an organization by its
members. For example, there are increasing calls for WHO to be granted a stronger mandate by its
Member States, especially in relation to health security. The decision-making procedures of inter-
national organizations – including those active in global health diplomacy – are continually being
questioned, as are their transparency and representativeness. While such questioning is necessary,
it can also have a corrosive effect on the legitimacy of organizations and thwart processes seeking
to put multi-stakeholder diplomacy into practice.
Finally, it is important to keep in mind that organizations themselves confer legitimacy: working
with highly respected organizations results in a bonus in trust for their partners, which is why close
attention needs to be paid to the building of partnerships.
A guide to global health diplomacy 81
4.3 Legitimacy and sovereignty of States
Diplomacy existed long before the present understanding of sovereign States emerged. The prac-
tice of diplomacy in the modern international system, however, builds on the concept of State
sovereignty that was promoted in Europe in the 17th century (also referred to as Westphalian
sovereignty, from the Peace of Westphalia, which ended the Thirty Years’ War in 1648). According
to this principle of international law, which is enshrined in the Charter of the United Nations, each
State has exclusive sovereignty over its territory. Moreover, every State, no matter how large or
small, has an equal right to sovereignty. The UN Charter also lays down the principle of non inter-
vention (exclusive sovereignty).
These two principles have been challenged in recent years by the UN’s promotion of a further
principle of international law, namely, the “responsibility to protect”, which provides for humanitar-
ian interventions by the international community. The extent to which public health crises fall under
the scope of the principle of responsibility to protect has yet to be clarified. This principle has
proved powerless in the face of prolonged conflict and geopolitical stand-offs. Its weakness also
reflects the ever-greater difficulties in reaching agreement at the UN Security Council and the ur-
gent need for reform of the Security Council.
Globalization processes have led to transformations that weaken sovereignty. For example, the
activities of transnational companies and global capital flows, but also development strategies,
have made poorer countries dependent on donors and caused them to incur significant levels of
debt. Of particular relevance for global health diplomacy is the fact that successive waves of glo-
balization have shown that States cannot cope on their own with emerging global threats, such as
environmental pollution or pandemics. This has led to new forms of diplomacy, with countries
sharing a common interest coming together to engage in issue diplomacy. Indeed, issue diplomacy
was at the origin of multilateral health negotiations in the 19th century during the first major wave
of globalization. Thus, the first two international sanitary conferences in the 1850s were concerned
with standardizing international quarantine regulations so as to combat the spread of cholera,
plague and yellow fever.
The tension between national sovereignty and global welfare continues to characterize many global
health negotiations and has proven to be one of the reasons for key shortcomings of the Internation-
al Health Regulations and the Paris Agreement on Climate Change. Analysts argue that there are no
real grounds for such tension: the concept of “smart sovereignty” implies that in policy areas where
interdependence features prominently it is in countries’ enlightened self-interest to cooperate.
Growing concerns have been raised over the unequal power relations in global health and global
82 Global Health Centre | February 2021
health diplomacy, in particular over the lack of influence of countries and other actors from the
Global South. Considerable power is wielded by the wealthier countries that provide large part of
the funds for the global health system and are therefore able to influence negotiation outcomes to
their own advantage and to the detriment of poorer countries. This has been observed in studies of
the impact of trade negotiations on health.
The influence of large philanthropic organizations – often termed “philantrocapitalism” – has like-
wise attracted criticism, as these often borrow such concepts from for-profit organizations as “in-
vestors”, “investment cases” and “social returns”. Criticisms are also levelled against the model of
economic growth that has made possible their extraordinary wealth.
Recent critiques of power structures and relations in global health have invoked the concept of
neocolonialism and called for a “decolonialization” of global health (see Box 3 in Chapter 2). The
proponents of such arguments point to the “Washington Consensus” era of the 1990s, when the
International Monetary Fund and the World Bank were making loan agreements subject to unnec-
essarily strict criteria, leading to a drastic reduction in health and social spending in debtor coun-
tries and, thereby, exacerbating social and economic inequalities. Offering aid to countries in ex-
change for their agreeing to introduce austerity measures, it is argued, is simply a manifestation of
colonialism in a new guise. It is also pointed out how market- and target-driven family planning
policies have infringed on the sexual and reproductive health rights of vulnerable women. Accord-
ingly, such commentators call for a decolonization process based on reclaiming space and advanc-
ing alternative visions. Another focus of criticism is the underrepresentation of women in global
health and global health diplomacy (see Box 8).
Box 8: Women as global health diplomats
At the start of 2020, only 6% of Heads of Government worldwide (12 countries) were led by wom-
en and only 25% of parliamentarians were female. There were only 47 female ministers of health
(representing 25% of 190 countries). Although women make up half of the world’s population,
they do not have an equal say in political decisions on the development and financing of health
systems in the vast majority of countries.
Much the same picture may be observed in global health diplomacy. Since invitations to special
sessions of the United Nations General Assembly and United Nations high-level meetings are
made to Heads of State and Government, women are necessarily in a small minority during nego-
tiations on health at the highest level. Similarly, analysis shows that the share of heads of dele-
gation to the annual World Health Assembly who are women has remained persistently low. Af-
A guide to global health diplomacy 83
ter peaking at 31% in 2017, it fell to 23% in 2020. Women make up just 25% of the heads of
global health organizations and 25% of the chairs of the boards of those organizations. Women
from low-and middle-income countries are particularly underrepresented in health diplomacy at
the global level.
These trends are striking, particularly when contrasted with the fact that women make up 75% of
the health workforce and, globally, account for 90% of nurses and midwives – the biggest single
health worker cadre. Women are the experts in the areas of health they know best, but their skills
and knowledge have not guaranteed them equality in global health diplomacy.
This pattern also manifested itself in 2020 with regard to decision-making during the COVID-19
pandemic. Although women work at all levels in health security—from the front lines of health
services to research facilities and health policy-making – they have not been represented equally
in global or national decision-making bodies dealing with the pandemic. In January 2020, just
five women were invited to join the 21-member emergency committee on the novel coronavirus
established by the World Health Organization. Only two of the 27 members of the White House
Coronavirus Task Force in the United States are women. In over 80% of national task forces on
COVID-19, men are in the majority. Even in health emergencies, women are expected to deliver
front-line services, while it is men who generally make the decisions.
Including women in equal numbers in health leadership and diplomacy – and, in particular, wom-
en from diverse social groups and geographical regions – is about effectiveness and saving lives,
as well as representation. The invaluable perspectives that women are able to bring, drawing on
their expertise and experience, are currently being lost; decision-makers are not being selected
from the whole talent pool. Diverse leadership groups make better-informed decisions, and it can-
not be denied that global health diplomacy is undermined by the underrepresentation of women.
Resources
See the section entitled “Publications on Women as global health diplomats” in Annex 2
84 Global Health Centre | February 2021
A guide to global health diplomacy 85
CHAPTER 5 | KEY GLOBAL
HEALTH INSTRUMENTS
5.1 Introduction to global health instruments
Global health instruments make up a key domain of global health. Indeed, setting up institutions
and mechanisms to promote global health cooperation is not enough: collectively agreed instru-
ments are necessary so that such cooperation can be carried out in practice. These instruments
derive from multilateral diplomacy and negotiations taking place on various political platforms.
Internationally agreed instruments are not a new phenomenon in public health. The first interna-
tional sanitary conventions were adopted as early as the 1890s, and they were revised and updated
throughout the first half of the 20th century.
The establishment of WHO in 1948 further accelerated the adoption of multilateral health instru-
ments: their scope was extended, and they achieved truly global coverage. As part of this process,
the earlier international sanitary conventions were replaced by the WHO International Health Reg-
ulations, the first version of which was issued in 1969.
Moreover, several international instruments adopted under the aegis of other multilateral institu-
tions – for example, trade and environmental treaties – have a significant impact on health, even
though health is not their primary objective.
Multilateral instruments for health can be grouped into the following broad categories:
Æ
pre-WHO, WHO or external to WHO
Æ
regional or global
In view of its scope, this Guide focuses on the categories shown in bold above.
5.2 Instruments adopted by the World Health Organization
The World Health Assembly, which is the principal governing body of WHO, can adopt the following
86 Global Health Centre | February 2021
types of normative instrument: recommendations (in line with Article 23 of the WHO Constitution),
regulations (in line with Article 21) and conventions or agreements (in line with Article 19).
Recommendations can be on any matter within the competence of WHO. They are normally drawn
up as, or approved through, resolutions and decisions of the World Health Assembly and take var-
ious forms, including codes of practice, strategies, frameworks and action plans. Some notable
examples are the Global Code of Practice on the International Recruitment of Health Personnel
(2010); the Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Proper-
ty (2008); the Recommendations on the Marketing of Foods and Non-Alcoholic Beverages to Chil-
dren (2010); the Framework on Integrated People-Centred Health Services (2016); and the Global
Action Plan on Physical Activity (2018).
Regulations, in contrast, can be adopted on certain matters only, as listed in Article 21 of the WHO
Constitution (namely, on sanitary and quarantine requirements, nomenclatures, standards and pro-
cedures). Indeed, WHO has adopted only two sets of regulations so far: the International Health
Regulations (1969; most recently revised in 2005), which are aimed at preventing, controlling and
providing a public health response to the international spread of disease; and the less well-known
Nomenclature Regulations (1967), which require countries to compile mortality and morbidity statis-
tics in line with the International Statistical Classification of Diseases, Injuries and Causes of Death.
Conventions and agreements (often also referred to as treaties) can be adopted on any matter
falling under the competence of WHO. However, WHO has so far used its constitutional power to
adopt a global health treaty only once, namely when the Framework Convention on Tobacco Con-
trol was adopted in 2003 (it entered into force in 2005). The Parties to the Convention subsequent-
ly negotiated and adopted the Protocol to Eliminate Illicit Trade in Tobacco Products, a new treaty
in its own right, which entered into force in 2018.
Article 19 of the WHO Constitution
The Health Assembly shall have authority to adopt conventions or agreements with respect to any
matter within the competence of the Organization. A two-thirds vote of the Health Assembly shall
be required for the adoption of such conventions or agreements, which shall come into force for
each Member when accepted by it in accordance with its constitutional processes.
A guide to global health diplomacy 87
5.3 The legal status of WHO instruments
Only regulations and conventions are legally binding. Accordingly, they are often referred to as
“hard law”. They create binding obligations under international law and are thus generally consid-
ered to be the strongest instruments in terms of global application and impact.
Recommendations, in contrast, are legally non-binding; they are often referred to as “soft law”.
However, soft instruments do generally also carry significant normative and political weight and
can have a substantial impact on public health. Despite not having binding legal force, they are
expected to be universally respected and implemented because countries are interdependent and
have to work together to tackle global health challenges. In addition, recommendations usually
enable a quicker response to evolving challenges than legally binding instruments, which are more
laborious to negotiate, adopt and bring into force. In a few rare cases recommendations may also
contain some compulsory measures, such as the Pandemic Influenza Preparedness Framework
adopted in 2011.
5.4 Entry into force of WHO instruments
Recommendations do not require a formal process or a specific timeline for entry into force: they
become effective once adopted.
Regulations come into force for all WHO Member States after a jointly agreed period of time – it
was, for example, 24 months in the case of the International Health Regulations (2005) – although
Member States are entitled to notify the WHO Secretariat of their rejection of the new regulations
or to submit their reservations, as long as they do so by an agreed deadline. In other words, regu-
lations come into force simultaneously for all WHO Member States (except those opting out); it is
not necessary for each Member State to ratify them individually.
Conventions, in contrast, do require formal ratification by individual countries. Accordingly, they
enter into force after an agreed number of ratifications has been reached: for example, 40 ratifica-
tions were required in the case of the Framework Convention on Tobacco Control. As far as the
remaining countries (and regional economic integration organizations where applicable) are con-
cerned, the convention enters into force separately for each country following that country’s ratifi-
cation (or acceptance, approval or accession in some legal systems).
88 Global Health Centre | February 2021
5.5 Proposals for new WHO conventions
The Framework Convention on Tobacco Control (FCTC) to this day remains the only convention ad-
opted under the auspices of WHO. The question as to why no further conventions have followed –
or at least been attempted – has often been discussed among policy makers and experts. One
common explanation is that the negotiations for and adoption of the FCTC coincided with the so
called golden era of global health in the late 20th and early 21st centuries, and that multilateralism
has generally been in decline since then. Some experts have also argued that, given the over-
whelming evidence of the devastating effects of tobacco and growing awareness of the inadequa-
cy of national measures to tackle a major global epidemic – which had been aggravated by global-
ization, trade liberalization and the aggressive tactics of the transnational tobacco industry – there
was no choice other than to agree on a legally binding treaty.
Over the years, proposals have been made for new WHO conventions covering such areas as non-
communicable diseases, nutrition, alcohol, air pollution, antimicrobial resistance, falsified/substan-
dard medicines, and R&D, and pandemics. The idea of a more general “framework convention on
global health” has also been mooted. However, no formal processes or negotiations on a new
convention covering any of these areas have been initiated yet. Among the reasons for this state of
affairs are the potential duration and costs of treaty negotiations; concerns about enforceability;
sensitivities regarding the sovereignty of national decisions vis-à-vis international obligations; the
more nuanced nature of some health determinants, such as diet, compared with the black and
white case of tobacco; the potential divergence of national health and economic interests; issues
of compatibility with other international agreements; and trade-offs between the legal power of
treaties and the pragmatism of “softer” instruments. It remains to be seen whether WHO will em-
bark on a new treaty-making process at some point in the future – possibly in the area of health
security, as some have called for in the light of the COVID-19 pandemic.
The following general criteria should be applied when deciding whether a specific problem could
be covered by a future global health treaty: (a) the problem should be of a global and growing
magnitude; (b) transnational factors play a dominant role; and (c) the existing instruments have
proved inadequate to tackle the problem.
5.6 Instruments adopted outside WHO
Several conventions adopted outside WHO have a significant influence on health, although their
main objectives are not related to health. Most of them were negotiated and adopted within the
UN system; some by other international organizations (such as the WTO).
A guide to global health diplomacy 89
Examples in the area of the environment include the Basel, Rotterdam and Stockholm Conven-
tions,
12
the United Nations Framework Convention on Climate Change (UNFCCC) (entered into force
in 1994) and the more recent Minamata Convention on Mercury (2017); in international trade, the
WTO Agreement on Technical Barriers to Trade (1995), the TRIPS Agreement (1995) and the WTO
Agreement on the Application of Sanitary and Phytosanitary Measures (1995); and in human rights,
the International Covenant on Economic, Social and Cultural Rights (1976) and the Convention on
the Rights of Persons with Disabilities (2008). Other relevant examples are the conventions cover-
ing biological and chemical weapons
13
and the Single Convention on Narcotic Drugs of 1961 (en-
tered into force in 1964). The Single Convention is particularly notable for enshrining a statutory
review role for WHO as part of its implementation.
However, conventions are not the only form of non-WHO instruments that may have a health im-
pact. States often adopt other prominent instruments covering global health issues, such as decla-
rations and agreed goals and mechanisms. Despite being legally non-binding, these instruments do
carry political weight and are in general widely implemented. The Sustainable Development Goals
(2015), in which health occupies a key role, are a case in point. Another notable example is the se-
ries of political declarations and resolutions adopted by the UN General Assembly on global health
and foreign policy (from 2008 onwards), noncommunicable diseases (2011, 2018), antimicrobial
resistance (2016), tuberculosis (2018) and universal health coverage (2019). In 2006 and 2008 there
were high-level meetings of the General Assembly on HIV/AIDS. In a few cases, issues with imme-
diate relevance for international security (such as HIV/AIDS, polio and Ebola) have been considered
by the UN Security Council. Similarly, political declarations by the Heads of State and Government
of the G7 and the G20 have proved to exercise significant influence over the global health agenda.
Another category of instruments that are not exclusively WHO instruments are those issued jointly
by WHO and other international agencies. Notable examples include the Codex Alimentarius com-
pendium of food standards, guidelines and codes issued under the Joint WHO/FAO Food Standards
Programme; the WHO–FAO–OIE tripartite framework on antimicrobial resistance;
14
and, most re-
cently, the Global Action Plan for Healthy Lives and Well-being for All, which was launched by 12
multilateral agencies in 2018, led by WHO. Such instruments represent an additional layer in glob-
12 Basel Convention on the Control of Transboundary Movements of Hazardous Waste and Their Disposal (entered into force in
1992); Rotterdam Convention on the Prior Informed Consent Procedure for Certain Hazardous Chemicals and Pesticides in
International Trade (2004); Stockholm Convention on Persistent Organic Pollutants (2004).
13 Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin
Weapons and on Their Destruction (entered into force in 1975); Convention on the Prohibition of the Development, Production,
Stockpiling and Use of Chemical Weapons and on Their Destruction (1997).
14 Global Framework for Development and Stewardship to Combat Antimicrobial Resistance initiated in 2017 by WHO, FAO and
the World Organisation for Animal Health (OIE).
90 Global Health Centre | February 2021
al health negotiations – specifically, they are the fruit of negotiations where the cultures and en-
gagement strategies of sometimes very different organizations have been reconciled in order to
achieve a common goal.
Box 9: Negotiating health at the World Trade Organization
The overriding objective of the World Trade Organization (WTO) is to help trade to flow smoothly,
freely and predictably, supported by a rules-based, inclusive international trading system that
benefits all its members. The WTO provides a common institutional framework for the conduct of
trade relations among its members in matters related to trade in goods and services and to
trade-related intellectual property rights. In addition to operating a global system of trade rules,
the WTO serves as a forum for negotiating trade agreements, settles trade disputes between its
members, and it supports the needs of developing countries.
The WTO has 164 members, which together account for 98% of world trade. A total of 23 coun-
tries are in the process of acceding to the Organization. Both negotiations and decision-making
at the WTO are member-driven processes. The WTO Secretariat conducts activities that are in-
strumental to the functioning of the system, including maintaining regular dialogue with
non-governmental organizations and other international organizations, coordinating activities
and preparing reports such as the Trade Policy Reviews.
What are the core functions of the WTO?
Article III of the Marrakesh Agreement Establishing the World Trade Organization lists five core
functions:
Æ
Facilitating the implementation, administration and operation of WTO trade agreements;
Æ
Providing a forum for trade negotiations;
Æ
Handling trade disputes;
Æ
Monitoring members’ trade policies; and
Æ
Cooperating with other international organizations.
In addition, the WTO supports developing and least developed countries through technical assis-
tance and training so that they are able to build their capacity to engage in trade, to handle dis-
putes and to implement technical standards.
Decision-making at the WTO
Decisions are made by the entire membership by consensus. A majority vote is also possible on
A guide to global health diplomacy 91
the basis of one vote per member, but such a procedure has never been used at the WTO as yet;
it was extremely rare under the Organization’s predecessor, the General Agreement on Tariffs
and Trade (GATT).
The WTO’s top-level decision-making body is the Ministerial Conference, which meets usually
every two years. The Ministerial Conference can take decisions on all matters under any of the
multilateral trade agreements. The General Council acts on behalf of the Ministerial Conference
on all WTO affairs. It meets as the Dispute Settlement Body and the Trade Policy Review Body to
oversee procedures for settling disputes between members and to analyse members’ trade poli-
cies, respectively. All WTO members are represented in three councils, the Council for Trade in
Goods, the Council for Trade in Services and the Council for Trade-Related Aspects of Intellectual
Property Rights (TRIPS Council), which are responsible for facilitating the operation of the WTO
agreements covering their respective areas of trade.
Numerous specialized WTO bodies (committees, working groups and working parties) deal with
the individual agreements and other areas, such as the environment, development, accessions
and regional trade agreements. Subsidiary bodies dealing with the plurilateral multi-stakeholder
agreements (not signed by all WTO members) on trade in civil aircraft and government procure-
ment also report regularly to the General Council on their activities.
Where are the WTO negotiating rules to be found?
Most of the WTO agreements are the result of the 1986–1994 Uruguay Round negotiations and
were signed at the Marrakesh Ministerial Meeting in April 1994. These agreements are not static:
they can be renegotiated from time to time. New agreements can also be added, and WTO bodies
may adopt decisions or guidelines. Accordingly, negotiations have led to the adoption of a num-
ber of additional legal texts since 1994, including the 2005 Protocol amending the Agreement on
Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement), intended to enable the
manufacture of affordable generic medicines under compulsory licence for export to countries
with insufficient or no manufacturing capacities; and the 2013 Agreement on Trade Facilitation,
which aims to reduce border delays by slashing red tape. New negotiations were launched at the
Doha Ministerial Conference in November 2001. They are taking place at the Trade Negotiations
Committee and within specific negotiating groups.
Health-related issues at the WTO
Health-related work at the WTO covers numerous areas, such as tariffs, import licensing proce-
dures, regulatory issues, intellectual property rights, government procurement, trade in services
and trade facilitation, to name but a few. While WTO disciplines influence the public health-relat-
ed policies, strategies and laws of WTO members, the rules were designed to take into account
92 Global Health Centre | February 2021
WTO members’ obligation to protect public health. WTO members have stressed the need for a
positive, mutually reinforcing link between public health and the global trading system. Thus, the
2001 Doha Declaration on the TRIPS Agreement and Public Health recognized the gravity of the
public health problems faced by many developing countries and least developed countries – in
particular those arising from HIV/AIDS, tuberculosis, malaria and other epidemics – and called for
the TRIPS Agreement to be part of national and international efforts to tackle these problems.
Various aspects of trade that may have an impact on health policies are regularly considered by
the competent WTO bodies. At the TRIPS Council, for example, members have discussed the im-
portance of intellectual property rights for the development of new pharmaceutical products and
the role of TRIPS flexibilities in facilitating access to affordable medicines. Moreover, members
regularly review the functioning of the system that permits the granting of special compulsory
licences exclusively for the export of medicines (Article 31bis of the amended TRIPS Agreement).
They also review health-related intellectual property laws or regulations that have been notified
to the TRIPS Council.
The Committee on Technical Barriers to Trade (TBT Committee) and the Committee on Sanitary
and Phytosanitary Measures (SPS Committee) are key WTO bodies in the context of health poli-
cies that affect trade. A wide range of domestic health-related policies, standards and regula-
tions prepared and adopted by governments are collectively discussed at these committees. Both
the Agreement on Technical Barriers to Trade (TBT Agreement) and the Agreement on the Appli-
cation of Sanitary and Phytosanitary Measures (SPS Agreement) encourage members to base
their measures on international standards. The TBT and SPS Committees receive for consider-
ation many of the health-related trade measures notified by members to the WTO. Both commit-
tees frequently negotiate and adopt general guidance for members on how to enhance imple-
mentation of the TBT and SPS Agreements. Much of this guidance, in particular that adopted by
the SPS Committee, has a direct bearing on some human health-related issues as well as on an-
imal and plant health.
Import licensing procedures (such as licences, permits, authorizations and other procedures re-
quiring the submission of an application to a competent authority as a prior condition for importa-
tion) are used by many members for health policy reasons and are reviewed by the Committee on
Import Licensing. In addition, two sectoral initiatives have provided for the elimination of import
duties on certain health products. The Agreement on Trade in Pharmaceutical Products (Pharma-
ceutical Agreement) covers pharmaceutical products, including the chemical components and
active ingredients used in their production. Negotiated during the Uruguay Round by a number of
members, it eliminated tariffs on these products. The product coverage of the Pharmaceutical
Agreement is subject to periodic reviews in order to ensure that it remains up to date. In 2015, 24
A guide to global health diplomacy 93
participants (including the European Union) agreed on an expansion of the Information Technolo-
gy Agreement (ITA) to provide for the elimination of tariffs on a number of high-technology prod-
ucts, including medical equipment, such as scanners, machines for magnetic resonance imaging,
tomography, dental care and ophthalmology. By 2020 the ITA Expansion Agreement had 26 par-
ticipants covering 55 WTO members that together account for approximately 90% of world trade
in these products. In addition to the elimination of import duties, the ITA Committee is also en-
gaged in efforts to eliminate non-tariff barriers to international trade in those products.
Although only a few market access commitments have been made by WTO members in the area
of health to date, trade in health-related services is covered by the General Agreement on Trade
in Services. During discussions at the Council for Trade in Services, members have considered the
various ways in which health services are delivered, such as e-health, the provision of medical
treatment abroad, foreign investment in the health sector, and certain aspects of the cross-border
movement of health professionals.
Health-related discussions at council and committee meetings can be complementary. For in-
stance, proposals on plain packaging measures for tobacco were initially discussed at both the
TRIPS Council and TBT Committee before they were moved on to the dispute settlement stage.
Furthermore, a number of international bodies (including those in charge of setting health related
international standards) and intergovernmental organizations (such as the World Health Organiza-
tion (WHO)) regularly participate in health-related discussions at meetings of various WTO entities.
The WTO and other organizations
The WTO works with other intergovernmental organizations under the banner of “coherence”, a
term originating in the Ministerial Declaration on the Contribution of the World Trade Organiza-
tion to Achieving Greater Coherence in Global Economic Policymaking, adopted in Marrakesh in
April 1994. Indeed, it is now recognized that the WTO system is just one part of a much broader
framework of international rights and obligations that WTO members must uphold and fulfil.
The WTO’s work on issues relating to public health, trade and intellectual property rights is com-
plementary to that of WHO and the World Intellectual Property Organization, in particular. To-
gether, these organizations share a responsibility to strengthen dialogue on practical matters –
both among themselves and with other partners – in order to fulfil their mandates more
effectively, to ensure the efficient use of resources for technical cooperation and to avoid the
duplication of efforts. In particular, the Doha Declaration on the TRIPS Agreement and Public
Health has served as a catalyst for intensifying collaboration and developing coherence at the
international level.
94 Global Health Centre | February 2021
5.7 Steps after the adoption of instruments
Instruments, once adopted, often require further negotiations, diplomacy and governance deci-
sions if they are to be implemented effectively. This is particularly true of conventions. They normal-
ly require a great deal of multisectoral diplomacy and political compromises in the process culmi-
nating in ratification by a State party’s national parliament; they often also require new types of
governance body (such as a conference of the parties) and mechanisms (such as intergovernmen-
tally agreed guidelines on the implementation of specific legal provisions) to be established, lead-
ing to further multilateral diplomacy and negotiations once the treaty is in force.
The process for amending adopted instruments may also involve a fresh round of multilateral nego-
tiations. Legal instruments do usually provide for revisions and amendments to be made under
certain conditions. The FCTC, for example, allows for amendments to be adopted by a three quar-
ters majority vote in the Conference of the Parties, further subject to ratification or acceptance by
each individual Party. The International Health Regulations, first adopted in 1969, were later re-
vised and amended in 1973, 1981 and 2005. Global health crises of particular magnitude may often
trigger such changes. The last revision of the IHR, for example, although already in progress in the
late 1990s, gained in momentum following the SARS outbreak in 2002–2004, the first global public
health emergency of the 21st century. Some 15 years later, the COVID-19 pandemic has sparked
worldwide discussions on whether the IHR in their 2005 version are adequate for dealing with
global crises of such magnitude. A World Health Assembly resolution adopted in 2020 called for an
independent evaluation of the functioning of the IHR as part of a broader review of the global re-
sponse to the pandemic.
The WTO also cooperates on health-related topics with a number of other intergovernmental or-
ganizations, including the World Organisation for Animal Health, the FAO/WHO Codex Alimenta-
rius Commission, the United Nations Conference on Trade and Development, and the World
Customs Organization.
A guide to global health diplomacy 95
CHAPTER 6 | KEY GLOBAL
VENUES AND ACTORS
6.1 The World Health Organization and the changing field of global health
The World Health Organization is the key venue for global health negotiations. An intergovernmen-
tal organization in which all decision-making power is vested in its Member States, WHO is the
United Nations specialized agency tasked with coordinating and steering global health efforts. In its
early years, WHO dealt mainly with State actors, that is the ministries of health and ministries of
foreign affairs, often through States’ diplomatic representations in Geneva and, especially in later
years, the health attachés based there. The latter are a mixture of representatives of States’ foreign
and health ministries. The Member States are the key actors at WHO: it is they that govern the Or-
ganization and negotiate major agreements. However, as the global health landscape has become
more and more complex, WHO has had to reconsider its relationship with a wide range of actors.
Accordingly, WHO has adopted a policy on its relationship with non-State actors in line with its
constitutional mandate: the Framework of Engagement with Non-State Actors (FENSA), which was
approved at the Sixty-ninth session of the World Health Assembly in May 2016. The Framework
seeks to strengthen WHO’s engagement with non-State actors, including NGOs, private sector
entities, philanthropic foundations and academic institutions. At the same time, the Framework is
meant to protect WHO and its work from potential risks, such as conflicts of interest, reputational
risks and undue influence.
Non-State actors are not involved formally in global health negotiations at the WHO governing
bodies, but they attend consultations and are often asked to provide input and comments. They
come to Geneva on occasion of the meetings of the WHO governing bodies (that is, the World
Health Assembly and the Executive Board) in order to engage in advocacy, hold informal discus-
sions with negotiators and – if in official relations with WHO – to give statements at the meetings
of the governing bodies. Such participation can seem like a pro forma gesture at best, particularly
in comparison to other parts of the UN system. The WHO Constitution, FENSA and the Rules of
Procedure of the World Health Assembly lay down the type of engagement which the various ac-
tors may have. The WHO leadership is committed to a more open approach, and the present Direc-
tor-General reaches out to civil society more extensively than many of his predecessors. Yet, the
Organization’s culture as a whole often seems somewhat “closed” and risk-averse. Creative think-
96 Global Health Centre | February 2021
ing should be applied by all the stakeholders so that they can make the most of the opportunities
that arise and develop new mechanisms for interaction where possible.
There is a special category of actors with which WHO works together more closely: the non State
actors in official relations with WHO. Official relations are a privilege that the Executive Board
may grant to NGOs, international business associations and philanthropic foundations that have
had and continue to have “a sustained and systematic engagement in the interest of the Organiza-
tion”. The aims and activities of these entities must be in conformity with the spirit, purpose and
principles of the WHO Constitution, and they are expected to contribute significantly to the ad-
vancement of public health. WHO is in the process of compiling a register of non-State actors de-
tailing, among other things, their type of engagement with the Organization. There is considerable
scope for further increasing the engagement and involvement of non-State actors in WHO’s work.
During the COVID-19 pandemic it became clear that new forms of cooperation must be found, in
particular with the science and digital technology sectors.
Global health is now one of the most prominent areas of multi-stakeholder diplomacy. This type of
diplomacy encompasses a remarkably wide range of initiatives and institutions: international orga-
nizations, national sectors and agencies, development banks, civil society, private industry, philan-
thropic and academic institutions, professional associations, and dedicated – and sometimes also
very powerful – individuals. By including many stakeholders in the SDG negotiations and adopting
Goal 17 on partnerships, the UN gave multi-stakeholder diplomacy a high degree of legitimacy. In
the field of global health, in particular, many hybrid organizations have been created, along with
alliances and initiatives that derive their legitimacy from the representation and involvement of a
large number of stakeholders, on the one hand, and from a focus on results, on the other.
HANDBOOK
FOR NON‑STATE
ACTORS ON
ENGAGEMENT
WITH THE
WORLD HEALTH
ORGANIZATION
A guide to global health diplomacy 97
It is important to note that the decision-making processes in the World Health Assembly and the
UN General Assembly are quite different. While voting is not used that much at the former, it is
employed in the latter for agenda items that are highly political or sensitive, such as nuclear weap-
ons. In the past, health-related General Assembly resolutions have usually been adopted without a
vote, yet, significantly, a vote had to be called on the most recent resolutions in September 2020 on
the response to the COVID-19 pandemic (A/RES/74/306 and A/RES/74/307). Moreover, Member
States are increasingly “disassociating” themselves from sections of a resolution or declaration. An
example is the US Government’s disassociation from World Health Assembly resolution WHA73/1
on the COVID-19 response.
15
6.2 Other international health organizations and entities
Global health diplomacy is characterized by the many innovative features and approaches that have
been developed throughout its history. About 20 years ago, a new set of health organizations with
very different governing structures began to emerge. The first was UNAIDS – the only co-sponsored
joint programme in the UN system – whose work is steered by a multi-stakeholder Programme Coor-
dinating Board comprising representatives of 22 governments from all geographical regions; the UN-
AIDS Cosponsors; and five representatives of NGOs, including associations of people living with HIV.
Similarly, Gavi, the Vaccine Alliance (a foundation) and the Global Fund to Fight AIDS, Tuberculosis
and Malaria (a partnership) are both governed by boards featuring representatives from countries, the
private sector, civil society and other international organizations. The Gavi Board also includes indepen-
dent, or “unaffiliated”, individuals. The Board of the Global Fund has 20 voting seats, with equal repre-
sentation for implementers and donors, including NGOs; communities affected by HIV, tuberculosis
and malaria; the private sector; and private foundations. In addition, there are eight non-voting mem-
bers, including the Chair and Vice-Chair of the Board; representatives of partner organizations such as
WHO and the World Bank; and the Additional Public Donors constituency (see Box 10 and Box 11).
15 See: https://geneva.usmission.gov/2020/05/19/explanation-of-position-covid-19-response-resolution/
Box 10: The governance model of Gavi, the Vaccine Alliance
Gavi, the Vaccine Alliance (formerly the Global Alliance for Vaccine and Immunization, hence the
acronym), is an international organization established in 2000 to provide affordable and accessi-
ble vaccines for children in the developing world. Today, the Gavi Alliance is one of the most im-
portant actors in global health governance.
98 Global Health Centre | February 2021
The Gavi Board has 28 seats in total; there are both permanent and time-limited seats. Board
members are appointed in accordance with the Gavi statutes and operating procedures. Repre-
sentatives of key partners of the Gavi Alliance hold 18 seats; independent or unaffiliated individ-
uals have nine; the Chief Executive Officer of the Alliance holds one. While the Bill and Melinda
Gates Foundation, the World Bank, the United Nations Children’s Fund (UNICEF) and the World
Health Organization (WHO) hold permanent seats at the Board, other Gavi partners’ representa-
tives serve on a time-limited basis.
The members on “representative” seats are responsible for ensuring that their governments or
institutions provide formal inputs to the development of Gavi’s policies and to the management
of its operations. Independent or unaffiliated individuals do not have any professional connection
to Gavi’s work, but they provide expertise in critical areas such as investment, auditing, and
fundraising. They also bring independent and balanced scrutiny to all of the Board’s deliberations.
These members are appointed in their personal capacity on the basis of their skills and networks.
Other types of representatives are alternate Board members and observers. Each eligible organi-
zation and constituency may designate one person per Board member as an alternate, who is
entitled to act in lieu of the representative Board member. Both Board members and alternates
are invited to attend the Board meetings; at least one of them should attend to ensure represen-
tation of their constituency. With the Chair’s permission, observers may also participate in the
Alliance’s Board or Committee meetings.
Governance structure
A guide to global health diplomacy 99
The partners of the Gavi Alliance
Æ
The governments of implementing countries identify their immunization needs and co
finance and implement vaccine programmes.
Æ
Vaccine manufacturers make affordable, quality vaccines and cold chain equipment
available to implementing countries.
Æ
Civil society organizations help to ensure that vaccines reach every child.
Æ
Private sector partners contribute resources, expertise and innovation to help achieve the
Gavi Alliance’s mission.
Æ
The Bill and Melinda Gates Foundation provides funding and expertise, pioneers
innovative approaches, and supports research and development work on new vaccines.
Æ
Research and technical health institutions help to generate the evidence base and
communicate the value of vaccines.
Æ
The governments of donor countries make long-term funding commitments and
collaborate with Gavi on the ground.
Æ
The World Bank helps to support innovative financing mechanisms such as the Internation-
al Finance Facility for Immunisation and advance market commitments.
Æ
UNICEF procures vaccines and supports countries in maintaining their cold chain systems,
improving access and collecting data.
Æ
WHO regulates vaccines and supports their introduction in individual countries, with a
focus on increasing immunization coverage and improving data quality.
Adapted from: Gavi, the Vaccine Alliance website (https://www.gavi.org, accessed 12 October 2020).
100 Global Health Centre | February 2021
The Global Fund to Fight AIDS, Tuberculosis and Malaria (hereafter referred to as the Global Fund)
is an international financing organization founded in 2002, its mission being “[t]o attract, leverage
and invest additional resources to end the epidemics of HIV, tuberculosis and malaria and to
support attainment of the Sustainable Development Goals”. The Global Fund mobilizes and in-
vests more than US$ 4 billion a year to support programmes in over 100 countries. It is a partner-
ship between governments, civil society, technical agencies, the private sector and people affect-
ed by those diseases.
The composition of the Board of the Global Fund is illustrative of the concept of plurilateral health
diplomacy. The Board includes 20 voting members, with equal representation by implementers
and donors, and an additional eight non-voting members. The Chair and Vice-Chair chair Board
meetings and play roles in advocacy, partnership and fundraising. The 20 voting members repre-
sent the constituencies, with an equal number of seats (10) representing donor constituencies
and implementer constituencies. One Board member heads each constituency and is seconded
by an alternate Board member.
The 20 constituencies (groups of voting members) are as follows: Australia, Canada and Switzer-
land; communities of people affected by the diseases; nongovernmental organizations (NGOs)
from developed countries; NGOs from developing countries; Eastern Europe and Central Asia;
Eastern Mediterranean Region; Eastern and Southern Africa; European Commission, Belgium,
Italy, Portugal, Spain; France; Germany; Japan; Latin America and the Caribbean; “Point Seven”
(Denmark, Ireland, Luxembourg, Netherlands, Norway, Sweden); private foundations; private
sector; South-East Asia; United Kingdom; United States; West and Central Africa; and the West-
ern Pacific region.
The remaining eight of the Board’s 28 seats are non-voting members: the Board Chair; the Board
Vice Chair; the Executive Director; Partners; the Joint United Nations Programme on HIV/AIDS
(UNAIDS); the World Health Organization; the World Bank; and “Additional Public Donors”, a
constituency created by the Board to accommodate public donors that are not already represent-
ed by a voting constituency.
Box 11: The governance model of the Global Fund to Fight AIDS, Tuberculosis and Malaria
A guide to global health diplomacy 101
Partnership Approach to Governance
The Global Fund Board
Public Sector
(Governments
and Agencies)
Private
Sector
Civil
Society
Technical
Agencies
and Partnerships
Donors
Recipient Countries
NGOs from Global North
NGOs from Global South
Communities living with,
and affected by, the diseases
WHO
UNAIDS
World Bank
UNITAID
RBM
Stop TB
Partnership…
Private Sector
Private Foundations
Adapted from: Global Fund website (https://www.theglobalfund.org/en/).
The Framework Convention on Tobacco Control, WHO’s first global health treaty which entered into
force in 2005, is another newcomer to the global health architecture. It has its own governing body
(Conference of the Parties) and a Secretariat hosted by WHO (more details on the FCTC can be
found in Chapter 5). In addition, several health partnerships, with their own specific governance
structures and operating modes, are hosted by WHO (for example, the Partnership for Maternal,
Newborn and Child Health) or other UN system organizations (such as the RBM Partnership to End
Malaria, which is hosted by the United Nations Office for Project Services (see Chapter 5).
Countries, like other actors, are involved in negotiations and decision-making at many of the health
organizations, but they do not always adopt the same national position in each of these organiza-
tions. This is partly because the ministries represented are different: in WHO it is mainly the health
ministries, while in the other health organizations it is mainly the development ministries (or the
foreign ministries through their development agencies). In many cases, there is a lack of coopera-
tion between the various national authorities, which sometimes even compete with one another.
102 Global Health Centre | February 2021
6.3 Health diplomacy at the United Nations
By the turn of the millennium it had become apparent that tackling global health problems requires
a high level of political commitment and a concentration of resources. Greater attention has there-
fore started to be paid to the decision-making bodies of the UN in New York.
In principle, health can appear on the agenda of four UN forums, namely:
Æ
The General Assembly, under the Charter of the United Nations, may make recommendations
on any matters within the scope of the UN, including global health.
Æ
The Security Council, which, as its name implies, watches over peace and security, rarely puts
health issues on its agenda: this has happened so far only with AIDS and Ebola, which were
declared a threat to international stability in 2000 and 2014, respectively. Additionally, in 2013
the Security Council issued a press statement on polio vaccination in the Sudan.
Æ
The Human Rights Council and the Economic and Social Council are involved, together with
other bodies, in preparing the deliberations of the General Assembly. The Economic and Social
Council is the central platform for fostering debate and innovative thinking on the three dimen-
sions of sustainable development – economic, social and environmental. These two bodies also
employ special mechanisms in relation to health, such as establishing UN inter-agency task
forces – for example on noncommunicable diseases – under the auspices of the Economic and
Social Council, or the appointment of a Special Rapporteur on the right to health under the
auspices of the Human Rights Council.
A guide to global health diplomacy 103
The UN’s interest in health was strengthened by the Oslo Declaration of 2007, in which the foreign
ministers of seven countries identified global health as a pressing foreign policy issue of modern
times. Since 2008, the General Assembly has every year discussed the links between foreign policy
and health, drawing attention to the broader context of topics on the WHO agenda (see Box 12).
The negotiations on and subsequent adoption of the 2030 Agenda for Sustainable Development
with its 17 SDGs in 2015 created even more favourable conditions for devoting greater attention to
global health issues. The UN recognized that, in an interconnected world, infectious diseases can
spread across continents in a matter of days; the lifestyle factors spread by media and advertising
can influence global populations within months (such as smoking, alcohol and junk-food consump-
tion); and knowledge can be shared instantly. Determinants of health are therefore embedded in
each of the SDGs, and health diplomats too have become involved in ensuring that these are ad-
dressed as part of countries’ comprehensive sustainable development plans. A new mechanism
launched in 2019 – the Global Action Plan for Healthy Lives and Well-being for All – brings togeth-
er 12 international organizations with a view to providing more effective support to countries in
their efforts to achieve the health-related SDGs.
These developments have made possible an increasing number of high-level meetings of the Gen-
eral Assembly on specific health matters. The political declarations adopted by these meetings
(such as those on noncommunicable diseases, tuberculosis, antimicrobial resistance and universal
health coverage) were subsequently endorsed by the General Assembly, which has provided stra-
tegic guidance for international cooperation in the areas in question.
Global treaties with a health impact, negotiated under the auspices of different UN bodies and
agencies, are another “centre of attraction” for health issues at the UN. Prominent examples in-
clude the Minamata Convention on Mercury (under the auspices of UNEP), the Convention on the
Rights of Persons with Disabilities (under the auspices of the Human Rights Council) and the United
Nations Framework Convention on Climate Change.
When the COVID-19 pandemic broke out, the UN was mired in various conflicts. The General As-
sembly could only agree on a symbolic resolution on solidarity. Interestingly, the Security Council
did not put the consequences of the pandemic on its agenda, although that is what it had done
during the more limited Ebola epidemic. The Council has been unable to back a resolution that
would endorse the Secretary-General’s call for pandemic-related ceasefires in war zones, including
the Syrian Arab Republic, Yemen, Libya and Afghanistan, because of a dispute between the United
States and China over whether or not to include a reference to WHO in the text of the resolution. In
the first six months of the COVID-19 response, political commitments to roll back the pandemic
were being made at the WHO, the G20 and at the regional level.
A guide to global health diplomacy 105104 Global Health Centre | February 2021
Source: https://www.un.org/en/pdfs/18-00159e_un_system_chart_17x11_4c_en_web.pdf
The United Nations System
UN PRINCIPAL
ORGANS
GENERAL
ASSEMBLY
SECURITY
COUNCIL
ECONOMIC AND
SOCIAL COUNCIL
SECRETARIAT
INTERNATIONAL
COURT OF JUSTICE
TRUSTEESHIP
COUNCIL
6
Subsidiary Organs
• Disarmament Commission
• Human Rights Council
• International Law Commission
• Joint Inspection Unit (JIU)
• Main Committees
• Standing committees and
ad hoc bodies
Funds and Programmes
1
UNDP United Nations Development
Programme
• UNCDF United Nations Capital
Development Fund
• UNV United Nations Volunteers
UNEP
8
United Nations Environment
Programme
UNFPA United Nations Population Fund
UN-HABITAT
8
United Nations Human
Settlements Programme
UNICEF United Nations Children’s Fund
WFP World Food Programme (UN/FAO)
Regional Commissions
8
ECA Economic Commission for Africa
ECE Economic Commission for Europe
ECLAC Economic Commission for
Latin America and the Caribbean
ESCAP Economic and Social
Commission
for Asia and the Pacific
ESCWA Economic and Social
Commission for Western Asia
Functional Commissions
• Crime Prevention and Criminal
Justice
• Narcotic Drugs
• Population and Development
• Science and Technology for
Development
• Social Development
• Statistics
• Status of Women
• United Nations Forum on Forests
• International Residual Mechanism
for Criminal Tribunals
• Military Staff Committee
Subsidiary Organs
• Counter-Terrorism Committee
• Peacekeeping operations and political missions
• Sanctions committees (ad hoc)
• Standing committees and ad hoc bodies
Departments and Offices
9
EOSG Executive Office of the
Secretary-General
DCO Development Coordination Office
DESA Department of Economic and
Social Affairs
DGACM Department for General
Assembly and Conference
Management
DGC Department of Global
Communications
DMSPC Department of Management
Strategy, Policy and Compliance
DOS Department of Operational Support
DPO Department of Peace Operations
DPPA Department of Political and
Peacebuilding Affairs
DSS Department of Safety and Security
OCHA Office for the Coordination of
Humanitarian Affairs
OCT Office of Counter-Terrorism
ODA Office for Disarmament Affairs
OHCHR Office of the United Nations
High Commissioner for Human
Rights
OIOS Office of Internal Oversight
Services
OLA Office of Legal Affairs
OSAA Office of the Special Adviser
on Africa
SRSG/CAAC Office of the Special
Representative of the Secretary-
General for Children and Armed
Conflict
SRSG/SVC Office of the Special
Representative of the Secretary-
General on Sexual Violence in
Conflict
SRSG/VAC Office of the Special
Representative of the Secretary-
General on Violence Against Children
UNDRR United Nations Office for Disaster
Risk Reduction
UNODC
1
United Nations Office on Drugs
and Crime
UNOG United Nations Office at Geneva
UN-OHRLLS Office of the High Representative
for the Least Developed Countries,
Landlocked Developing Countries and Small
Island Developing States
UNON United Nations Office at Nairobi
UNOP
2
United Nations Office for Partnerships
UNOV United Nations Office at Vienna
Research and Training
UNIDIR United Nations Institute for
Disarmament Research
UNITAR United Nations Institute for
Training and Research
UNSSC United Nations System Staff College
UNU United Nations University
Other Entities
ITC International Trade Centre (UN/WTO)
UNCTAD
1,8
United Nations Conference on
Trade and Development
UNHCR
1
Office of the United Nations
High Commissioner for Refugees
UNOPS
1
United Nations Office for Project
Services
UNRWA
1
United Nations Relief and Works
Agency for Palestine Refugees in the Near East
UN-WOMEN
1
United Nations Entity for Gender
Equality and the Empowerment of Women
Notes:
1 Members of the United Nations System Chief Executives Board for
Coordination (CEB).
2 UN Office for Partnerships (UNOP) is the UN’s focal point vis-a-vis the United
Nations Foundation, Inc.
3 IAEA and OPCW report to the Security Council and the General Assembly (GA).
4 WTO has no reporting obligation to the GA, but contributes on an ad hoc basis
to GA and Economic and Social Council (ECOSOC) work on, inter alia, finance
and development issues.
5 Specialized agencies are autonomous organizations whose work is
coordinated through ECOSOC (intergovernmental level) and CEB (inter-
secretariat level).
6 The Trusteeship Council suspended operation on 1 November 1994, as
on 1 October 1994 Palau, the last United Nations Trust Territory, became
independent.
7 International Centre for Settlement of Investment Disputes (ICSID) and
Multilateral Investment Guarantee Agency (MIGA) are not specialized
agencies in accordance with Articles 57 and 63 of the Charter, but are part of
the World Bank Group.
8 The secretariats of these organs are part of the UN Secretariat.
9 The Secretariat also includes the following offices: The Ethics Office, United
Nations Ombudsman and Mediation Services, and the Office of Administration
of Justice.
10 For a complete list of ECOSOC Subsidiary Bodies see un.org/ecosoc.
This Chart is a reflection of the functional organization of the United Nations
System and for informational purposes only. It does not include all offices or
entities of the United Nations System.
FAO Food and Agriculture Organization of the United Nations
ICAO International Civil Aviation Organization
IFAD International Fund for Agricultural Development
ILO International Labour Organization
IMF International Monetary Fund
IMO International Maritime Organization
ITU International Telecommunication Union
UNESCO United Nations Educational, Scientific and Cultural
Organization
UNIDO United Nations Industrial Development Organization
UNWTO World Tourism Organization
UPU Universal Postal Union
WHO World Health Organization
WIPO World Intellectual Property Organization
WMO World Meteorological Organization
WORLD BANK GROUP
7
• IBRD International Bank for Reconstruction and
Development
• IDA International Development Association
• IFC International Finance Corporation
Specialized Agencies
1, 5
Other Bodies
10
• Committee for Development Policy
• Committee of Experts on Public
Administration
• Committee on Non-Governmental
Organizations
• Permanent Forum on Indigenous Issues
UNAIDS Joint United Nations Programme on
HIV/AIDS
UNGEGN United Nations Group of Experts on
Geographical Names
UNGGIM Committee of Experts on Global
Geospatial Information Management
Research and Training
UNICRI United Nations Interregional Crime and
Justice Research Institute
UNRISD United Nations Research Institute for
Social Development
Peacebuilding
Commission
HLPF
High-level Political
Forum on Sustainable
Development
Related Organizations
CTBTO PREPARATORY COMMISSION
Preparatory Commission for the Comprehensive
Nuclear-Test-Ban Treaty Organization
IAEA
1, 3
International Atomic Energy Agency
ICC International Criminal Court
IOM
1
International Organization for Migration
ISA International Seabed Authority
ITLOS International Tribunal for the Law of the Sea
OPCW
3
Organization for the Prohibition of Chemical
Weapons
WTO
1, 4
World Trade Organization
Published by the United Nations Department of Global Communications 19-00073 — July 2019© 2019 United Nations. All rights reserved worldwide
106 Global Health Centre | February 2021
Box 12: What are the characteristics of health negotiations at the United Nations?
In negotiations at the United Nations (UN), health is viewed through the lens of global politics.
Public health arguments and evidence have an indirect (sometimes subordinated) effect, while
geopolitical aspirations, power considerations and interests have a stronger impact. There are
three aspects to setting and debating health-related agenda items: the world economy; the secu-
rity environment; and the humanitarian, human rights and social justice arenas.
The complexity of global health challenges and their economic and development policy contexts
call for more thorough and organized preparation of the diplomats involved in the negotiations. It
is no longer sufficient for diplomats to have foreign policy experience: background support based
on cooperation between experts from various sectors in their home countries is essential if they
are to succeed at the negotiating table.
Although professional diplomats play a key role in UN health deliberations, they are increasingly
relying on experts, notably the health attachés at Geneva-based missions. The link between Ge-
neva and New York is becoming stronger, since high-level health conferences at UN Headquar-
ters are often prepared at the World Health Organization, together with representatives of the
Member States. At the same time, there has been a growing demand for health diplomats to be
based in New York. Ensuring that diplomats possess or can call on specialist knowledge is less
affordable for countries from the Global South, yet it is important that these countries’ interests
should be represented strongly during health negotiations. Coordinated action and the pooling of
expertise by regional organizations such as the African Union or the Caribbean Community can
help in that respect.
The influence of non-State actors commanding large amounts of resources, particularly financial
resources, is growing in the UN. They can exert political pressure on governments that is difficult
to resist and may be at odds with the public good. A prime example is noncommunicable diseas-
es, where the market power of large companies can counteract the public health objectives of
governments. Indeed, some countries seem to be less assiduous in their efforts to regulate big
business (pharmaceuticals, food and drink, tobacco and alcohol and so on) than in the past. This
could have a significant impact on efforts to find policy solutions for improving global health. On
the other hand, space is increasingly being provided at the UN for the views and positions of in-
ternational nongovernmental organizations, philanthropic foundations, academic institutions,
advocacy groups, religious groups and humanitarian organizations.
A guide to global health diplomacy 107
There is a risk that the rules-based multilateral system that governs global political and trade re-
lations could suffer further fragmentation as more self-assured emerging nations assert their
own values and rules. The COVID-19 pandemic has shown that the rise in nationalist sentiment
throughout the world poses yet another threat to the multilateral system, with multilateral insti-
tutions and the very notion of global governance being rejected outright.
6.4 The central role of States in global health diplomacy
States remain critical actors in old and new international health organizations. Indeed, in many
cases it was at the initiative of States that new organizations were created to address common
challenges. In their foreign policy, States have to strike a balance between various goals: serving
the national interest, providing development assistance and supporting collective action. Their po-
sitions reflect geopolitical realties. Significant shifts occurred in the power balance between States
in the course of the 20th century. The first decades after the Second World War were defined by
the conflict between the former Soviet Union and the United States, often referred to as the Cold
War. From the 1960s onwards, the nations of the developing world began playing a more promi-
nent role, and membership of the various UN bodies increased significantly. However, the most
powerful countries have, by and large, preserved to this day their disproportionate influence on
decision making at global institutions. Some newer health organizations have tried to address this
issue by giving donor and recipient nations an equal number of votes.
The current geopolitical power conflict between China and the United States is reflected in the de-
liberations of the UN and those of many other multilateral bodies and political clubs. New alliances
have become possible, especially between “middle powers”. Nations from the Global South now
have greater influence on global health policy, as reflected, for instance, in the election of the first
African WHO Director General in 2017. This increase in the influence of Africa is related both to the
impact that most health issues have on that region and to the cumulative weight of the votes of its
countries in a voting scenario. Similarly, regional bodies, such as the EU, are gaining in relevance.
The COVID-19 crisis has shown just how political the field of global health is. It has also highlighted
the crucial role of global health diplomacy in ensuring that collective action can be taken.
Experience shows that States will continue to establish and develop international organizations in
order to achieve objectives that they cannot attain on their own, or if they consider that an existing
organization is not delivering on its mandate or if they are not satisfied with the role that they are
playing in it. However, the very different mandates and (perceived) legitimacy bases of existing in-
108 Global Health Centre | February 2021
ternational organizations and their different organizational cultures are often not fully understood
by political actors. This can have significant implications for judging their effectiveness.
New organizations may be created because countries and other actors consider existing organiza-
tions to have lost their legitimacy or because they wish to try a new, more promising funding
mechanism. Organizations are also created to give donors a greater say in how the money they
donate is spent. Sometimes, parallel entities and mechanisms are set up by countries that fail to
secure sufficient influence within existing multilateral organizations – a phenomenon referred to as
parallel or competitive multilateralism. The Belt and Road Initiative launched by China is an exam-
ple of such multilateralism.
One striking feature of 21st-century diplomacy is the expansion of both club diplomacy and net-
work diplomacy, which reflects the way international politics is moving towards multipolarity. In-
fluence is no longer solely exerted along the channels traditionally associated with developed and
developing countries. The BRICS countries, in particular, are playing a more important role in glob-
al affairs by taking the lead on certain issues and by acting as regional power brokers. For example,
China is now the second-largest economy in the world and the second-largest contributor to the
UN budget. In the field of global health, too, China has become both a major donor and a major
investor. Similarly, India is currently at the forefront of discussions on digital health.
As they seek to become regional leaders, the BRICS countries, along with certain other countries in
Asia and Africa, are building broad alliances and strengthening their regional cooperation (see Box
13). For example, Indonesia is currently promoting cooperation between Indo-Pacific States, which
has the potential to be used by key policy-makers to draw attention to the urgency of collective
action on transnational health issues. The shift in power relations has opened new spaces for inter-
national political engagement, notably also for global health diplomacy. In the coming years it is
likely that many more new types of alliance will spring up.
Small groups of countries can exercise considerable influence if they build alliances based on the
UN principle of one vote per country. Such alliances are increasingly conducting group and network
diplomacy – with considerable success, as shown by the way in which the CARICOM countries
managed to put noncommunicable diseases on the UN agenda. In general, the influence of region-
al integration blocs on health matters is steadily rising, as discussed in Chapter 7.
A key development has been the incorporation of global health challenges – at first mainly related
to health security – into the agendas of high-level political meetings, such as the G7 and G20 sum-
mits, and of political clubs such as the BRICS countries. This widening of the political space for
health negotiations has increased the likelihood of health matters being taken up in other venues
A guide to global health diplomacy 109
such as the World Bank or the WTO. For example, during the G20 summit in Osaka, Japan, in June
2019 a joint session of the health and finance ministers was organized for the first time; the minis-
ters discussed some of the financial issues that had been raised at the 2019 Spring Meetings of the
World Bank Group and the International Monetary Fund.
6.5 The role of non-State actors in global health diplomacy
The global health diplomacy space features a wide range of non-State actors that interact mainly
through network diplomacy. The WHO Register of Non-State Actors (in the process of compilation)
reflects the diversity of these actors – including global health alliances, initiatives, public–private
partnerships and foundations – and of their interests. Many of them seek to combine global agen-
da setting with on-the-ground action.
Given the variety and diversity of actors in global health diplomacy, in-depth stakeholder analysis
should be performed before any negotiations are undertaken. This involves seeking to understand
not only the various stakeholders’ interests but also how they operate (for example, their social
media strategies).
The activities of civil society organizations are critical to the success of global health negotiations.
Examples include the negotiations that led to the adoption of the Framework Convention on Tobac-
co Control (FCTC) in 2003 and the International Code of Marketing of Breast-milk Substitutes in
1981, or the many negotiations dealing with access to medicines and with the commercial determi-
nants of health. As outlined in Section 1.3, it is now standard practice to include NGOs in the
global health diplomacy process. NGO diplomats represent the interests of the wider public and
demand transparency, especially on attempts by the private sector to exert undue influence. A
study of the negotiation of the FCTC revealed that NGOs played five key roles during that process:
monitoring, lobbying, brokering knowledge, offering technical expertise and fostering inclusion
(Lencucha, Kothari & Labonté, 2011).
Philanthropic foundations have acquired a significant level of influence on the global health agen-
da. Many foundations are active in global health, the most influential being the Bill and Melinda
Gates Foundation (BMGF). Since its creation in 2000 it has channelled significant resources into
global health and helped to set up many new health organizations, alliances and programmes. The
BMGF seeks to support innovative, ambitious and scalable solutions to health problems that have a
major impact in developing countries. Moreover, it is the leading donor among the non State actors
contributing voluntarily to the financing of global health. While the BMGF has no formal decision
making power at WHO, its decisions to fund major programmes, such as those on polio eradication
110 Global Health Centre | February 2021
or management innovation, do have a significant impact on the Organization’s work. The BMGF’s
intensive interactions with both donor and recipient countries, as well as with the WHO leadership,
clearly give the Foundation considerable influence in the field of global health diplomacy – some-
thing that is severely criticized by many civil society actors.
The overt role of the private sector in global health diplomacy has increased significantly in recent
years. In this respect, a great deal of attention has been paid to pharmaceutical companies and their
role in determining access to medicines, and also to large multinational companies that have con-
tributed to the staggering increase in the prevalence of noncommunicable diseases. Accountability
clearly needs to be strengthened in these areas. Yet, at the same time, many private companies are
contributing to the advancement of global health goals, a case in point being the ARM Industry Al-
liance launched in 2017 to help combat antimicrobial resistance. In many countries beyond OECD
economies, notably India, the private health sector plays a crucial role. A wide range of new part-
nerships have emerged, as have initiatives by the companies themselves in relation to their employ-
ees. The World Economic Forum increasingly brings together governments and major companies to
promote innovative approaches and build new alliances. New challenges have arisen as information
technology becomes more and more important for the development of global health. WHO recently
reached out to major technology companies and platforms, enlisting their help both in tackling the
infodemic associated with COVID-19 (see Section 2.5) and in promoting digital health innovation.
Multi-stakeholder diplomacy in action
Microsoft has opened a representation office to the United Nations (UN) in New York. Its task is
to intensify the company’s support for the UN’s mission and work. This includes promoting global
multi-stakeholder action on key technology, environmental, humanitarian, development and secu-
rity issues, and helping to achieve the Sustainable Development Goals. Microsoft has initiated
numerous projects focusing on Goal 4 (quality education), Goal 8 (decent work and economic
growth), Goal 13 (climate action) and Goal 16 (peace, justice and strong institutions).
The new representation office will concentrate on developing Microsoft’s partnerships with the
UN and UN system agencies, building relationships with UN representatives, identifying new op-
portunities for partnerships, building stronger connections between Microsoft and UN teams,
lobbying for the UN’s priorities within Microsoft, and working across the company to support Mi-
crosoft teams in their collaboration with the UN community.
A guide to global health diplomacy 111
Adapted from: Microsoft (2020). Microsoft appoints senior government affairs leaders in
Brussels and New York, establishes New York office to work with the United Nations. In:
Microsoft/EU Policy Blog [website] (https://blogs.microsoft.com/eupolicy/2020/01/17/
senior-gov-affairs-leaders-appointed-brussels-new-york/, accessed 12 October 2020).
6.6 Maintaining a balance
Civil society organizations, in particular, have expressed concerns over the possibility of SDG based
multi-stakeholder diplomacy giving the private sector excessive influence on negotiation processes
that should be about safeguarding global public goods. The private sector is invited – as are civil
society organizations – to share their views and provide inputs during regional or global consulta-
tions on a particular topic but not during the negotiation process itself, in which only Member
States may participate. In preparation for a number of high-level meetings of stakeholders on non-
communicable diseases in 2011, WHO invited relevant private sector entities to a stakeholder hear-
ing and a web-based consultation, where they could share their views with the Organization. These
views served as an input for the preparation of Member State negotiations.
Civil society organizations continue to fear that if the private sector is given access to the presti-
gious platform of multi-stakeholder diplomacy, its lobbying power, which has long made itself felt
in economic and commercial diplomacy, will increase further and lead to less attention being de-
voted to development, equity and human rights concerns. It would also become harder to challenge
companies on their health, environmental and human rights records.
In this respect, it is important to note that the UN system not only thrives on its own legitimacy but
can itself also confer a high degree of legitimacy on the various actors involved in its work. A strong
tendency may currently be observed among private sector entities to seek to conclude memoranda
of understanding with UN system organizations. This applies to such diverse entities as the Interna-
tional Federation of Association Football (FIFA), the World Economic Forum and the new “big tech”
companies. In conjunction with the increasing number of public–private partnerships, this tenden-
cy means that multi-stakeholder diplomacy faces the challenge of maintaining a delicate balance
so that trust in the multilateral system is not undermined. This also includes a recurring concern
that some civil society organizations may have undisclosed business links. With regard to WHO, the
FENSA framework and transparency measures are meant to allay such concerns, but constant vig-
ilance is still required. Other organizations without such a robust system are more vulnerable.
112 Global Health Centre | February 2021
To manage this complexity, one must navigate the interface between diplomacy and science, con-
duct multilevel, multi-factor and multi-actor negotiations, and take into account existing power re-
lations. The value base of global health – equity and human rights – has repeatedly been chal-
lenged by some States and defended by civil society actors. In principle though the field of health
provides diplomats with a range of opportunities to both advance national interests and to strength-
en multilateral institutions.
Geneva Global Health Ecosystem Map
88
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A guide to global health diplomacy 113
CHAPTER 7 | THE ROLE
OF REGIONAL ORGANIZATIONS
7.1 The interface between regional bodies,
diplomacy and global health
Regional diplomacy is an increasingly important factor in multilevel global health diplomacy. As well
as complementing processes taking place at the global level, regional diplomacy strengthens nation-
al contributions to global health. However, its role in global health has not been sufficiently analysed.
WHO regional bodies and offices provide a key platform for regional health diplomacy – often
supported by regional civil society organizations and professional networks engaged in promoting
international cooperation on health. Meanwhile, regional integration organizations and processes
have acquired greater prominence in recent years.
Although regional integration processes pursue mainly trade, economic and security objectives,
health does come into the picture because of its interface with each of those domains. Thus, trade can
both improve and undermine health, while a low level of health of the general population prevents
economic gains. The transborder spread of infectious diseases, on the other hand, threatens security.
In addition, human rights and social justice – two important elements of the interface between health
and foreign policy – are treated as cross-cutting issues in most regional integration processes. Health
and well-being, therefore, inevitably feature on regional integration agendas. Indeed, the level of
health among a region’s population may be used as a gauge of the social benefits of integration.
Another aspect of regional diplomacy is the pooling of knowledge and capacities to tackle common
challenges, including health-related ones. In many cases – particularly where region-specific is-
sues are concerned – regional negotiations are the first to be conducted; they may then prompt
global negotiations and feed into these.
Health is often seen as an area for the exercise of soft power whereby regional organizations are
able to strengthen ties, cooperation and trust among their member countries, and to promote re-
gional stability in general. Since health now receives more attention in global governance, health
diplomacy often helps regional organizations and their members, particularly smaller States, to be
heard on the global stage. Moreover, they can draw on their shared expertise when conducting
114 Global Health Centre | February 2021
negotiations on health issues in global forums.
7.2 An overview of regional integration
Regional integration processes vary in terms of the specific forms they take and in the level of inte-
gration pursued or achieved. They range from free trade areas as the most basic form of integration
to customs unions, common markets and fully fledged political and economic unions. Regional or-
ganizations operate mainly on the basis of intergovernmental decision-making, buttressed by su-
pranational institutions in some cases. Several organizations even have their corresponding parlia-
ments, parliamentary assemblies or unions with a distinct legal authority.
In economic terms, the European Union (EU) is the largest regional bloc; it also exemplifies the most
advanced form of regional integration. In addition, the EU’s single market extends to the area of the
European Free Trade Association (EFTA), a smaller bloc of four countries. Straddling parts of East-
ern Europe and Central Asia, the Eurasian Economic Union (EAEU) is the world’s newest regional
economic organization. Three other regional organizations also span parts of Europe and Asia.
16
Several regional organizations exist in Asia and the Pacific.
17
Additionally, one organization strad-
dles parts of Asia and Africa and one intergovernmental forum links economies in the Pacific Rim.
18
The integration architecture is more complex in Africa and the Americas, where in some cases it has
multiple layers (subregional, cross-regional, continental) and overlapping membership. In addition,
some of the organizations contain smaller subgroups that have a higher degree of integration (for
example, customs and/or monetary unions).
In Africa, there are eight regional organizations covering different subregions:
19
these regional eco-
nomic communities are the pillars of the African Economic Community, which is in the process of
being created by the African Union (AU).
16 Organization of the Black Sea Economic Cooperation (BSEC), Shanghai Cooperation Organisation (SCO), Economic Cooperation
Organization (ECO).
17 South Asian Association for Regional Cooperation (SAARC), Association of Southeast Asian Nations (ASEAN), Gulf Cooperation
Council (GCC), Pacific Islands Forum (PIF), Pacific Community.
18 The League of Arab States (LAS) and the Asia–Pacific Economic Cooperation (APEC), respectively.
19 Arab Maghreb Union (AMU), Common Market for Eastern and Southern Africa (COMESA), Community of Sahel-Saharan States
(CEN-SAD), East African Community (EAC), Economic Community of Central African States (ECCAS), Economic Community of
West African States (ECOWAS), Intergovernmental Authority on Development (IGAD), Southern African Development
Community (SADC).
A guide to global health diplomacy 115
In the Americas, there are six organizations covering different subregions.
20
This integration architec-
ture was recently complemented by organizations with wider regional coverage: the Union of South
American Nations (UNASUR) and the Community of Latin American and Caribbean States (CELAC).
7.3 Regional integration and health
The integration of health agendas into the work of regional organizations generally takes place at
four different levels, as shown below:
Treaty level Political level
Technical level
Intersectoral level
(mixed)
Regional action
on health
At the treaty level: The founding (constitutive) treaties of most regional organizations address
health indirectly, through overarching goals (for example, social and human development, internal
market, human and labour rights, free movement of goods and services, technical regulations) and
sectoral policies (for example, on food safety, consumer protection, agriculture, medical products,
migration and the environment).
In some cases, however, health is explicitly referred to in the founding (or complementary) treaties
of regional organizations, usually with an emphasis on specific areas or aspects: public health and
health in other policies (EU); action on preventable diseases and promotion of good health (AU);
universal access to health services (UNASUR), health systems and harmonization of policies (EAC);
20 Amazon Cooperation Treaty Organization (ACTO), Andean Community (CAN), Caribbean Community (CARICOM), Central
American Integration System (SICA), Pacific Alliance, Southern Common Market (MERCOSUR).
116 Global Health Centre | February 2021
sanitary and veterinary measures (EAEU); health as a prerequisite for development (SADC); and
health as an essential ingredient of social integration (SICA).
At the political level: High-level declarations, strategies and action plans on health have been ad-
opted at summits and by the highest governing bodies of several regional organizations. Examples
of such documents include the Africa Health Strategy 2016–2030 (AU), the ASEAN Post-2015 Health
Development Agenda and the Strategic Plan on Health (Andean Community). In the EU, some nor-
mative acts (directives and regulations) have higher legal status than others (recommendations).
Several regional organizations have initiated regular meetings of their member countries’ health
ministers, including the Andean Community, MERCOSUR and SAARC. Others have established
councils, committees or assemblies as political bodies with responsibility for the health sector, in-
cluding ECOWAS, SICA and UNASUR. In the EU, the member countries’ health ministers meet
regularly as part of the Employment, Social Policy, Health and Consumer Affairs Council configura-
tion – one of the 10 configurations of the Council of the EU, which is the Union’s main legislative
body alongside the European Parliament. In large organizations with an executive commission such
as the AU and the EU there is a designated commissioner who is responsible for health and is
supported by a specialized department of the commission.
Health objectives are often supported by other regional bodies and institutions, such as: regional
parliaments and legislative assemblies (which endorse relevant legislation); regional development
and investment banks (which may fund health, medical and biotechnology projects); and regional
courts of justice (which may be called upon to interpret relevant regional legislation or settle legal
disputes concerning, for example, citizens’ rights to cross-border care).
At the technical level: Some regional organizations have established specialized health agencies,
which are probably the most advanced mechanism for technical cooperation. Examples of such
health agencies, with the parent organization indicated inside square brackets, are:
Æ
Africa Centres for Disease Control and Prevention [AU];
Æ
Andean Health Organization [Andean Community];
Æ
Caribbean Public Health Agency [CARICOM];
Æ
East African Health Research Commission [EAC];
Æ
West African Health Organization [ECOWAS];
Æ
European Centre for Disease Prevention and Control, European Medicines Agency,
European Monitoring Centre for Drugs and Drug Addiction [EU]; and
Æ
South American Institute of Governance in Health [UNASUR].
A guide to global health diplomacy 117
Other mechanisms employed by various organizations include regional reference and regulatory
networks, registries, databases, initiatives and partnerships. In some cases, these mechanisms
have resulted in public health goods that are of particular importance for the region as a whole,
such as MERCOSUR’s database of pictorial warnings on the dangers of tobacco, SAARC’s telemed-
icine network, the EU’s eHealth Digital Service Infrastructure and UNASUR’s medicines price bank.
At the intersectoral level: In addition to traditional multisectoral approaches to health, some spe-
cial mechanisms have been used at both the technical and political level. Examples include APEC’s
joint annual meeting of the ministers for health and the economy; SICA’s joint meetings of its
bodies responsible for health and economic integration; the Pacific Community’s High-Level Dia-
logue on Water and Sanitation; and SADC’s cross-cutting policy on HIV/AIDS and sexually transmit-
ted diseases. Furthermore, international health emergencies often trigger urgent regional diploma-
cy and coordination in closely related sectors, as for example in the case of ASEAN, where the
member countries’ ministers of the economy, agriculture, labour, social welfare and transport con-
vened their respective coordination meetings during the early phase of the response to the
COVID-19 pandemic.
7.4 Regional integration and global health diplomacy
A considerable amount of negotiation and consensus-building is necessary – at both the intergov-
ernmental and intersectoral level – to ensure that health is not crowded out by the various political,
trade, economic and security agendas that primarily drive the processes of regional integration. In
addition to strengthening the health dimension of regional integration, such negotiations help to
lay the foundations for a region’s engagement in global diplomacy for health.
There are three different types of mechanism for the interaction between regional integration and
global health diplomacy: internal, horizontal and vertical.
Internal: Some organizations have formally set out their region’s role in global health (EU) or have
promoted global treaties that are of particular relevance to their region (as in the case of the Amazon
Cooperation Treaty Organization with its strong support for the Minamata Convention on Mercury).
Horizontal: Regional organizations cooperate with one another in order to achieve improved collec-
tive outcomes, including health outcomes. Such cooperation may occur both within a continent (for
example, the COMESA–EAC–SADC Tripartite, which seeks to accelerate economic integration in
eastern and southern Africa), or intercontinentally (for example, the EU’s cooperation on communi-
cable diseases with the AU and ASEAN, or the recent EU–MERCOSUR free trade agreement, which
118 Global Health Centre | February 2021
may have an impact on health). A related horizontal mechanism is the way in which major cross-re-
gional political clubs (G7, G20, BRICS) are paying ever greater attention to global health issues.
Vertical: Several such mechanisms have emerged over the years. First, the members of some re-
gional organizations adopt a coordinated stance at WHO – a mechanism that supplements the well
established coordination between Member States within the WHO regions. In that case, a regional
organization/grouping acts as a voting bloc. This has long been the case with the EU, but there are
more recent examples, such as UNASUR’s call for action against counterfeit medicines. Secondly,
the political stance of some regional organizations has proved instrumental in pushing certain is-
sues to the top of the global agenda. Two examples are CARICOM’s catalytic role in raising the
profile of noncommunicable diseases at the UN and the Pacific island States’ powerful statements
on climate change at WHO and other global forums. Thirdly, regional integration organizations can
directly support global health treaties, as demonstrated by the EU’s support for the negotiations on
the FCTC and its Protocol to Eliminate Illicit Trade in Tobacco Products, followed by its accession to
the both instruments. Given the dominance of cross cutting agendas in most integration processes,
regional multisectoral diplomacy is important to ensure that health objectives are achieved when
negotiating future global health treaties (or treaties with a health impact) and when implementing
the existing treaties.
Global health crises often trigger demand for the above mechanisms – internal, horizontal and
vertical – to be rolled out in a pooled manner or simultaneously. This could be seen, for example,
during the global crisis caused by the COVID-19 pandemic. The EU, while slow in its initial response
to the pandemic, later nevertheless undertook substantial coordinating efforts. It also spearheaded
the difficult negotiations for a recovery fund totalling an unprecedented a750 billion, which was
eventually approved in July 2020. In parallel, at the global level, the EU proposed and facilitated
adoption of the crucial World Health Assembly resolution on the COVID-19 response; provided
substantial resources to the Gavi Alliance; and championed the Coronavirus Global Response initia-
tive, for which pledges worth nearly a16 billion were secured over a few months. Similarly, the AU
established the Africa Joint Continental Strategy for COVID-19, the African Union COVID-19 Re-
sponse Fund and a joint medical supplies platform. At the global level, the AU appointed a special
envoy to mobilize international economic support for the continent’s fight against the pandemic
and actively supported WHO’s global response to the pandemic. As for interregional (horizontal)
mechanisms, notable examples include the EU’s promptly activated COVID-19 response dialogue
with ASEAN and the AU, and various response measures under the Tripartite Transport and Transit
Facilitation Programme in eastern and southern Africa. However, the pandemic also showed that
existing divisions between member countries may seriously hamper an organization-wide coordi-
nated response, as for example in the case of MERCOSUR.
A guide to global health diplomacy 119
In summary, regional health diplomacy acts as a complement to – and intermediary between – di-
plomacy at the national (in some cases also subregional) and global levels. Regional integration
helps to harness the collective will and knowledge of States, particularly smaller ones, when it
comes to tackling shared health challenges at global forums. An important conclusion is that the
three levels of health diplomacy are interrelated and complementary.
Box 13: Global health diplomacy in Africa
The spread of diseases increasingly threatens national security, trade, economic and develop-
ment agendas in Africa. These agendas are the building blocks of the Agenda 2063 of the African
Union (AU). Recognizing the importance of the nexus between global health threats and broader
goals in diplomatic efforts towards realizing Agenda 2063, the AU decided to establish the Africa
Centres for Disease Control and Prevention (Africa CDC). Its mandate is to support the public
health initiatives of AU Member States, and to strengthen the capacity of their public health in-
stitutions to detect, prevent, control and respond quickly and effectively to disease threats. The
fact that Africa CDC is based at the AU is a reflection of the diplomatic implications of its work,
particularly in a global health context. Health diplomacy is an important dimension of Africa’s
wider diplomatic engagement. Africa’s high disease burden, its difficulties with health financing
and consequent reliance on external funding call for effective health diplomacy and concerted
steps by both African and international stakeholders to prompt global health policies and action
that are relevant to the continent’s needs with regard to improving the health of all its citizens.
Health has become an important bargaining chip in diplomatic negotiations, as most recently
demonstrated in global efforts on the COVID-19 pandemic. Before the pandemic, the political and
economic interests of donors (bilateral and multilateral organizations, the private sector and so
on) were often facilitated through donor health packages. These packages were geared towards
leveraging soft power and gaining relevance in negotiations on security, trade agreements and
development policies. African countries on the whole benefited from donor packages, and donor
countries built on this to consolidate their influence and promote their own interests. Conversely,
health diplomacy has been relatively underused to advance African countries’ interests. However,
during the pandemic, governments adopted drastic policies and took bold action to mitigate the
human and socio-economic toll of COVID-19, especially on the informal sector, which employs
over 85% of Africans. Public health measures have informed policy- and decision-making to miti-
gate the spread of the pandemic – for example, curfews and lockdowns, safe border initiatives
and negotiations to safeguard trade between countries.
In an effort to mitigate the pandemic’s impact, the Bureau of the AU Assembly of Heads of State
120 Global Health Centre | February 2021
and Government issued a joint statement at its onset requesting debt forgiveness. This highlights
the critical need for political and diplomatic action informed by health goals.
However, there is untapped potential for health diplomacy in Africa to become more systematic
than previously. Despite the development of the Africa Health Strategy 2016–2030 and the estab-
lishment of Africa CDC, public health is not treated as a core priority in key agenda setting docu-
ments such as Agenda 2063. Moreover, before the inception of Africa CDC, a unified African
voice on health matters was not discernible, leaving countries vulnerable to different positions
and influences. Two events may be cited as an illustration of the effect of not having such a uni-
fied voice:
Æ
The African region, as a regional bloc, did not collectively support the Political Declaration of
the high level meeting on universal health coverage in 2019. Since countries signed sepa-
rately, Africa’s collective negotiating power was weakened. This resulted in some countries
signing an alternative statement on universal health coverage initiated by the United States
of America, which excluded sexual and reproductive health rights.
Æ
At the 2019 World Health Assembly, 20 countries (five of which were African) sponsored a
resolution to improve the transparency of markets for medicines, vaccines and other health
products. The resolution provides governments with useful information to negotiate fairly.
However, some critical elements of transparency were omitted. This was the result of objec-
tions raised by Germany, Japan, the United Kingdom and the United States on publishing data
relating to production and other relevant costs, and to subsidies from governments and other
groups. Despite the fact that the lack of access to and availability of vaccines, drugs and com-
modities is a public health crisis in African countries, there was no objection from the region as
a whole to those omissions in the final text of World Health Assembly resolution WHA72.8.
The COVID-19 pandemic offers exceptional scope for health diplomacy to come into its own in
Africa. Africa’s joint response to the pandemic has created the policy space for global health
processes. Governments, through the Africa CDC or regional economic communities, such as the
East African Community (EAC), the Southern African Development Community (SADC) and the
Economic Community of West African States (ECOWAS), have coordinated their pandemic re-
sponses, policies and guidelines. The President of South Africa, in his role as AU Chairperson,
appointed four Special Envoys of the AU to mobilize support for Africa’s COVID-19 response. In
addition to the health implications, the support being sought is also intended to help address the
economic challenges faced by African countries as a result of the COVID-19 crisis. Through con-
certed engagement, certain regional economic communities and designated envoys have
emerged as negotiators for Africa’s response to the pandemic. This consensus on the response
A guide to global health diplomacy 121
framework has promoted the adoption of shared goals in pandemic response and made it possi-
ble to raise more funds from both traditional donors and African philanthropists. Such coordinat-
ed and strategic health diplomacy is likely to have a positive impact on health and other so-
cio-economic factors.
In developing strategic health diplomacy in Africa further, African policy-makers may like to con-
sider the following actions:
Æ
Institutionalize the integration of health into foreign policy. Governments should collaborate
to develop common positions that will enable them to influence resolutions adopted at the
global level. Broader engagement within the region will strengthen the ability to achieve
coordinated positions and responses on health matters, such as joint guidelines, the pooling
of resources (for the financing and deployment of first responders, for procurement and so
on) and exchange of best practices.
Æ
Negotiate as a regional bloc in order to manage complex partnerships and protect Africa’s
interests. By advancing its own health agenda, Africa can increase its purchasing power and
ability to access innovative technologies, medicines, vaccines and other health commodities.
Strengthening the dialogue between diplomats and health experts will ensure that health
impacts are a key consideration in all negotiations. This requires inclusive and transparent
decision-making processes not only during programme implementation but also in research
and development.
Æ
Build capacity to develop and proactively engage in health diplomacy, that is in the interface
between health and foreign policy. With African governments recognizing that health secu-
rity is not only a national concern, the pandemic is demonstrating the growing link between
domestic and foreign policy. Policy-makers need to be aware of international health agree-
ments and to anticipate attendant risks or threats. Special technical skills are also required
to negotiate health agendas within foreign policy and development agreements (including
trade and commerce). To that end, a cohort of key officials should be trained in these skills.
Such capacity-building can be enhanced by offering placements to these officials at the di-
plomacy hubs of Addis Ababa, Geneva and New York and within ministries of foreign affairs.
Governments should also cooperate with academic institutions to build capacity in health
diplomacy and, specifically, to enable the officials to familiarize themselves with the latest
public health trends. Governments could go even further by establishing global health diplo-
macy units within their foreign ministries, which would interact with health attachés at dip-
lomatic missions, relevant AU entities (Department of Social Affairs, Africa CDC, African
Continental Free Trade Area), parliamentarians and WHO country and regional offices.
122 Global Health Centre | February 2021
In view of the critical role of global health diplomacy in improving health indicators across Africa,
it is imperative to restructure and systematize the way such diplomacy is conducted in the region.
This is necessary in order both to increase Africa’s negotiating power and to build better institu-
tions that can promote positive health diplomacy and public health outcomes.
A guide to global health diplomacy 123
CHAPTER 8 | POLICY COHERENCE
FOR GLOBAL HEALTH
8.1 Creating synergies
In the SDGs era, strategies for health equity and sustainable development should be integrated,
taking into account the links between social, environmental and economic policies. However, dif-
ferent sectors have their own objectives and tend to operate in “silos”. Introducing health issues
into the policy space of non-health sectors is often perceived as interference unless the potential
co-benefits are clearly pointed out.
Sectors other than health have always made a fundamental contribution to health promotion and
disease prevention, as exemplified by the social medicine movements of the first half of the 20th
century and by such milestones in the second half as the Alma-Ata Declaration on primary health
care (1978), the Health for All Strategy (1981) and the Ottawa Charter for Health Promotion (1986).
More recently, the intersectoral approach to health was reinforced by the Health in All Policies
Framework (2006), the final report (2008) of the WHO Commission on Social Determinants of Health,
and the emphasis on health as a cross-cutting dimension in the SDGs (2015). International legal
instruments such as the revised International Health Regulations (2005) and the WHO Framework
Convention on Tobacco Control (FCTC), which also entered into force in 2005, have resulted in
124 Global Health Centre | February 2021
binding obligations for different sectors (and for governments as a whole) with regard to protecting
and promoting public health.
Because of the influence of different sectors on health – an influence that may be either positive or
negative – it is necessary to achieve effective intersectoral engagement and coordination. Both at
the domestic level and in the international arena, such integrative diplomacy has become increas-
ingly important for the promotion of health. The adoption of the SDGs has accelerated this shift to-
wards policy coherence and integrative diplomacy. However, governments often find it difficult to
align, for example, their trade and economic policies with their national and global health objectives.
Policy coherence is particularly important – and difficult to achieve – when cross-sectoral interac-
tion is tightly embedded in multilateral processes and negotiations. Notable examples illustrating
the need for policy coherence through integrative diplomacy are the negotiations and processes in
the framework of international legal regimes such as the FCTC and the revised IHR; multidisciplinary
negotiations on how to tackle the mounting global challenges of health security and antimicrobial
resistance; and efforts to place more emphasis on health in the global dialogue on climate change.
Negotiations on issues of high priority at the global level are conducted not only at regular multilat-
eral forums and summits, but increasingly also at ad hoc high-level conferences. The more relevant
such negotiations are to certain States, the more these will strive for the synergistic interaction of
diplomacy efforts at various levels and within the framework of different organizations, processes
and meetings – a strategy sometimes referred to as “forum shopping”.
8.2 Using existing mechanisms more effectively for policy coherence
Policy coherence is about upholding shared values and achieving common goals. By using univer-
sally accepted platforms, such as the 2030 Agenda for Sustainable Development, more effectively,
cross-sectoral coherence in support of health and agreed values – such as human rights – can be
achieved through integrative diplomacy.
By virtue of their binding force, international legal instruments in the field of health can contribute
greatly to cross-sectoral coherence. For example, the FCTC requires countries to establish a nation-
al coordination mechanism for tobacco control. Similarly, the revised International Health Regula-
tions (2005) stipulate that a public health response to the international spread of disease should
“avoid unnecessary interference with international traffic and trade”. Moreover, several environ-
mental, labour, trade and other sectoral treaties contain binding provisions that support health
objectives. All these legal regimes can help to foster cross-sectoral synergies.
A guide to global health diplomacy 125
While the contribution of such sectors as education, social protection, agriculture, trade and trans-
port to health has long been recognized, in recent years there has been increasing involvement by
other sectors that were not previously regarded as partners for the health sector’s day-to-day
work. Examples of such sectors are customs (in relation to the Protocol to Eliminate Illicit Trade in
Tobacco Products, which entered into force in 2018), migration (in connection with the rising inter-
est in migration and health) and telecommunications (as a result of the rapid expansion of digital
health). Keeping experts and authorities aware of new and emerging issues at the interface of
health with other sectors is important to ensure effective policy dialogue and coherence. Policy
networks play an increasingly important role in this regard.
In some cases, opportunities arise when all relevant sectors are brought together by a major health
crisis, such as a disease outbreak or a heatwave. The ensuing intense interactions improve these
sectors’ mutual understanding and trust, which can help to sustain regular dialogue afterwards.
8.3 The domestic groundwork for global policy coherence
Health and health-related issues are frequently on the table during multilateral negotiations, both
within and outside WHO. Because of the cross-sectoral nature of health matters, front-line negoti-
ators are often under pressure to reconcile the views – often conflicting ones – of different sectors.
Achieving a coherent government stand on the various issues, before or between negotiating ses-
sions, is an important factor in determining the success of negotiations. Governments therefore
frequently set up national multi-stakeholder coordination mechanisms to support multilateral nego-
tiations. Some countries have developed national global health strategies to support coherence
and clarify the objectives of such efforts (more on this in Section 8.4).
National coordination mechanisms vary depending on the issues and actors involved. There are,
however, some common features, as follows:
A proactive approach by the health ministry is essential. This is above all because other sectors may
not be aware of the health implications (often hidden or largely technical) of issues discussed in
non-health forums. Moreover, it is the health sector that has to deal with the consequences, should
the protection of public health fail.
Cross-sectoral coordination within a country involves both technical and political debate. The tech-
nical exchange of rules, norms and evidence across sectors is usually not sufficient. Higher-level
political consensus, often involving compromise and trade-offs, is normally required when develop-
ing the mandate for subsequent negotiations.
126 Global Health Centre | February 2021
Foreign ministries need to be involved in order to ensure coherence with a country’s relevant mul-
tilateral commitments and priorities. Such umbrella involvement may not be as intense as the ex-
change between sectoral ministries, but it is still essential from a political and foreign policy per-
spective. In many negotiations, particularly those taking place in the principal international forums
and hubs, foreign ministry representatives are members of the national delegation, or they may
actually lead it. This makes prior coordination even more important.
National intersectoral coordination can be promoted by coherence between the approaches of
relevant international organizations. Intersectoral arguments presented by WHO that are harmo-
nized with those of other organizations – such as the World Bank, FAO, the International Labour
Organization (ILO) and UNEP – help to increase the various sectors’ understanding of and confi-
dence in one another.
Achieving convergence on key intersectoral issues during, rather than before, multilateral negotiations
is usually difficult because of the intensity and changing dynamics of negotiations and the lack of time
to consult with relevant ministries in the capital. Unless sufficient preparatory work has been carried
out at home, seeking convergence within a national intersectoral delegation can often be as demand-
ing as negotiating with other delegations. Chapter 11 explains in more detail how coordination with
different non-health sectors works, including the role of the health sector in such coordination.
While preparing a coherent negotiating platform is the responsibility of governments, these will
frequently involve relevant non-State actors in the process – for example, through open multi-stake-
holder dialogue to provide input for the formal preparations. It is particularly helpful to draw on the
knowledge of civil society and professional organizations that are members of international allianc-
es with observer status at the multilateral negotiations on the issues at stake.
8.4 The importance of a national global health strategy
Global health is one of the few areas of diplomacy in which countries have drawn up national strat-
egies to address a global issue. Switzerland was the first country to adopt a health-related foreign
policy in 2006. Since then, a number of countries have adopted national strategies on global health,
enabling them to align their commitments to global health with national health and foreign policies.
These include France, Germany, Japan, Thailand, the United Kingdom and the United States. Many
other countries – including Brazil, Cameroon, Canada, China, Norway, South Africa and Sweden –
have identified specific priority areas for engaging more proactively in global health diplomacy.
Most of the countries that have so far adopted national strategies on global health are donor coun-
A guide to global health diplomacy 127
tries, high-income countries and emerging economies. They are often pursuing specific geopolitical
interests and striving for influence. However, all countries should consider such strategies, since
national health issues are tightly interlinked with global health ones. Additionally, in the case of
low- and middle-income countries, ensuring that the national health strategy meets donors’ expec-
tations and engaging as a country (or regional group) in international forums are both essential to
optimize the impact of donor funding on health at the national level.
The health ministry is normally the ministry responsible for liaison with WHO, and it usually has a
department dealing with international health. However, on political matters, the positions adopted
by the foreign ministry will overrule those of the health ministry. In some cases, there is a focal
point for global health within the foreign ministry, while some countries have even appointed glob-
al health ambassadors. In high-income countries, the ministry of development and development
agencies are often the focal points for health organizations, such as the Global Fund, that receive
significant financial contributions from donors. These various players will interact with the network
of diplomatic representations in Geneva or New York to give instructions or develop positions. The
first point of contact will usually be a health attaché in the diplomatic mission – normally a diplomat
who has been assigned the health portfolio (often together with a few other portfolios), though
sometimes it is a health professional seconded from the health ministry.
It can be very difficult to achieve coherence at the national level between global health efforts,
since this requires working with different agencies and actors at various levels of governance both
at home and abroad. There is inevitably competition – sometimes even conflict – between minis-
tries and agencies. This means that diplomatic representations often have to contend with and
reconcile the divergent positions of different ministries. In donor countries, it is the national parlia-
ment that ultimately decides the level of global health funding. Parliaments also decide the
amounts that are to be spent bilaterally and multilaterally, and which ministries are to have control
of the budget.
In many countries the international health departments in the health ministry are weak and under-
staffed. Yet, they are expected to be able to provide sound technical advice on the many proposals
emerging out of different multilateral processes. In some cases, they are also expected to take the
initiative and develop resolutions on behalf of their country.
The agendas of the WHO Executive Board and of the World Health Assembly have expanded signifi-
cantly, and their implications are more complex and political than in the past. Engaging fully with
these agendas requires knowledge of other multilateral processes that are under way – for exam-
ple, in order to understand the positions taken by Member States on antimicrobial resistance it is
necessary to be aware of relevant negotiations at FAO. Similarly, a donor country’s decision to be-
128 Global Health Centre | February 2021
come involved in funding health systems requires coordination between the ministry (health or
foreign affairs) overseeing Global Fund investments and the finance ministry, which represents the
country at the World Bank.
Low- and middle-income countries often lack sufficient capacity in their various ministries and the
diplomatic service to be able to engage properly in complex negotiations. Moreover, smaller dele-
gations at global health negotiations find it difficult to participate fully and influence the outcome
of these. Sharing the burden between different country representations from the same region or
between countries with shared interests in Geneva and New York is becoming an essential part of
successful global health diplomacy. Regional entities, such as the AU and EU, are increasingly
making such arrangements.
As far as their global health strategies are concerned, a priority for low- and middle-income coun-
tries is to be well prepared to engage with the various global health actors, including international
organizations. Many such countries, for example, have a cooperation strategy with WHO. Several
ministries and government bodies other than the health ministry play a key role in this respect,
especially when the focus is on donor coordination and securing foreign investment to build up the
health system. African countries have for a long time been calling for greater donor coordination
and accountability. Despite agreements negotiated at major conferences – such as the Internation-
al Conference on Financing for Development held in Monterrey, Mexico, in 2002, which brought
together more than 50 Heads of State and Government and over 200 ministers of foreign affairs,
trade, development and finance – the reality on the ground leaves much to be desired. A key objec-
tive of global health negotiations at the country level is to make the delivery of aid more efficient by
aligning donor programmes with national plans. A good example is the way in which Ethiopia has
aligned Global Fund and PEPFAR investments with its national priorities to establish a primary
health care system capable not only of combating HIV but also of dealing with child vaccination,
maternal health care, tuberculosis and hypertension treatment, and the promotion of hygiene.
Middle-income countries and emerging economies are often at a halfway point between focusing
on bringing coherence to national efforts supported by international donor funding, on the one
hand, and being an active player in global health forums, on the other. For example, Brazil has long
advocated universal access to medicines, India has been a driving force in mobilizing global efforts
to combat tuberculosis, and the Russian Federation has been instrumental in putting noncommuni-
cable diseases on the global agenda.
Box 14 below provides brief guidance on negotiating a national strategy on global health.
A guide to global health diplomacy 129
Preparing a national strategy on global health starts with information-sharing, capacity-building
and internal negotiations among diplomats and civil servants at the national level to promote the
concept of a global health strategy and raise awareness of its expected positive impacts. The ra-
tionale for developing such a strategy is based on the notion, enshrined in the SDGs, that global
health issues are relevant to all countries, regardless of their economic status and political influ-
ence, and can only be tackled by a joint global effort. The concept is not yet universally accepted,
though. Moreover, securing political acceptance for such a strategy has become harder lately,
because of growing nationalism and questioning of the multilateral system. The adoption, in Oc-
tober 2020, by the German Government of a global health strategy for 2020–2030 is therefore a
very important signal.
Moving towards a global health agenda at the national level implies a strong national commit-
ment to the strengthening of multilateral institutions in health and to multilateral governance. In
donor countries, a focus on multilateral engagement may be interpreted by some as a weakening
of bilateral development aid that has the potential to reduce the country’s visibility and political
influence on the global stage.
One of the main challenges in the design of a national global health strategy is to achieve coher-
ence between national policies in various areas. The multisectoral nature of global health should
be a key element in its governance both at the national and international level. This is something
that diplomats need to understand and take into account. Global health strategies encompass
common goods, development and peace, ethical values and multilateralism, and primary responsi-
bility for them rests with the whole of the government, rather than with the ministry of health alone.
The key preparatory step is conducting consultations with a large number of stakeholders. Such
consultations may be overseen by a steering committee with, ideally, joint leadership provided by
the health and foreign ministries (or the development ministry). In countries with a formally des-
ignated ambassador for global health, he or she may be the most appropriate person to chair the
steering committee. In addition to a steering committee, an international advisory board on glob-
al health can provide helpful input, as recently pioneered by Germany. Consultations should start
by undertaking a comprehensive review of national health and foreign policies, and also of the
country’s international and multilateral commitments. Experience has shown that it is often more
effective to share a so-called zero draft and ask stakeholders for comments and additions, rather
than holding open ended consultations. The selection of stakeholders for the consultations will
inevitably have an impact on their outcome.
Box 14: Preparing a national strategy on global health
130 Global Health Centre | February 2021
The next step is setting priorities. Strategies are national, which means that their specific priori-
ties will vary from country to country. A common feature of all strategies, however, is that they
deal with all or some of the issues generally regarded as key global health issues, such as com-
bating epidemics or tackling antimicrobial resistance. National strategies will also have in com-
mon several underlying values, such as a commitment to defending human rights, reducing
health inequalities and achieving universal health coverage. Taking decisions on the priorities in
a national strategy on global health may prove to be quite challenging. Tensions may arise, for
example, between a political discourse in favour of universal access on the one hand, and the
protection of national commercial interests on the other.
A successful national strategy not only sets the policy priorities, but also outlines the interminis-
terial process for defining negotiation positions. This can be done through regular interministerial
coordination meetings or through a specific process for global health, and should combine incen-
tives for collaboration at ministerial, senior official and desk officer level.
Ultimately, decisions are taken by the executive branch of government and are not usually debat-
ed by the legislative branch.
The Swiss national strategy on global health, for instance, sets out six priority areas to which a
common approach has been agreed on by government bodies as diverse as the Federal Office of
Public Health, the Federal Department of Foreign Affairs, the State Secretariat for Economic Af-
fairs and the Federal Institute of Intellectual Property. The six areas were identified through con-
sultations with central and local government bodies, the research community, civil society, the
private sector and patients’ organizations. Officially entitled Swiss Health Foreign Policy 2019–
2024, the strategy is intended to enable Switzerland to develop a coordinated, coherent public
health policy at both the national and international level. Given the rapidly changing internation-
al environment, it will be reviewed periodically.
The six priority areas of the Swiss Health Foreign Policy 2019–2024
1. Health protection and humanitarian crises
2. Access to medicines
3. Sustainable health care and digitalization
4. Health determinants
5. Governance of the global health regime
6. Addiction policy
A guide to global health diplomacy 131
The five priorities of the German global health strategy for 2020–2030
1. Promoting good health, preventing diseases and developing adequate responses
2. Holistic approaches to the environment, the climate change and public health
3. Strengthening health systems
4. Protecting health by addressing cross-border health threats
5. Advancing research and innovation for global health
132 Global Health Centre | February 2021
A guide to global health diplomacy 133
PART C:
THE ELEMENTS
OF SUCCESSFUL
GLOBAL HEALTH
DIPLOMACY
134 Global Health Centre | February 2021
A guide to global health diplomacy 135
CHAPTER 9 | ACHIEVEMENTS
IN GLOBAL HEALTH DIPLOMACY
9.1 Defining success in global health diplomacy
Judging success or failure in global health diplomacy always depends on the context and the actor.
Success should arguably be measured in terms of the extent to which opportunities have been
created to change the direction of events – in this case the benefit to health and well being. How-
ever, agreements reached at the global level have to be enacted at the national – in some cases
also subnational – level. This means that success depends very much on States’ implementation of
global agreements and resolutions, not just on achieving certain outcomes in global venues. In part
such implementation is further influenced by the type of agreement reached – for example, if it is
hard or soft law.
It is important to note that success in global health diplomacy is at times also linked to extraordinary
individuals and negotiators. Because of the diversity and complexity of the issues involved, a strong
personality and passionate commitment can make a big difference in many global health negotiations.
Success depends of course on what a country or other interested party had set out to achieve in the
first place. What one negotiator considers to be success may represent failure for another, which is
why WHO strives for decision-making by consensus, trying to ensure that all countries are on board.
However, this can sometimes result in outcomes based on the lowest common denominator.
Member States may occasionally try to push specific issues that do not merit global attention at the
time (such as a control plan for a single disease) on to the agenda of the WHO governing bodies
just to please domestic audiences or, in some cases, to promote vested business interests. Further-
more, certain agenda items keep recurring at WHO on which progress has yet to be achieved, such
as tackling substandard and falsified medical products (a topic which has occupied a WHO working
group for many years), or the destruction of any remaining stocks of smallpox virus. In these cases,
public health interests are overshadowed by political agendas.
The COVID-19 pandemic posed new challenges for WHO, whose work was made harder by the po-
litical tensions between China and the United States, and which had to coordinate a response using
limited resources. Multilateral response has not worked well at the UN level either. The Security
136 Global Health Centre | February 2021
Council was unable, because of disagreements between permanent members, to adopt a resolution
endorsing the Secretary-General’s call for ceasefires during the pandemic in conflict zones.
Nevertheless, the Seventy-third World Health Assembly in May 2020 – the first Health Assembly to
be conducted in virtual format – achieved a relative success by adopting a balanced, albeit cau-
tiously worded resolution on the COVID-19 response (WHA73.1). This EU-initiated resolution covers
many aspects of the pandemic and calls for an independent evaluation of the international re-
sponse, including, but not limited to, WHO’s role. It recognizes extensive immunization against
COVID-19 as a global public good. The resolution also makes several references to the right of
countries to legally override international patent rules during a health emergency, making use of
the “flexibilities” under the TRIPS Agreement – an issue that was central to advocacy efforts by
civil society.
Well-conducted global health diplomacy can lead to the following key results:
Æ
Better health: better population health outcomes for each and every one of the countries in-
volved, along with an improved global health situation in achievement of the SDGs;
Æ
Improved global solidarity: improved relations between States and a commitment of a wide
range of actors to working together to advance health, common goods for health and support
multilateralism; and
Æ
More equity: outcomes that are deemed fair and support the goals of promoting human rights,
reducing poverty and increasing social justice.
A guide to global health diplomacy 137
9.2 Examining success
The 10 examples presented briefly below can serve as an entry point for closer examination and an
assessment of lessons learned from successful past negotiations in global health diplomacy.
Æ
The SDGs, which were negotiated by the UN Member States with significant input from other
actors, include almost 50 health-related targets, many of which require constant vigilance and
negotiations at several different venues. Health, as a result, is widely seen both as a beneficia-
ry of and contributor to almost all of the SDGs, not just the health-specific Goal 3. A key mea-
sure of successful global health diplomacy is its contribution to progress towards the SDGs.
Several high-level meetings have helped to move this agenda forward.
Æ
A major success in global health diplomacy over the past decade has been the way in which
health issues were taken up by non-health forums at the UN, that is, by the General Assembly
(noncommunicable diseases, tuberculosis, antimicrobial resistance, universal health coverage)
and
the Security Council (HIV/AIDS, health in conflict areas, Ebola). This success was facilitated
to a great extent by pro-health statements by the G7 and the G20.
Æ
At the UN General Assembly in September 2019, 12 multilateral health, development and hu-
manitarian agencies launched a joint plan to support countries in making swifter progress to-
wards the health-related SDG targets. The Global Action Plan for Healthy Lives and Well being
for All, as it is entitled, is designed to help countries to identify their priorities and to plan and
implement their work; it will also support efforts in key areas, such as primary health care.
Æ
A UN high level meeting on 23 September 2019 resulted in the adoption of a landmark declara-
tion on universal health coverage, which recognizes that it is not only access to health care
services that matters but also access to a healthy lifestyle, information allowing one to make
the right choices, health literacy, healthy food, transport, a healthier environment and other
determinants of health.
More details of the negotiations leading to the Political declaration of the high-level meeting on
universal health coverage (2019) are provided in Case Study 2.
Æ
The world’s first-ever summit of Heads of State and Government on the prevention and control
of noncommunicable diseases (NCDs) was convened by the Caribbean Community (CARICOM)
in 2007, resulting in the Declaration of Port of Spain entitled “Uniting to stop the epidemic of
chronic non communicable diseases”. The English-speaking Caribbean once had the highest
per capita burden of chronic NCDs in the Americas region. Building on a long history of cooper-
138 Global Health Centre | February 2021
ation in health among its member countries and on past successes in eliminating or reducing
communicable diseases through collective action, CARICOM therefore decided to target NCDs
and subsequently turned this approach into a global one by successfully campaigning for a first
UN high-level meeting on NCDs.
Æ
The 2014 outbreak of Ebola in western Africa posed a severe threat to human life in a globalized
world in which pathogens are able to spread quickly. In the countries most affected, however,
national capacities were inadequate to deal with the epidemic and leaders were reluctant to
acknowledge its full implications. WHO declared a Public Health Emergency of International
Concern in August 2014 to alert countries and trigger action. The epidemic was subsequently
declared by the UN Security Council to be a global threat, which made it possible for the inter-
national community to further bolster direct support to the countries concerned.
Æ
The Seventy-second World Health Assembly in May 2019 adopted a landmark resolution urging
Member States to introduce transparency policies and the Human Rights Council adopted a
resolution on improving access to medicines in July 2019.
After nearly a decade of global health diplomacy, NGOs and professional organizations, supported
by a group of Member States, succeeded in ensuring that the third UN high-level meeting on
NCDs (2018) expanded the earlier meetings’ focus on four major NCDs (cardiovascular diseases,
cancer, diabetes and respiratory diseases) and four risk factors (tobacco use, physical inactivity,
the harmful use of alcohol and unhealthy diets). The result was the adoption of a “five-by-five”
approach, with mental health conditions now included as an NCD and air pollution as a risk factor.
Successes in this area (political commitments) are overshadowed by the impact of commercial
determinants. The Political Declaration of the United Nations General Assembly on the Prevention
and Control of NCDs in 2011 included a commitment from governments to explore the provision
of adequate resources through, inter alia, domestic and bilateral channels. However, this goal has
not been fulfilled. NCDs remain the largest, most internationally underfunded public health issue
globally, where most lives could be saved or improved, because the political momentum was
offset by the interference in international health policy-making of vested economic, market and
commercial interest groups in donor countries. Unfortunately, most developed countries show
limited interest in pursuing policy coherence and recognizing the interconnectedness of promot-
ing a multilateral trading system under the WTO with promoting health in their international de-
velopment policies as two sides of the same coin in terms of achieving the indivisible SDGs.
A guide to global health diplomacy 139
See Case Study 1 on the above mentioned World Health Assembly resolution.
Æ
The adoption of the WHO Global Code of Practice on the International Recruitment of Health
Personnel in May 2010, which created a global framework, including ethical norms and institu-
tional and legal arrangements, to guide international cooperation on the critical problem of
health worker migration. Mandated in 2004, it took six years in all to draw up the Code of
Practice. The art of compromise proved to be essential during the long and tortuous negotia-
tions in order to reach a satisfactory but non-binding agreement for both countries of origin of
health worker migration and destination countries (Taylor & Dhillon, 2011). More on global
health instruments can be found in Chapter 5.
Æ
Since the entry into force of the FCTC in 2005, the biennial global progress reports prepared by
the Convention Secretariat have provided a good overview of its implementation by the Parties.
Although the rate of progress differs considerably from country to country, it is a tremendous
achievement that, despite the tobacco industry’s resistance, so many effective measures have
already been taken to reduce the use of tobacco. Implementation has been most successful in
the following three areas: the creation of smoke-free environments; the banning of misleading
tobacco packaging and labelling; and education, communications and public awareness pro-
grammes. In general, though the implementation of the Convention’s provisions has been quite
uneven in many countries.
Æ
The International Health Regulations, in their revised version from 2005, are the key internation-
al legal instrument regulating the public health preparedness and response of countries to the
international spread of disease. However, both the Ebola epidemic and the COVID-19 pandem-
ic have highlighted a lack of preparedness. Many Member States have failed, for financial or
political reasons, to build up adequate capacity and to honour their obligations to implement all
the measures provided for in the IHR.
140 Global Health Centre | February 2021
A guide to global health diplomacy 141
CHAPTER 10 | ANALYSING
NATIONAL AND GEOPOLITICAL
INTERESTS
10.1 Understanding the complexity of global health issues
Global health diplomacy has to deal with several complexities at the same time: the new complex-
ity of the international system, the complexity of the organizations and actors operating in the field
of global health, and the complexity of global health issues, which have strongly interlinked social,
political and economic determinants. These complexities require upstream political responses at
the national and supranational level. However, experience shows that negotiations in Geneva tend
to follow a technical and segmented approach. Such an approach should be resisted because
global health diplomacy cannot be dissociated from geopolitics.
A global health diplomat needs to be able to understand the national and geopolitical interests that
may lie behind negotiations on a resolution or decision. There are several aspects to consider.
The world is going through a period of transition and geopolitical instability. Globalization continues
to advance, which means that domestic conditions in a country are increasingly shaped by events
and processes taking place elsewhere. At the same time, and somewhat paradoxically, confidence
in and commitment to multilateralism are decreasing, which is leading to the rise of regionalism,
nationalism and protectionism. In some parts of the world, the international order based on the rule
of law has been openly challenged. In this tense atmosphere, health was until recently one of the
few areas in which multilateral governance continued to be fully accepted and active. This changed
during the COVID-19 pandemic, with the geopolitical stand-off between China and the United
States leaving its mark on global health. Moreover, a new “vaccine nationalism” has emerged in
several countries.
As members of a larger diplomatic network, health diplomats can benefit from the regular analyses
of the state of the world and of specific regions, countries and issues conducted by specialized
departments of their foreign ministry. A diplomat must make every effort to understand geopolitical
changes. Similarly, it is important to understand different mindsets. In global health diplomacy – as
in other areas of diplomacy – much of the academic analysis has been conducted from a Western
perspective on international relations. Other perspectives and diplomatic cultures need to be taken
into account, too.
142 Global Health Centre | February 2021
10.2 Building relationships in Geneva and other negotiating hubs
Since global health issues are highly interconnected, they may come up for discussion concurrent-
ly or separately at different forums in Geneva, the main negotiation hub for global health diplomacy.
Access to medicines, for example, has been and is being debated at the WTO, WIPO, the Human
Rights Council, the ICRC, the UNAIDS Programme Coordinating Board and the Board of the Global
Fund, as well as at WHO.
It is essential for diplomats to liaise regularly with fellow diplomats and with technical experts
within the mission who are in charge of following up on the work of the various Geneva-based or-
ganizations. This may be easier in a small mission. In a larger one, it will require coordination –
something that is done remarkably well in some of the largest missions in Geneva – and, most im-
portantly, initiative, talent and energy.
Communicating with the non-health sectors and with colleagues in the mission who are responsi-
ble for those other areas will enable awareness of important issues that may first come up outside
the health context. It will also contribute to coherence in the positions and language adopted by a
country’s delegation at different forums.
Communication with fellow diplomats from other missions in Geneva should take place both on a
personal basis and within the framework of formal and informal groups, which may include groups
such as the AU, the EU, constituents of the WHO regional groups, subregions (for example, West
Africa) and gatherings of like-minded or donor countries.
10.3 Gathering available information
Studying documents and other information material from previous negotiations at WHO or other
organizations helps in understanding better the subject matter and the national and geopolitical
complexities behind an issue that is to be discussed.
Moreover, such information-gathering will shed light on the positions previously taken by negotiat-
ing countries. It also enables the compilation of examples of previously agreed language on the issue
under debate or on other issues or processes relevant to the current negotiation. Resolutions and
declarations adopted by consensus at the UN are the most promising in that respect. In negotiations
on a controversial global health issue, referring to the language adopted at the General Assembly
during the SDG negotiations in 2015 can serve as a good starting point for building consensus.
A guide to global health diplomacy 143
In contrast, drawing on the language used in conclusions and reports that were not approved by
consensus is less useful for the above purpose. For example, the final report of the UN Secretary
General’s High-Level Panel on Access to Medicines, issued in 2016, anticipated to a great extent
the resolution on transparency in the pricing of medicines that was adopted at WHO in 2019. How-
ever, the impact of that UN report was impaired by the disagreement between Panel members on
a number of other issues in the document.
The importance of agreed language should not be underestimated. One particular UN forum may
be more suited than another to endorse language or terminology on a sensitive issue. Language on
sexual and reproductive rights and vulnerable populations at high risk of HIV infection has been
adopted, for example in the UN General Assembly resolutions on HIV/AIDS and can be used as a
precedent to support such language in other resolutions in other organizations.
10.4 Understanding positions
Understanding how Member States develop their positions for negotiations comes with experience.
A senior diplomat in Geneva once remarked that she had spent most of her first year at WHO listen-
ing to debates and observing negotiations in order to understand better how geopolitics and na-
tional interests determine the issues taken up by Member States and are reflected in the positions
they try to defend and promote. Countries normally take positions informed by their specific needs.
To start with, these positions are often more radical than the interests they are seeking to defend,
which creates some leeway for negotiation.
There are a number of issues that some countries will constantly raise or take a strong position on
in a debate or during negotiations, for example NCDs (Russian Federation), primary health care
(Kazakhstan), drug policy (Switzerland), substandard medicines (India), tuberculosis (South Africa)
and sexual and reproductive rights (United States and the Nordic countries). The positions of some
countries on these issues are often predictable over longer time periods – for example, the Nordic
countries’ support for sexual and reproductive health. In the case of the United States, it may de-
pend on the administration in power.
While a common line is normally to be expected from EU Member States, some dissent may appear
on issues such as sexual and reproductive rights or the prevention of NCDs. Similarly, the BRICS
countries now constitute a less cohesive bloc than a few years ago.
China shows relative restraint at WHO but remains highly influential. Thus, China may ally itself
with different countries on different issues – for example, with the Russian Federation on security
144 Global Health Centre | February 2021
issues and with India and South Africa on medicines policy and transparency in the pricing of
medicines. A global game changer was South Africa’s historic legal challenge on access to cheaper
drug treatment for HIV/AIDS. Usually in each region there are countries that are more vocal than
others in global health forums.
As part of their stakeholder analysis, global health diplomats have to be able to recognize situations
in which hidden interests, be they political or economic, determine a country’s position or in which
a smaller country is serving as a vehicle for the agenda of a larger country or entity.
10.5 Examining negotiation blocs and alliances
Health negotiations often see the long-standing blocs come together, although the geopolitical
landscape has changed considerably since the first decade of the 21st century. The United States
still often leads the way, entering into shifting and sometimes surprising alliances, though its once
hegemonic position is weakening. The EU is a bloc that adopts a common position in negotiations,
although countries such as Hungary and Poland tend to dissociate themselves from the EU consen-
sus on such sensitive issues as lesbian, gay, bisexual and transgender persons, sexual and repro-
ductive rights, or health and migration. The AU is another bloc, often strongly united when the is-
sue under discussion is more political than technical – for example, an election within an
international organization. There are of course several other regional blocs; they are described in
more detail in Chapter 7.
A guide to global health diplomacy 145
When preparing for a negotiation it may be useful to analyse negotiation blocs, their members and
other stakeholders with reference to the following diagram:
Level of importance
Level of influence
high importance
low influence
the “victims”
high importance
high influence
the ones that can
make the difference
high importance
low influence
the “bystanders”
low importance
high influence
the “irresponsible”
A. B.
D. C.
Source: Multi-Stakeholder Partnerships (http://www.mspguide.org/tool/stakeholder-analysis-importanceinfluence-matrix)
While a bloc may adopt a common position on the text to be negotiated, countries within that bloc
may still express their own specific views once the negotiations have started. Any red lines decided
on by the bloc will, however, be respected by the countries belonging to it.
A country’s diplomatic representation will regularly study political groups and voting blocs in the
UN context and how those operate. Some countries, such as the United States, are using publicly
available UN records to track “voting coincidence” with their positions, while some researchers and
think tanks have conducted analysis of voting patterns, which can be useful for diplomats.
An asset of being the member of a bloc, such as the AU or EU, is that the detailed preparatory work
for negotiations may be undertaken by a member that has a particular interest in the issue at stake
(referred to as the “penholder”). The other members can benefit from that work thanks to the rela-
tionship of mutual trust that exists within the bloc. Special groups – such as the Geneva Group, an
informal group (established in 1964) of UN Member States each of which pays more than 1% of the
UN’s regular budget – also play an important role. Those blocs and individual countries that wield
146 Global Health Centre | February 2021
great influence in global health – such as the EU, the AU, the United States, the United Kingdom,
France, Germany, Japan or Brazil – tend to have a position on all the topics that may come up
during negotiations. Many other national delegations will listen attentively to the debates but will
intervene only on specific topics. The Russian Federation, for example, always participates vigor-
ously in any discussion on NCDs and health security. Smaller countries with small Geneva-based
missions – whose diplomats have to deal simultaneously with health, human rights and labour is-
sues, and which have less expertise in global health to draw on in their capitals – will often partic-
ipate less actively in the negotiations, unless the topic is essential to them. Some of these countries
may be part of geographical groups (for example, the Middle East and North Africa) or of ad hoc
alliances with larger countries or blocs that will defend their positions on their own and in conjunc-
tion with their allies.
An example of a permanent alliance is the South-Eastern Europe Health Network (SEEHN), which
brings together nine countries, mostly from the Balkans. Established in 2001, SEEHN aims to
strengthen national health systems, promote stability and help to prepare the region for EU integra-
tion. This cross-country cooperation now takes the form of health diplomacy, reflecting the weight
of concerted actions, primarily in the WHO governing bodies. The lessons learned from engaging in
health policy negotiations at the European level mean that SEEHN member countries have the po-
tential to speak with an influential voice in global WHO negotiations as well.
A guide to global health diplomacy 147
CHAPTER 11 | COORDINATION
WITH NON-HEALTH SECTORS
11.1 The interface between health and other sectors
at the national level
The role of different sectors in advancing global health has not always been properly acknowledged.
There is a long history of cooperation with some sectors, while cooperation with others has only
recently increased or begun in the first place. Very frequently, opportunities are lost to promote
health by addressing the health determinants in other negotiations. The sectors that can play an
important role when it comes to taking a global health agenda forward are discussed below.
Foreign policy has a fast-growing interface with health. This is the result of multiple factors: the
growing prominence of health in key global agendas (economic, security and social justice); the
mounting pressure of global health challenges that call for global solutions; the proliferation of in-
ternational actors and negotiations in the field of health; the rising profile of global health issues in
the UN and influential political blocs; and the complex mix of synergies and asymmetries (often
conflicts) between countries’ health-related commitments and their other international commit-
ments. The interaction of foreign policy and health is multifaceted: health can be an integral part of
foreign policy; foreign policy and diplomacy can be used to promote – and often protect – health in
multilateral forums; and health in turn can be used as a foreign policy instrument to achieve other
goals. Because of its wide scope, the interface between health and foreign policy manifests itself
in most health-related intersectoral relations in the multilateral arena.
Fiscal and budgetary matters have long been important factors in health policy in general and in
making progress towards universal health coverage in particular. Relevant issues in intersectoral
diplomacy for health include: bridging governments’ approaches to health and finance; assessing
political and institutional risks to the fiscal sustainability of health systems; creating mechanisms
for cooperation between health and finance ministries (though this is difficult and not always effec-
tive in practice); cost-effectiveness analysis and price containment strategies for medicines and
health technologies; and exploring innovative approaches to the financing of health (albeit with
caution because of the economic distortion often brought by higher or new taxes).
148 Global Health Centre | February 2021
International trade can both promote and impede health. Key issues related to the interface be-
tween trade and health include the cross-border spread of communicable diseases and food safety,
which are linked to trade restrictions introduced on grounds of health; access to medicines and
medical technologies, which is linked to import duties and intellectual property rights; trade in
health-related services, which has to do with cross-country health insurance and care, telemedi-
cine and medical tourism; and concerns over trade in unhealthy products such as soft drinks and
tobacco. Several WTO global trade agreements – the TRIPS Agreement, the Agreement on Techni-
cal Barriers to Trade, the Agreement on the Application of Sanitary and Phytosanitary Measures
and the General Agreement on Trade in Services – have substantial linkages to health. Moreover,
there are a large number of trade agreements at the regional (often also bilateral) level.
Health, therefore, often comes to the fore in international trade negotiations – particularly the
challenge of protecting public health interests vis à vis trade and economic interests. In recent
years, the potential impact of international investment agreements on health has also become
clear. Such agreements can, for example, be used to challenge strong national tobacco control
measures. Vigilance and diplomacy are essential to protect public health interests in trade and in-
vestment negotiations.
Environment has a profound impact on health. WHO estimates that 23% of all deaths worldwide
could be prevented through better management of the environment. The environmental determi-
nants of health are manifold: they include, in particular, air pollution (both ambient and household),
water and sanitation, chemical safety and radiation. Climate change is another global concern be-
cause of the health risks associated with extreme heat and water events, increased air pollution,
food and water insecurity, and vector- and water-borne diseases. Consequently, it is important to
coordinate efforts with a wide range of non-health sectors, including transport, housing, energy,
agriculture, land planning, water management and industry. Global mechanisms and processes
can facilitate national multisectoral dialogue. Examples of this include the International Decade for
Action, “Water for Sustainable Development”, 2018–2028; processes under several environmental
treaties; and the ongoing global dialogue on climate change.
Education has a positive effect on health by improving people’s employment prospects, income,
living conditions, literacy, access to information and general life skills. Investing in education is
synonymous with investing in health. Better health in turn promotes learning environments, oppor-
tunities and achievements. From a health diplomacy perspective, dialogue between the two sec-
tors can be expected to take place in both intersectoral and multisectoral settings, since health and
educational challenges often co-exist with other social challenges, such as housing conditions and
unemployment. It is also worth taking into account the potential of relevant multilateral forums –
that is, processes within the framework of UN human rights treaties and UNESCO treaties and
A guide to global health diplomacy 149
recommendations – to promote health and education at the same time.
Social and labour protection play a key role in health. Employment policies contribute to health by
helping to generate sufficient income for households, promoting active lifestyles and access to
health services, providing social benefits, fostering health-friendly working conditions and occupa-
tional safety, and preventing job insecurity. Good health in turn enables workers to work for longer
and be more productive. Housing policies are vital in improving social and living conditions and
preventing injuries and disease. The synergies between labour market and social policy, on the one
hand, and the health sector, on the other, can help to reduce social exclusion and inequalities.
Cross-sectoral diplomacy can tap into these synergies, both within a country and in multilateral
forums such as the ILO.
Food and agriculture have traditionally been linked to population health. Effective agricultural
policies can increase the supply and affordability of healthier and safer food, which is key in tack-
ling the challenges posed by malnutrition, unhealthy diets, obesity, NCDs and foodborne diseases.
Collaboration between the human and animal health sectors is critical in the fight against antimi-
crobial resistance. Coordination to ensure the production of healthier and safer food is required
across the entire food supply chain from better and more sustainable production and processing
models to accurate and informed nutrition labelling systems. There are also important linkages with
other sectors, such as trade, environment, consumer protection and education.
From a global health diplomacy perspective, several existing multilateral mechanisms provide op-
portunities for cross-sectoral dialogue and cooperation, including the FAO/WHO Codex Alimentari-
us Commission, the FAO/WHO International Conferences on Nutrition, mechanisms under relevant
WTO treaties such as the Agreement on the Application of Sanitary and Phytosanitary Measures
and the Agreement on Technical Barriers to Trade, and the FAO–OIE–WHO tripartite collaboration
on antimicrobial resistance.
Water is critically important for health. Access to clean water and sanitation facilities is a basic
human right, and improving such access is an important target in the SDGs. Key issues related to
water include quality standards, water supply, safety, access, storage and wastewater treatment.
Cooperation between the health and water management sectors at the national and local level is
fundamental to public health.
At the international level, health is often promoted through so-called water diplomacy, which is
about resolving disagreements and conflicts over shared – and often scarce – water resources in
the interests of cooperation, stability and peace. Several regional mechanisms support water diplo-
macy, including its interface with health. The Protocol on Water and Health (to the Water Conven-
150 Global Health Centre | February 2021
tion
21
) is a good example of a targeted multilateral response in the pan-European domain. Other
regional mechanisms have an impact on health by enabling broader cooperation on water manage-
ment. Examples include the Mekong River Commission in Asia, the Water Charter of the Lake Chad
Basin in Africa, the EU Water Framework Directive, and the Guarani Aquifer Agreement in South
America. National intersectoral dialogue contributes significantly to such cooperation.
Transport is linked to health in many ways. Key concerns related to transport include road safety,
air pollution, noise, congestion, greenhouse gas emissions, mobility constraints and sedentary life-
styles. Promoting safe, accessible and affordable public transport, along with walking and cycling,
can significantly improve population health. The interface between transport and health is also
linked to environmental and urban planning policies, and, more generally, to sustainable develop-
ment. Intersectoral and multisectoral dialogue within countries is essential to improve transport-re-
lated health outcomes. Such dialogue frequently also occurs in multilateral forums – for example,
the Global Ministerial Conferences on Road Safety, the UN Decade of Action for Road Safety
2021–2030, the Transport, Health and Environment Pan-European Programme conducted jointly by
WHO and the United Nations Economic Commission for Europe (UNECE), and various multilateral
forums dealing with air pollution, physical activity and NCDs.
11.2 Emerging linkages to other sectors
The health impacts of the sectors discussed in the preceding section have long been acknowledged.
However, globalization and the greater influence of transnational factors on health have led to
certain other sectors becoming more prominent in this context.
Law enforcement plays a growing role in public health. The areas of interaction between the two
sectors include violence prevention, misuse of alcohol and drugs, road safety, catastrophes, sex
work, mental health management, human trafficking and, most recently, illicit trade in tobacco
products (along with customs, another sector with an emerging interface with health). More
broadly, the interface also extends to community safety, public protection, migration, the manage-
ment of disease outbreaks, and health in prisons. Cooperation between the health and law enforce-
ment sectors can lead to improved health outcomes in countries. Such cooperation also helps to
strengthen cross-sectoral diplomacy in the relevant international forums – for example, processes
and mechanisms under the aegis of UNODC, negotiations to operationalize the Protocol to Elimi-
nate Illicit Trade in Tobacco Products, and global debates on road safety and violence.
21 Convention on the Protection and Use of Transboundary Watercourses and International Lakes (adopted in 1992).
A guide to global health diplomacy 151
The interface between migration and health is not new, but it has attracted particular attention in
the 21st century. It is an area in which multisectoral, and multilateral diplomacy should reinforce
each other. Action is needed both within and outside the health sector to meet the health needs of
refugees and migrants and to alleviate the pressure that they put on the health-care systems of
both transit and destination countries. Several non-health sectors are closely involved in this inter-
face, including education, employment, social security, housing, law enforcement and foreign pol-
icy. In wider terms, the health–migration interface is directly related to the fundamental values of
equity, solidarity and human rights. The recently adopted Global Compact for Safe, Orderly and
Regular Migration and Global Compact on Refugees (both under the aegis of the UN) – along with
relevant forums at WHO, the International Organization for Migration (IOM) and the Office of the
United Nations High Commissioner for Refugees (UNHCR) – have created greater opportunities for
multisectoral and multilateral dialogue.
Another emerging interface is that between health and the information technology and telecom-
munications sector, as testified by the growing interest in digital health worldwide. Thus, WHO
has initiated cooperation with the International Telecommunication Union, established a multidis-
ciplinary platform and issued its first set of guidelines on digital health interventions (2019). All of
these developments have created new opportunities for strengthening cross-sectoral dialogue.
11.3 The health sector’s role in cross-sectoral cooperation
The health sector plays a central role in cross-sectoral dialogue and coordination. Health ministries are
expected to initiate such coordination, advocate joint solutions, provide evidence, negotiate respons-
es and lead by example. Significantly, health ministries in most countries are not so adept at repre-
senting health interests in other sectors. This often proves to be a liability in global health diplomacy.
From a health diplomacy perspective, it is important that health ministries should persevere in
putting health issues higher on their countries’ political and foreign policy agendas. This strength-
ens the health sector’s influence and convening power with regard to multisectoral dialogue in
both the domestic and international arenas.
There are also other approaches that the health sector should consider in dealing with cross-sectoral
issues. For example, it is advisable to strive for a whole-of-government decision on issues that have
a significant multisectoral impact, rather than pressing ahead with a decision taken solely by the
health ministry. Similarly, dialogue with and feedback from parliaments on major multisectoral issues
can strengthen the political – and often legislative – support that parliaments are able to provide.
152 Global Health Centre | February 2021
Conducting a health impact assessment of major economic legislation and initiatives at an early
stage is another tool that health ministries can and often do use effectively. Finally, the health
sector should harness the potential of relevant international legal instruments to achieve better
intersectoral responses. For example, the FCTC contains binding obligations that impinge on sever-
al non-health sectors. Similarly, the comprehensive implementation of various non-health treaties
(covering areas such as human rights, labour and the environment), to which most countries are
party, can help to improve national health outcomes.
A guide to global health diplomacy 153
CHAPTER 12 | CONDUCTING
GLOBAL HEALTH NEGOTIATIONS
12.1 Competencies for global health diplomacy
Competency can be defined as a set of skills, knowledge and attitudes that enable people to per-
form well at work. A recent qualitative study has explored the state of competency management in
the Finnish diplomatic service, seeking to identify the main characteristics of a competent diplomat
(Kallinen, 2016). The OECD has developed a competency framework for employees at the various
levels of the Organisation (OECD, 2014). Many of the elements of this checklist-type framework also
apply to global health diplomacy (see Box 15). WHO also has a competency model of its own.
22
22 See: https://www.who.int/employment/competencies/WHO_competencies_EN.pdf.
Twelve tips for successful global health negotiations
1. Be prepared for all scenarios
2. Start by offering a clear road map, schedule and deadlines
3. Build trust with secretariat (WHO staff)
4. Understand the subject: read up on it and consult the experts
5. Know your partners and their strengths and weaknesses; identify how far they are
willing to compromise (their red lines); consider how flexible they may be in their
positions
6. Identify any vested interests: personal ambitions, geopolitical agendas and so on
7. Create alliances with key Member States, like-minded groups in the negotiation
hubs, fellow diplomats and so on
8. Know and apply the rules of procedure
9. Adapt to the cultural context
10. Be aware of tactics: ask for time; introduce constructive compromises, package deals,
face saving solutions and so on
11. Consider options outside the conference room: informal side meetings, coffee breaks
12. Remember that nothing is agreed until everything is agreed
154 Global Health Centre | February 2021
Effective global health diplomacy requires coordinated work by experts from various disciplines
who have different sets of skills, especially experts from the fields of foreign policy and public
health. Global health diplomats may come from the most diverse backgrounds and, consequently,
the extent of their knowledge of global public health and health policy varies greatly. Experience
suggests that the foreign affairs institutions tasked with training diplomats need to equip these
with additional knowledge, skills and abilities in health communication, analysis and public health
ethics so that they are able to promote global health more effectively. Similarly, public health insti-
tutions that train health professionals need to ensure that these acquire diplomatic skills and a
good knowledge of foreign languages and foreign policy matters.
Negotiations at the World Health Assembly require Member States’ diplomats and experts to wear
several hats, so to speak: in addition to participating in the formal structure of the World Health Assem-
bly (with plenary meetings and meetings of two committees), they also take part in meetings of draft-
ing groups, and they are involved in regional consultations and informal meetings with counterparts
from countries with similar interests and with non-State actors. Further informal interaction takes
place at coordination meetings, side events and technical briefings. Informal meetings over coffee
breaks and at receptions should not be underestimated either. Most of the substantial negotiations
take place within the drafting groups, outside of the committees. NGOs are typically not allowed to
attend meetings of drafting groups, which are reserved for Member States and essential WHO staff.
Ensuring that diplomats have a combination of different skills increases the professionalism of
global health diplomacy negotiations and the likelihood of achieving successful outcomes. Thailand
has systematically built national mechanisms and capacity for preparing young professionals for
global health diplomacy. The authorities there have recognized the importance of training, develop-
ing skills and practising these in real-life situations such as the World Health Assembly.
12.2 Understanding values
Values are fundamental pillars in global health negotiations. Global health is about delivering glob-
al public goods. Human dignity and rights, equity and universal access are key principles that must
be taken into account when seeking to achieve global health objectives. Since some countries may
express their own values and preferences or insist on their own way of interpreting universal values,
this may generate friction during negotiations on global health issues. Countries may even draw
red lines, making it harder to reach an acceptable compromise. This is happening more frequently
– not least in global health negotiations.
For example, the negotiations in New York in 2016 on the outcome document of the UN General
A guide to global health diplomacy 155
Assembly Special Session on the World Drug Problem could not overcome the red line drawn by
countries opposed to abolishing the death penalty for drug-related offences. Those countries that
consider capital punishment for such offences to be a violation of human rights finally agreed to
relinquish their position and to sign a declaration that did not mention abolition of the death pen-
alty. However, within minutes of the declaration having been adopted, these countries presented
their opposing views at the General Assembly and expressed their reservations on the text of the
declaration. They clearly felt that having no approved declaration as the outcome of the Special
Session would have posed a higher risk to global health and human rights in the future than reluc-
tantly agreeing to leave that matter out of the text.
There are a number of topics in global health negotiations with regard to which countries perceive
universal values to be at odds with their own values or interests. Among these topics are equitable
access to medicines (which poses a challenge to intellectual property frameworks and the interests
of national pharmaceutical industries); sexual and reproductive rights; the rights of sexual minori-
ties; out-of-pocket financing of health by citizens (an unacceptable concept for some countries);
and harm reduction (despite having been recommended by WHO, such medical interventions re-
main unacceptable to a number of Member States).
Countries may sometimes draw their red lines on the strength of empirical considerations, rather
than value-based arguments. For example, Finland’s opposition to vaccinating everyone against
hepatitis B is based on national epidemiological studies and considerations of cost-effectiveness.
Yet, that stance is at variance with the notion of universal vaccination coverage aimed at achieving
ultimate eradication of the disease.
12.3 Negotiation tactics and conflict resolution
What are the main negotiation tactics and why does WHO prefer decision-making by consensus?
In negotiation, “tactics” refer to the skilful use of the available means in order to reach a desired
outcome. Two different types of negotiation tactics may be distinguished in global health diplomacy:
policy type tactics (integrative bargaining) and transaction-type tactics (distributive bargaining).
In policy-type tactics, the parties share their views and values, and strive for reasonable compro-
mises (or a win–win situation), as is usually the case during negotiations of the WHO governing
bodies. In transaction-type tactics, power aspects are prevalent: one side usually wins at the ex-
pense of another, for instance when negotiating a commercial contract for the supply of medicines.
The UN system prefers decision-making by consensus as it confers legitimacy on the outcomes of
156 Global Health Centre | February 2021
negotiations: they are then more likely to be implemented and less costly in political terms. Howev-
er, this approach is often time-consuming, masks political and ideological divisions, and can hinder
rapid action in an emergency.
Integrative, or win–win, bargaining means that the parties seek to find a solution that leaves ev-
eryone better off. This approach requires the parties to collaborate and arrive at a compromise by
making some concessions. It is the preferred negotiation strategy in global health diplomacy.
The essential elements of integrative bargaining in negotiations are:
Æ
Identifying interests – trying to understand the interests of each party and how these could be
satisfied through a win–win solution.
Æ
People – separating the people from the problem. The better the relationship between fellow
negotiators, the more likely it is that the best win–win solution will be achieved.
Æ
Alternatives – it is crucial to think about alternatives even before the negotiations start. If the
negotiations do not result in an agreement, having alternatives means that the discussions can
be resumed at a later point.
Æ
Options – proposing realistic options together with the other parties helps in attaining a win–
win solution. This can be done through collective brainstorming.
Æ
Criteria/legitimacy – it may sometimes happen that two (or more) parties propose incompatible
solutions. In such cases, opting for one solution, even if it seems fair, could lead to resentment.
Instead, joint decision-making may help to reach an agreement.
Æ
Commitments – negotiations can only succeed if all parties honour the outcome and keep their
promises.
Æ
Communication – good communication skills are important to achieve the best solution and
may help to overcome the scepticism or hostility of other parties.
Distributive, or win–lose, bargaining is a competitive bargaining strategy in which one party
gains only if the other party loses something. Global health negotiations try to avoid such a situa-
tion. The ultimate aim, in a distributive bargaining approach, is not to attain a win–win kind of sit-
uation but for one side to win as much as it can. Both parties will try to get the maximum share from
the asset or resource which needs to be distributed.
A guide to global health diplomacy 157
Distributive Negotiation Strategy Integrative Negotiation Strategy
Distributive negotiation connotes a negotiation
technique wherein the parties try to gain
maximum value for themselves, from definite
resources.
Integrative negotiation can be described as
negotiation strategy which attempts to settle the
dispute, with a mutually acceptable solution.
Distributive negotiation is a competitive strategy.
Integrative negotiation uses a collaborative
approach.
Distributive negotiation has a win-lose
orientation.
Integrative negotiation is based on win-win
orientation.
When the resources are limited, distributive
negotiation is better.
Integrative negotiation is used when the
resources are in abundance.
In distributive negotiation, the parties' self-
interest and individual profit motivate the
parties.
In integrative negotiation mutual interest and
gain act as a motivation for the parties involved.
Distributive negotiation discusses only one issue
at a time.
Multiple issues are taken into account in an
integrative negotiation.
Controlled and the selective environment is there
in a distributive negotiation.
The communication climate is open and
constructive in an integrative negotiation.
Source: Vskills (2019).
How to handle conflicts?
Conflicts may arise at any point during a negotiation. The most common cause of conflict is oppos-
ing interests. Conflict resolution depends largely on using the following tactics:
Æ
It is important to develop good personal relations and mutual trust with the other negotiating
parties, and to understand their perspective, cultural background, interests and constraints. An
informal dinner early on during the negotiations can achieve a lot in that respect. The use of
humour can sometimes help to lessen tensions; taking time out can also calm the atmosphere.
Æ
Understanding the background of the negotiation itself and of the various parties, as well as
identifying the issues that matter, is essential. If it seems likely that a certain party will not
make concessions, approaching other key actors with similar opinions to those of that party can
be useful in terms of identifying ways of achieving a compromise.
Æ
Opening statements are vital in negotiations because they set a benchmark for the expecta-
tions of all the parties concerned. An optimistic opening statement sets high expectations, but
the danger is that if the agreement reached falls short of those expectations, it may be per-
158 Global Health Centre | February 2021
ceived as a failure, even though it is in fact a good outcome.
Æ
Restating core shared objectives including the basic principles that underpin global health and
human rights helps to remind participants of their common values.
Æ
It can be very helpful to agree on objective measures of the outcomes that are to be achieved,
as there is then a practical way of assessing the various solutions proposed.
Æ
Creative problem-solving to come up with new solutions is possible even during formal negotiations,
but it requires the chairperson to demonstrate leadership and the parties to trust one another.
Æ
Generally, negotiators begin from a conservative position reflecting their own interests; they
then make concessions, starting often with larger gestures and proceeding to small-scale ad-
justments in response to concessions made by other parties.
Æ
While it may seem important to achieve a particular outcome, if this can only be done by jeop-
ardizing the later ratification or implementation of the agreement by other parties, the victory
scored during the negotiations would be meaningless. It is therefore vital that as many parties
as possible should be satisfied with the outcome.
Æ
Negotiating parties must remember that nothing is agreed until everything is agreed. This often
means shuffling back and forth between different parts of the document and agreeing on sev-
eral issues at the same time.
A guide to global health diplomacy 159
Æ
There are often late-night sessions especially on the final day, with the looming deadline for
conclusion of the negotiations creating additional pressure on the parties to reach agreement.
This means that diplomats have to be prepared for long hours.
12.4 Understanding the rules and procedures
A good understanding of the relevant rules and procedures is crucial in multilateral negotiations. In
WHO, the rules of procedure of the governing bodies determine the course of the proceedings,
dictating who may speak when and under which circumstances. The rules of procedure can also be
used by delegations to gain tactical advantages.
Some key terms are defined below:
Æ
Procedure refers to the way in which the conference is conducted; it is set out in the rules of
procedure.
Æ
Rules of procedure refer to a document describing in detail how a conference is meant to op-
erate. The rules define the chairperson’s responsibilities, and explain, among other things, how
to deal with a procedural motion or what the consequences are of violating the rules. In the
case of established conferences, the rules of procedure will typically have been agreed for
previous sessions. For a new conference, the rules of procedure need to be agreed on by all
parties before the session begins.
Æ
Process refers to the way in which a proposal is handled, in particular the sequence of steps
involved. All relevant formal processes are also described in the rules of procedure.
12.5 Understanding global health actors and partners at home
Diplomatic skills begin with developing an ability to listen to and understand the views of others.
The players in the field of global health are remarkably diverse, ranging from government, aca-
demia and the private sector to local communities and civil society. To succeed in global health
diplomacy it is necessary first of all to enlist the support of national authorities. Moreover, it re-
quires building a strong negotiating base in Geneva (and other international hubs) being familiar
with the issues at stake and drawing on comprehensive analyses undertaken by experts, civil soci-
ety and other relevant stakeholders. A carefully prepared position needs to be agreed on by the
government. Several skills are necessary for these tasks, not least the ability to build a good work-
160 Global Health Centre | February 2021
ing relationship with officials in capitals and with fellow diplomats in the forum at which the nego-
tiations are taking place.
The first port of call in the government will be diplomats from the ministries of foreign affairs and
development, and policy-makers in health. At the foreign ministry, one should consult the political
advisers to the minister, the diplomats who manage relations with the UN and other multilateral
organizations, and the diplomats dealing with continental/regional entities and with agencies that
provide bilateral international development aid.
Understanding the role and strategic objectives of the health ministry, along with identifying key
players in policy-making inside the ministry, is likewise essential. The health ministry is often fo-
cused on public health and public safety within national borders, and generally takes less interest
in global issues, except for transmissible diseases, emergency preparedness and implementation of
the International Health Regulations.
Within-country dialogue with the government should extend to other ministries – including those
responsible not only for finance, trade and agriculture (that is, issues falling under the “One Health”
approach), but also for education, gender equality and family – and to specialized entities, such as
the national agency tasked with evaluating and supervising medicinal products. The linkages be-
tween health and other sectors are described in detail in Chapter 11.
12.6 Understanding the positions of other actors
Negotiations with other governments will be conducted in various capitals, but mostly they will take
place as “front-line diplomacy” in Geneva and New York, and also in ad hoc multilateral forums. In
Geneva, the negotiations primarily involve fellow diplomats from missions. At other negotiation forums
such as the G7 or the G20, the front-line diplomats involved in the negotiation are called “sherpas”.
In that respect, establishing and expanding personal contacts and building networks are an im-
portant asset for future negotiations. Networks may take the form of formal structures or alliances.
However, the most effective networks are informal and based on interpersonal relationships.
Establishing a good relationship with like-minded delegations and building alliances are essential
to secure a favourable outcome in negotiations. Alliances may be forged with natural partner coun-
tries – for example, within a regional or political bloc – or on an ad hoc basis, depending on the
issue that is being debated. Although a partner government may have different views, this should
not rule out seeking to build a personal relationship with its representatives.
A guide to global health diplomacy 161
Respecting other people’s views and being sensitive to cultural differences are vital. In addition to
skills, empathy (that is, the ability to see the world from someone else’s perspective) and emotional
intelligence (that is, the capacity to understand one’s own emotions and those of others) can be critical.
Always remaining courteous helps to keep the discussion going, even in a tense and difficult context.
Understanding a partner’s position requires patience and the ability to put one’s own convictions
and opinions to one side for a while. It may be more difficult, though, to understand the reasons
behind the position of other parties. Sometimes the reasons are immediately apparent – for exam-
ple, if the negotiation is about a topic on which the other delegation has consistently taken a strong
public stand (say, the United States on sexual and reproductive health, or the Russian Federation
on harm reduction). Sometimes the reasons are less obvious, especially if they are linked to anoth-
er item on the political or trade agenda of the country concerned. Thus, health may be used as a
means of achieving other goals, such as promoting exports of medicines and medical infrastructure.
In other instances, it may well be that the position adopted by a negotiating country is deliberately
furthering the political objectives of a third party. It is critical not only to listen to what is being said
but also to how it is said so that one can respond in the most appropriate way.
Finally, assertiveness is a prerequisite for being able to influence others and for moving towards a
compromise solution in the negotiations. Assertiveness should be seen not simply as a personal
skill: it is also influenced by how thoroughly one has prepared for the negotiations.
Engaging with nongovernmental organizations
Communities of various kinds and civil society as a whole are key stakeholders in global health. It
is essential that civil society representatives should be meaningfully engaged in the preparatory
work for negotiations on global health issues.
NGOs operating in the field of health are able to bring the perspectives of patients to the negotiat-
ing table. They are often able to reach vulnerable and stigmatized communities more readily than
governments and health-care providers. The engagement of civil society and local communities
ensures that health-care programming is more responsive to people’s needs.
Civil society plays a further important role by gathering and analysing data that public entities
cannot easily access. Networks of civil society organizations in Eurasia and other parts of the world,
for example, have gathered most of the epidemiological data on HIV relating to sex workers and
men having sex with men in countries where those groups are stigmatized and criminalized.
Engaging with civil society usually means getting in touch with umbrella organizations and net-
works, rather than individual NGOs. Networks and umbrella organizations can offer the perspec-
162 Global Health Centre | February 2021
tives of their many member organizations and have often acquired considerable expertise in global
health and global health diplomacy.
The Global Fund, the Gavi Alliance and UNAIDS are three multilateral decision-making bodies in
global health in which communities and civil society are represented as negotiating partners in
their own right, not simply as the providers of input for other negotiators.
Engaging with the private sector
The views of the for-profit private sector are not collected so frequently by diplomats when prepar-
ing for multilateral negotiations. Diplomats tend to sound out the pharmaceutical industry, for ex-
ample, on specific issues, such as influenza preparedness measures.
The private sector’s views are, however, clearly discernible in the forums at which negotiations take
place. A number of umbrella organizations – for example, the International Federation of Pharma-
ceutical Manufacturers and Associations – are present in Geneva and other centres of global
health diplomacy, and they engage very actively.
Engaging academic expertise
Preparing for negotiations requires a comprehensive understanding of the issue at stake and of the
implications of the resolution or other document to be negotiated. This is the kind of information that
a diplomat should be seeking from experts, usually those based in his or her country, though it is
also possible to consult national experts working for a relevant international organization in Geneva.
Within a constituency or alliance – for example, among EU or AU countries in Geneva – member
countries may decide to delegate the task of collecting experts’ perspectives to one particular coun-
A guide to global health diplomacy 163
try (“burden-sharing”) with experience of the matter in hand so as to avoid duplication of efforts.
In a complex and interconnected world, there is a growing need for evidence and expertise to in-
form policy making. Expert analysis by scientists and academics can greatly support policy design.
Scientists should share the best available evidence, but at the same time acknowledge the limits of
what science can do. Policy-makers should be receptive to independent scientific advice, even
when that advice is not what they expected or wanted to hear.
However, scientific evidence is only one of the many types of information that will feed into the
decision-making process. The other inputs include ethical values, culture, politics and consider-
ation of the impact that any negotiated decision or resolution could have on other policy areas.
Thus, expert opinions should not be obtained solely from academia; it is important also to gather
the views of relevant government entities, the private sector and NGOs.
Box 15: Competencies required to conduct global health negotiations
Æ
Ability to represent and combine two professional cultures (public health and diplomacy)
Æ
Knowledge of diplomatic relations and a multidisciplinary understanding of how issues
such as security, trade, social justice and development impinge on global health
Æ
Awareness of new and emerging players in the field of global health
Æ
Knowledge of the evolution of global health diplomacy and an understanding of its key
concepts and mechanisms, including governance in global health, global public goods and
major shifts in the global political environment
Æ
Awareness of the determinants of global health and an understanding of their links to other
aspects of foreign policy
Æ
Understanding of the moral and ethical value basis of global health, and of how such
values are interpreted from different cultural perspectives
Æ
Familiarity with negotiation processes and skills in the practice of negotiation
Æ
Appreciation of the multinational and multilateral nature of global health diplomacy, including:
Æ
the roles of key venues and actors and an understanding of their perspectives and how
to engage with them;
Æ
the instruments of global health diplomacy: international law, treaties, agreements,
conventions, protocols, declarations, strategies and codes;
Æ
the key mechanisms of global health diplomacy: advocacy, consultation, conciliation
and arbitration.
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12.7 Chairing negotiations
What is the role of the chairperson in (global health) negotiations?
The chairperson’s role is to ensure that the negotiation process is conducted in an efficient and
orderly manner, in accordance with the rules of procedure and to steer the process to conclusion.
Before the negotiations start, a chairperson who is agreeable to all parties is elected to preside over
the proceedings, assisted by a secretariat. The chairperson must remain neutral in the negotiations.
This core principle of successful negotiations must be upheld consistently and not allowed to erode
in a difficult geopolitical context.
The chairperson is critical to success in global health negotiations. In addition to ensuring that the
rules and customary processes are being observed, he or she has considerable influence on the
atmosphere prevailing during the negotiations. If the negotiations are not managed well, the de-
sired outcomes are much harder to achieve.
What are the duties of the chairperson?
The chairperson’s role is essential at all stages of the negotiation process. Before the negotiations
start, the chairperson needs to prepare extensively, think about possible and desirable outcomes
and consider how they can best be achieved. During the negotiations, if they proceed according to
plan and towards achieving the goals that were set, the chairperson acts as a facilitator. However,
if the negotiations move in a direction that could lead to unsuccessful outcomes, the chairperson
needs to take a more active role and find creative solutions to attain the goals being pursued.
What kinds of challenges may the chairperson face during negotiations?
The chairperson is expected to act as a broker or facilitator, not as an interested party. In chairing
meetings, health diplomats can face many challenges, including the following:
Æ
On the one hand, consensus-building takes time (this is often emphasized by low-income coun-
tries, which are concerned about the inordinate influence that rich countries may exercise); on
the other, key donor countries are anxious for swift solutions to be found. Behind this antago-
nism one may detect the perennial dilemma at WHO between being strictly technical and as-
piring to a political role. However, the international community actually expects both, namely
evidence based policy solutions.
Æ
Geneva-based diplomats can be given too much weight in the discussions. Not so many mis-
sions have a well-prepared health attaché or sometimes even just a specialist in health. This
leads to time-consuming consultations with the national authorities in the capital.
A guide to global health diplomacy 165
Which qualities are essential in order to lead negotiations successfully?
The chairperson needs to possess certain qualities if he or she is to lead the negotiation process
successfully:
Æ
an encompassing vision of the values of global health and awareness of the political context
and of the situation as seen from all perspectives, so that he or she can frame the issue in a way
that can be accepted by all participants;
Æ
the emotional intelligence to understand and empathize with different perspectives and the
ability to influence thinking and action across national, cultural and institutional boundaries by
fostering shared understanding and a sense of common purpose;
Æ
the ability to encourage and draw on shared leadership by other individuals, institutions and
organizations with different skills and perspectives, encouraging these to act together to
achieve common goals;
Æ
the personal integrity, self-awareness, patience and self-control required to lead the negotia-
tions in an impartial manner and to speak truth to power where necessary, thereby earning the
trust of people from different countries and organizations; and
Æ
the courage to step beyond the conventional, to take the initiative and to lead.
How can the chairperson influence the negotiation process?
There are certain resources through which the chairperson is able to influence the negotiation process:
Æ
the rules of procedure and customary processes: these define the chairperson’s powers, and
process options that can be used judiciously to steer the negotiations in a productive direction
(for example, proposals of the “Chair’s text” type);
Æ
atmosphere: the chairperson plays a major part in ensuring that the atmosphere remains posi-
tive and constructive;
Æ
time: the available time depends to a great extent on the chairperson, who may allow more
time for certain agenda items or restrict the time available for interventions that do not serve
the desired outcome;
Æ
control over opportunities to speak: the chairperson determines who has the right to speak at
any given point of the proceedings. He or she may thus give the floor to underrepresented
166 Global Health Centre | February 2021
groups and encourage constructive interventions, and, conversely, restrict speaking opportuni-
ties for those whose interventions are unhelpful;
Æ
information: the chairperson closely monitors the negotiation process and usually has the most
information thanks to his or her discussions with the parties;
Æ
support: the parties understand that in order to achieve an outcome that is satisfactory to ev-
eryone, they need to support the chairperson throughout the process; and
Æ
prestige: the chairperson has been agreed on by all the parties and is the acknowledged leader
of the negotiations.
Two examples of memorable achievements in the chairing of WHO negotiations are given below:
Æ
The final deliberations on the WHO Global Code of Practice on the International Recruit-
ment of Health Personnel (2010): the World Health Assembly at its Sixty-third session im-
mediately sent the technically well-elaborated draft to a closed-door drafting group with an
experienced chairperson from Thailand to focus on the text, rather than ideology. The chair-
person did not allow any political debates and went through the text of the draft Code, pro-
vision by provision, until consensus was achieved. However, many compromises were neces-
sary. For example, the prescriptive nature was toned down by dropping terms such as
“standards” or “comply” and by changing “should” to “should consider”: without these
changes, the target countries would have rejected the Code. It became clear later that the
price of the much-lauded consensus was further deficiencies in implementation owing to the
softened text.
Æ
Negotiations on the Pandemic Influenza Preparedness Framework for the Sharing of In-
fluenza Viruses and Access to Vaccines and Other Benefits (2006–2011): after four years
of bitter acrimony, agreement on the Framework was reached in an open-ended working
group chaired by the Mexican and Norwegian ambassadors at the time, who were able to
secure Member States’ approval after a special understanding with the chief executive offi-
cers of major companies had been drawn up outside the formal negotiations.
A guide to global health diplomacy 167
This chapter presents some recent examples of global health diplomacy. They were selected to re-
flect the wide spectrum and complexity of negotiating health issues multilaterally in the 21st cen-
tury, and also to illustrate the various features and types of relations in global health diplomacy
described in the previous chapters.
13.1 Access to medicines
One of the most long-standing and controversial issues in global health diplomacy is access to
medicines. This topic must be considered in relation to the broader questions as to who will benefit
from scientific and technological progress, and to what extent is knowledge a global public good.
The costs of medicines are no longer a burden solely for developing countries: progress in areas
such as the development of cancer medicines has created a financing challenge for high-income
countries as well.
The WTO’s globalized system of intellectual property rights has led to a new generation of multilat-
eral, regional and bilateral negotiation processes and arrangements in areas of intersection be-
tween trade, intellectual property and health. The WTO agreements count as hard law and are
underpinned by a binding dispute settlement mechanism, which provides for the imposition of
sanctions for non-compliance. A central pillar of the international patent regime is the Agreement
on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement), an international legal
agreement between all the WTO member countries that lays down minimum standards for nation-
al governments’ regulation of many forms of intellectual property. The TRIPS Agreement was nego-
tiated between 1989 and 1990 and is administered by the WTO. Developing countries were op-
posed to many elements of the Agreement. As far as health is concerned, they were able to secure
a number of “flexibilities”, which were reiterated in the Doha round of trade negotiations launched
in 2001 but still left much to be desired. The negotiations on intellectual property, in particular, il-
lustrate both the lobbying power of pharmaceutical companies and the advocacy power of civil
society. Although neither pharmaceutical companies nor civil society organizations are involved
directly in the negotiations, they do exert significant influence on national positions and on public
opinion in the WTO member countries.
CHAPTER 13 | EXAMPLES
OF GLOBAL HEALTH DIPLOMACY
168 Global Health Centre | February 2021
Access to medicines is also a perennial subject of debate at WHO. After some unusually controver-
sial and heated negotiations, the Seventy-second World Health Assembly in May 2019 adopted a
landmark resolution (WHA72.8) to support greater public disclosure of prices for medicines and
other health products (see Case Study 1). Even though WHO resolutions count as soft law, the
Member States departed on this occasion from their usual consensus-based approach to health
diplomacy: several of them openly expressed their disagreement with both the content of the pro-
posed resolution and the negotiation process. It was also the first time that a concerted Twitter
campaign was launched by civil society, in which ministers and officials from countries opposing
the resolution were subjected to personal attacks.
The process and methods used in the above-mentioned negotiations suggest that the consensus
based approach to global health diplomacy may no longer be the sole modus operandi at WHO.
13.2 Vaccine diplomacy
The COVID-19 crisis has forcefully revived the field of vaccine diplomacy by re-opening the debate
on how to ensure affordable and equitable access to vaccines of global public interest.
At the time of publication of this guide and as vaccines begin to be rolled-out, significant gaps exist
between countries in the level of access to vaccines, diagnostics and essential supplies. It is antic-
ipated that most upper-income countries will see coronavirus vaccines widely available between
September 2021 and March 2022, large middle-income countries and emerging economies – be-
tween September 2021 and summer of 2022; a number of other middle-income countries in 2022
and low-income countries between spring of 2022 and 2023.
Vaccine diplomacy refers to all aspects of global health diplomacy pertaining to the development,
manufacture and delivery of vaccines as public health goods. Among the key features of vaccine
diplomacy are its potential as a humanitarian intervention and its proven role in helping to mediate
the cessation of hostilities and ceasefires during vaccination campaigns.
Modern vaccine diplomacy starts with the creation of Gavi, the Vaccine Alliance in 2000 after it was
recognized in the late 1990s that coverage of the six basic vaccines under the WHO Expanded
Programme on Immunization had been stagnating or declining, and that other vaccines, including
new potentially life-saving ones, were too expensive for developing countries.
The Gavi Alliance was established to bring UN agencies, governments, the vaccine industry and
other branches of the private sector, and civil society together with a view to improving childhood
A guide to global health diplomacy 169
immunization coverage in poor countries and providing future purchase guarantees for new vac-
cines. By 2018, Gavi-funded programmes had reached over 700 million children. Many countries
gained access to vaccines against rotavirus and Haemophilus influenzae type B. The Gavi Alliance
also facilitated the development of a new vaccine against Streptococcus pneumoniae.
The outbreaks of SARS, H1N1 influenza, Ebola, MERS and Zika, along with the growing problem of
antimicrobial resistance, have made the production, financing and availability of adequate and ef-
fective vaccines an even more sensitive political issue. Geopolitical and national interests have
hampered negotiations on vaccination. A “securitization” of the public health agenda made itself
felt in these negotiations, as did lobbying by health and pharmaceutical industries. Increasing in-
sistence on national sovereignty has slowed down global talks. Notably, during the long process of
the WHO-convened Intergovernmental Meeting on Pandemic Influenza Preparedness: Sharing of
Influenza Viruses and Access to Vaccines and Other Benefits (2007–2010), Member States failed to
come to an understanding for years because they could not agree on the assets to be provided to
developing countries. Indonesia, for example, was reluctant to share viral sequences. A compro-
mise was eventually reached whereby pharmaceutical manufacturers were no longer permitted to
access data on and samples of circulating viral strains for the development of influenza vaccines
unless they committed to benefit-sharing arrangements, including the provision of a certain per-
centage of influenza vaccines at heavily discounted prices. Other benefits included such measures
as technology transfers and improved access to diagnostic reagents and influenza test kits – re-
sources that many low-income countries had previously been struggling to obtain.
The COVID-19 pandemic has abruptly brought back the question of how a vaccine – if an effective
one can ultimately be developed – will reach everyone who needs it.
170 Global Health Centre | February 2021
Political and global leaders have called for a COVID-19 vaccine to be treated as a global public good
that should be available to all.
23
The full potential of vaccines cannot be realized if national interests
and economic power determine who gets access, instead of basic principles of fairness and ensur-
ing that allocation will optimize their public health impact. Nevertheless, rich countries have rushed
to place advance orders in order to ensure vaccine access for their citizens, since it is expected that
supply will be limited. This raises important questions concerning vaccine access for people in de-
veloping countries, particularly in middle-income countries that are not eligible for support from the
Gavi Alliance or other international aid mechanisms.
The task of addressing the key questions of how to develop effective global cooperation and who
should be given priority access has been pushed aside by the current disarray of multilateral health
governance and by the nationalistic and free-market-driven, competitive approaches taken by
some countries.
On the other hand, there are several vaccine diplomacy initiatives that point in the right direction.
The alliance between several EU countries for pooled advanced purchase of vaccines, for example,
requires the pharmaceutical companies with which the EU contracts to make a portion of vaccine
supplies available to low-income countries. The COVAX Facility – which brings together WHO, the
Gavi Alliance, the Coalition for Epidemic Preparedness Innovations (CEPI) and industry – allows the
participating countries to pool their resources so that they can back the development of a larger
number of candidate vaccines than any single country could do on its own. This initiative further
uses “push” investments in manufacturing facilities and “pull” mechanisms (advance purchase
commitments) to encourage manufacturers to invest in scaling up vaccine production and help
share the risks. If a vaccine is successful, doses as they become available will be distributed equi-
tably through the COVAX Facility between self-financing countries (there are currently 75), which
will pay for their doses, and developing countries (currently 90) that would otherwise be unable to
afford the vaccine.
Massive resources have been channelled into R&D work on a COVID-19 vaccine. Ensuring equitable
access to such a vaccine will require strong global governance and the use of vaccine diplomacy.
23 UNAIDS. Uniting behind a people’s vaccine against COVID-19. Geneva: Joint United Nations Programme on HIV/AIDS; 14 May
2020 (https://www.unaids.org/en/resources/presscentre/featurestories/2020/may/20200514_covid19-vaccine-open-letter,
accessed 16 November 2020).
A guide to global health diplomacy 171
13.3 Air pollution
Scientific evidence can play an important role in negotiating major agreements. Over the past de-
cade, WHO has become increasingly involved in tackling the problem of air pollution. One major
milestone was the adoption of a World Health Assembly resolution and an associated road map in
2015 to address this mounting global health challenge. In terms of health diplomacy, the resolution
and road map paved the way for a broad inter-agency collaboration with the UN and other interna-
tional organizations. They have also strengthened cooperation between WHO and urban health
networks – a significant development given that city health diplomacy (see Box 16) is rapidly be-
coming an important element of global health diplomacy in the 21st century.
Air pollution moved further up the global health agenda in 2018, when it was recognized, at the
third UN High-Level Meeting on the Prevention and Control of Noncommunicable Diseases, as a
fifth key risk factor for NCDs alongside the established “quartet” of tobacco, alcohol, unhealthy diet
and physical inactivity.
Many of the drivers of air pollution, such as the combustion of fossil fuels, lead to the emission of
carbon dioxide and other short-lived climate pollutants, including ozone and black carbon, which
greatly contribute to climate change and affect human health. Accordingly, WHO has stepped up
its knowledge-based activities during major negotiations on climate change within the UN frame-
work, notably at the UN Climate Action Summit held in New York on 23 September 2019 and during
the 25th session of the Conference of the Parties to the UNFCCC, which took place in Madrid from
2 to 13 December 2019. WHO had been mandated by the UN Secretary-General to help develop
two health-related commitments for the Climate Action Summit, namely (a) to save lives by cutting
carbon emissions and cleaning the air; and (b) to boost investment in climate action, public health
and sustainable development. WHO provides negotiators with evidence on the health impact of
climate change by quantifying and monitoring the effects of exposure to air pollution.
At the regional level, multilateral cooperation on air pollution has an even longer history. One nota-
ble achievement was the adoption of the Convention on Long-range Transboundary Air Pollution in
1979 under the auspices of UNECE. As the first international treaty in this area, it provided legal and
policy space for measures to protect both human health and the environment against transbound-
ary air pollution. The Convention is an example of what multisectoral, and science-driven diplomacy
can achieve at the international level.
172 Global Health Centre | February 2021
A guide to global health diplomacy cannot prescind from acknowledging the now well-estab-
lished role that subnational entities play in global governance. Among the many actors at this
level, cities have arguably been some of the most proactive on the world stage for the better part
of the past three decades. This box gives a brief overview of the recent rise of “city diplomacy”
and the current challenges in the intersection of such diplomacy with global health.
Cities have been in the spotlight across many global agendas, not just as an issue or as places,
but more and more formally called upon by multilateral initiatives and frameworks as interna-
tional actors in their own right. In turn, many local governments no longer defer to national
governments when developing strategies and terms for international engagement on key issues.
Mayors, city councils, metropolitan commissioners and representatives of local authorities are
reaching out directly to one another and more broadly to international actors, including corpora-
tions, United Nations (UN) system agencies, and overseas nongovernmental organizations. There
are now hundreds of formalized international cooperation mechanisms that have been estab-
lished by cities (city networks), giving cities a voice in discussion on many global issues, such as
the climate change agenda and the Paris Agreement or the Sustainable Development Goals
(SDGs). This means that cities have been accorded a key role in responding to major transnation-
al challenges. The COVID-19 crisis has further accentuated the front-line role of cities: as of
September 2020, approximately 95% of COVID-19 infections had occurred in urban settings, with
over 1500 cities affected worldwide. Accordingly, the UN Secretary-General has called for a clear-
er understanding of how the pandemic, like other health challenges, is unfolding in an urban
world. For their part, numerous cities and city networks have quickly activated their city diploma-
cy connections to form COVID-19 task forces, repositories of policy actions and mechanisms for
the exchange of best practices. Yet, city diplomacy should be understood in the context of a na-
scent global urban governance, not simply as city-to-city exchange.
A brief history of city diplomacy is telling in that respect. The modern evolution of cities’ interna-
tional engagement comprises at least three different “generations”. City diplomacy has gone
from more culture-based city-to-city relationships to a complex mechanism and circuit for inter-
national coalition-building and policy exchange, even in the wake of the considerable
COVID-19-related impacts on international travel and cooperation. While the first modern gener-
ation (early 20th century) of city diplomacy was based on formalized, bilateral “sister cities”, a
second (mid to late 20th century) generation has scaled up these twinning networks to more
formalized city network coalitions for advocacy and exchange, often backed by UN specialized
Box 16: City diplomacy for global health
A guide to global health diplomacy 173
agencies. The mid-1990s were the heyday of efforts towards more formalized city health diploma-
cy through the work of the European Healthy Cities Network under the aegis of the World Health
Organization (WHO) and other regional efforts such as the Alliance for Healthy Cities (in the
Western Pacific). Nowadays there are other similar, albeit more specialized, networks such as the
WHO Age-Friendly Cities project.
The 21st century has, however, seen the emergence of a more complex realm of urban diplomacy,
not least in health. This has led to even more specialized and often purpose-built networks that
are closely intertwined with private and major philanthropic investments. City diplomacy is en-
gaged directly in localizing major global agendas such as the 2030 Agenda on Sustainable De-
velopment. In health this includes the launch of initiatives such as the Bloomberg Philanthro-
pies-backed Partnership for Healthy Cities within WHO, or the localization of the health-related
SDGs via the WHO Shanghai Consensus on Healthy Cities. Understanding city diplomacy from
this angle allows greater room for manoeuvre beyond twinning and city-to-city cooperation, and
gives a clearer idea of the intersections between cities and global governance.
Although potentially paradigm-changing, the COVID-19 crisis has not affected the impetus for
city diplomacy. City governments still recognize the importance of engaging internationally but
lack the necessary formal diplomatic training and resources for doing so to maximum effect.
Nevertheless, cities’ commitment to global agendas such as the SDGs (and not least their health
related premises) remains strong, and international frameworks are increasingly influential in
municipal affairs. Cities remain confident in their capacity to tackle global challenges. The crisis
has also prompted attention for global health beyond the health sector: thus, health and well
being are now covered by city diplomacy efforts originally focused on other sectors (for example,
the environment in the case of the C40 Cities Climate Leadership Group, or migration in the case
of the Mayors Migration Council).
Nevertheless, the role of city diplomacy in global health remains relatively limited compared with
its role in other areas such as migration, climate or resilience. Cities and urban issues continue to
occupy very modest positions on the global health agenda. Apart from the self-organized initia-
tive of city networks, cities are at present still very much on the sidelines of official multilateralism.
WHO, for instance, still does not have a major unit for cities and has relegated the topic of urban
health to relatively few, often regional, conversations. More broadly, as in many other global
policy areas, capacity-building and investment remain critical at the local level, where there
are significant constraints on budgets and training opportunities for “city diplomats”. Recognition
and institutionalization of an urban voice are still a key challenge.
174 Global Health Centre | February 2021
13.4 Trade, intellectual property and health
Following the Doha Declaration on the TRIPS Agreement and Public Health of 2001, the interface
between trade, intellectual property and health has become one of the main focuses of global
health diplomacy in the 21st century. This interface is also one in which the multilateral and multi-
sectoral dimensions of health diplomacy are most closely interconnected. The present Guide ac-
cordingly deals with it in various places, notably Chapter 11 (covering intersectoral aspects), Chap-
ter 8 (policy coherence), Chapter 7 (regional health diplomacy), Section 13.1 (access to medicines)
and Case Study 1 (on price transparency). Dialogue on health and trade (and on intellectual prop-
erty in most cases) is taking place in national, multilateral and inter-agency settings alike.
Dialogue in national settings typically occurs in multisectoral committees covering a wide range of
issues affected by trade. In some cases, however, when health arguments are strongly articulated
by stakeholders, governments have established a dedicated mechanism (ad hoc or standing) to
assess the health impact of international trade. As the trade and health sectors are rarely involved
in each other’s respective spheres, such intense interaction increases mutual understanding of the
issues at stake.
International health-related trade disputes, too, foster closer intersectoral cooperation. Australia,
Norway and Uruguay, for example, successfully defended – at, respectively, the WTO, the EFTA
Court and the International Centre for Settlement of Investment Disputes – the tobacco control
measures they had introduced as part of their implementation of the FCTC. These cases highlighted
an emerging phenomenon, namely how a new international legal regime in health (the FCTC) can
help to balance the legal arguments on both sides of the trade and health interface, which in the
past was overwhelmingly dominated by the legal power of trade and investment agreements. In a
contrasting trend, regional and bilateral trade and investment agreements provide generally lower
protection for health than the flexibilities contained in the WTO’s global regimes. It is therefore im-
portant for the health sector to become proactively involved in the negotiation of such agreements.
In the inter-agency arena, a recent notable example of dialogue and cooperation is the second
edition (2020) of the trilateral WHO–WIPO–WTO study on promoting access to medical technolo-
gies and innovation. Building on the first edition (2013), the new publication is meant to support
dialogue and decision-making in this highly complex policy interface, thus serving as an invaluable
resource at a critical time for global health.
A guide to global health diplomacy 175
13.5 Antimicrobial resistance
The problem of antimicrobial resistance (AMR) is attracting growing attention in the 21st century,
and there is a need for more effective coordination of national intersectoral efforts to tackle it. In
terms of health diplomacy, several factors and processes lie behind a steep increase in multisec-
toral and multilateral dialogue on AMR.
First, multisectoral action involving the health, agriculture and veterinary sectors – something that
is not easy because of their frequently diverging approaches – has truly become a matter of urgen-
cy in view of the scale of the problem.
Secondly, several international initiatives and platforms have been launched within a short period,
including the WHO Global Action Plan on Antimicrobial Resistance (2015), the Political Declaration
of the High-Level Meeting of the UN General Assembly on Antimicrobial Resistance (2016), the G20
Osaka Leaders’ Declaration (2019), the FAO–OIE–WHO tripartite collaboration, the UN ad hoc In-
ter-agency Coordination Group on Antimicrobial Resistance, several regional and bilateral plat-
forms, and the Global Antibiotic Resistance Partnership (which focuses on low- and middle-income
countries). A further mechanism, the AMR Multi-Partner Trust Fund, was established under the
auspices of the FAO–OIE–WHO tripartite partnership. This proliferation of international mecha-
nisms has required concerted multisectoral input from governments, thereby also encouraging the
development of national multisectoral strategies within a relatively short period.
Thirdly, the international and inter-agency cooperation on AMR arose against the backdrop of ex-
isting collaborative arrangements in some closely related fields, such as the Codex Alimentarius
Commission and the International Food Safety Authorities Network, both under the dual auspices
of WHO and the FAO. These were important institutional foundations to learn from.
Fourthly, solutions in the fight against AMR are linked to broader (“One Health”) and parallel (phar-
maceutical innovation and R&D) concepts and processes. This is reflected in some global mecha-
nisms,
24
and also in the One Health Global Leaders Group on Antimicrobial Resistance that is to be
convened by the FAO–OIE–WHO tripartite partnership on behalf of the UN Secretary-General. Oth-
er sectors of relevance for these efforts are the environment, industry, economy, trade and intellec-
tual property rights.
24 For example, the Global Antibiotic Research and Development Partnership (launched jointly by WHO and the Drugs for
Neglected Diseases Initiative) and the World Bank’s One Health Operational Framework for Strengthening Human, Animal and
Environmental Public Health Systems.
176 Global Health Centre | February 2021
On the whole, AMR is one of the main items on the global health agenda of the 21st century. It is
closely linked to other politically and technically complex areas, such as the One Health approach,
R&D and innovation, and therefore requires increasing international (and intersectoral) diplomacy
and negotiations so that global solutions can be found.
13.6 Migration and health
One important lesson from the global dialogue on migration and health is that coherent inter-agen-
cy work and national intersectoral convergence can be mutually supportive when applied to a rel-
atively new – and acute – global health challenge. This is exemplified by the process leading to the
World Health Assembly’s adoption, in May 2017, of the landmark resolution WHA70.15 on promot-
ing the health of refuges and migrants and of the corresponding Framework,
25
which was subse-
quently cited in the UN Global Compact for Safe, Orderly and Regular Migration (hereafter the
“Global Compact”). Synergetic work by WHO, the IOM and the UNHCR during the preparatory work
and negotiations on resolution WHA70.15 went hand in hand with political leadership by a group
of core countries. That inter-agency work also provided evidence for and impetus to the pursuit of
national intersectoral convergence in support of the multilateral process – particularly in countries
with less technical and diplomatic resources. This is important because of the limited knowledge of
this area of public health and the many misconceptions and divergent views that have arisen.
The incorporation of health into the Global Compact – itself a complex political document of a
highly intersectoral nature – posed a number of challenges for health diplomacy. First, one must
bear in mind that negotiations at UN Headquarters in New York are led by foreign ministries and
diplomats and are highly political, offering fewer opportunities for day-to-day specialized input
than negotiations in Geneva, where WHO, other relevant specialized agencies and the health focal
points of countries’ permanent missions are based (see also Chapter 6). Significantly, the health
sector was very poorly represented at the crucial Intergovernmental Conference to Adopt the Glob-
al Compact held in Marrakesh, Morocco, in December 2018, in contrast to ministries of the interior,
labour, social welfare and foreign affairs. This goes to show that when negotiations on a major in-
ternational instrument with implications for health are taking place in highly political settings out-
side Geneva, it is essential, on the one hand, for WHO to work together with Member States and
like-minded international agencies, and on the other, for health ministries to engage actively with
their national delegations, so as to ensure that health aspects are adequately reflected in the out-
come of the negotiations.
25 WHO Framework of Priorities and Guiding Principles to Promote the Health of Refugees and Migrants (2017).
A guide to global health diplomacy 177
Secondly, health had not been identified as a specific topic for thematic sessions at the start of the
negotiation process for the Global Compact. It thus proved necessary to make use of other relevant
platforms, such as side events at high-profile events and the WHO–IOM global consultations on
migrant health, in addition to advancing priorities and principles already adopted by WHO and
promoting linkages to major international instruments, such as the Universal Declaration of Human
Rights, the relevant International Covenants
26
and the SDGs. Another key lesson from the process
of including health in the Global Compact is, therefore, that using parallel platforms and harnessing
the power of universally recognized existing instruments can play a critical role when promoting
health interests during negotiations at the UN on a document of broader scope.
13.7 Concluding remarks
All of the examples presented in this chapter demonstrate that tackling complex global health
challenges calls for multilevel diplomacy (that is, involvement in negotiations in different forums)
combined with multi-stakeholder diplomacy (involving different types of actors), usually over a
significant time period. Global health diplomacy efforts on complex issues have become more diffi-
cult owing to the large number of actors and the diversity of cultures and diplomatic styles. Togeth-
er with a weakening commitment to multilateralism, this is making it harder to reach agreement
(as reflected in the failure of the 25th session of the Conference of the Parties to the UNFCCC to
agree on global carbon markets) and leads to increasingly unpredictable outcomes.
These examples also illustrate another significant new development in international relations:
the way in which international organizations are becoming important players in multi-stake-
holder diplomacy, as shown by the involvement of WHO in G7 and G20 summits and various in-
ter-agency arrangements in the above areas. International civil servants are increasingly per-
ceived to be defending supranational interests, namely the production and supply of global
public goods. This is very much the case with diplomatic efforts on, for example, environmental
protection and health.
The examples further serve to illustrate synergistic health diplomacy, which is yet another feature
of contemporary global health diplomacy – namely, where States strive for the synergistic interac-
tion of diplomatic efforts at various levels and within the framework of different organizations,
processes and meetings.
26 The International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights
(both adopted in 1966).
178 Global Health Centre | February 2021
Preparing comprehensively for negotiations involves several key actions and the judicious en-
gagement of relevant stakeholders and partners at the country level and in Geneva (or wherever
the negotiations take place). All the actions are useful (to varying levels depending on the nego-
tiation in question) but are not necessarily sequential – often all are done simultaneously, or in a
different order depending on the issue and level of negotiation.
Action 1
The first step is to study the history of the matter under discussion. You should consult documents
that will help you to understand the background to the resolution or other text to be negotiated.
It is also important to be aware of (a) the positions adopted by your country on the matter in
previous negotiations; and (b) the positions adopted both by like-minded countries and by coun-
tries known to have different views.
Action 2
The second step is to identify the issues or language in the text under discussion that are likely to
provoke controversy during the negotiation process.
Again, looking back at earlier negotiations on the topic is essential. For example, referring to
sexual and reproductive rights has always sparked concerns among a specific group of countries
across the world while receiving strong support from another group.
Action 3
The third step is to mobilize experts so that you can achieve a comprehensive understanding of
the matter under discussion.
The experts may be based in a country’s capital, either within or outside the health ministry, for-
eign ministry or another relevant ministry. Further considerations on the role of different sectors
are to be found in Chapter 11.
Finally, some of the examples of global health diplomacy discussed in the preceding sections – par-
ticularly those related to trade, migration and antimicrobial resistance – highlight, from various
angles, the importance (and complexity) of achieving national intersectoral coordination and policy
coherence in multilateral processes and negotiations.
Box 17: Preparing for negotiations in Geneva
A guide to global health diplomacy 179
Requests may also be received by a country’s mission in Geneva to supply the national authorities
in the capital with additional expertise. This is because on some issues – as was the case with
the outbreak in early 2020 of a poorly understood influenza-like disease in Asia (later named
COVID-19) – the most relevant information may reside in Geneva at the World Health Organiza-
tion (WHO), rather than in the country’s capital.
Expertise may be national – this includes the expertise of nationals who are working for interna-
tional organizations in Geneva – or international. There is a large pool of experts in global health
in Geneva in particular, but also in New York, other international hubs and in universities around
the world. Great care should be taken to include experts from the Global South.
An important point worth stressing is that it is often best to seek expertise by contacting people
from an existing personal network. To continue with the example cited above, an expert opinion
on the influenza-like outbreak in Asia (later named COVID-19) would possibly be obtained more
readily from an expert known to you personally than by contacting a research institute.
The above recommendation may not be relevant where countries have a strong team of experts
based at – or associated with – the ministries concerned. This was the case, for example, with
the former Department for International Development in the United Kingdom (now part of the
new Foreign, Commonwealth and Development Office). Nor is the recommendation relevant
where countries have high-level research institutes that can provide information. It can be much
more difficult for low- and middle-income countries to gain access to such information.
Action 4
The fourth step is to mobilize stakeholders and partners in your country and in Geneva so that you
can prepare effectively for the forthcoming negotiations.
First, you should get in touch with the diplomats and civil servants who are your contact persons
(focal points) in the foreign ministry and the health ministry. They need to be informed about the
forthcoming negotiations and be given enough time to gather information, consult others, receive
relevant approvals from their immediate superior or from the minister, and, eventually, send you
instructions on the position you are to defend.
Typically, instructions from the capital will be developed through coordination among representa-
tives from relevant ministries after consultation with experts if needed, and, as is increasingly the
case in the field of global health, also with civil society. The instructions will ultimately be ap-
proved at the senior level in the lead ministry before being sent to the mission in Geneva. Often
coordination is via written exchange. The necessary approval level depends on the negotiation.
180 Global Health Centre | February 2021
As you engage with the national authorities in your capital, you may find them to be helpful or
less so, depending on a number of factors: the extent to which the matter under discussion is of
interest to the ministries and the government; the ability of focal points in the ministries to mobi-
lize expertise and opinions in the capital; and – equally important – your personal relationship
with, and style in relating to, the focal points and ministries.
Secondly, you should approach your contacts at WHO and other global health organizations in
order to understand, from their perspective, what is at stake in the forthcoming negotiations.
Here again, personal relationships and networks will give better results than addressing requests
to an institution in general.
Thirdly, you should contact your counterparts in diplomatic missions in Geneva to gather informa-
tion on the positions that their countries will adopt in the negotiations and, in some cases, gather
support and build alliances. Again, personal relationships, legitimacy and communication skills
are essential. Engaging with counterparts is crucial so that you can find out how others are pre-
paring for the negotiations. It is also a necessary step in developing a common position with
partner countries within a political entity, such as the European Union or the African Union, or
within more informal groupings, such as the Nordic countries.
In Geneva there exists a very important regional coordinator system of health attachés. Each of the
six WHO regions has an informal coordinator who usually rotates on an annual basis. These coor-
dinators’ activities range from routine communication between WHO governing bodies, the WHO
Secretariat and Member State missions to the extraordinary challenge of selecting chairs and
vice-chairs for intergovernmental negotiations.
Action 5
At the end of the process you will receive a set of instructions from your capital. The strong en-
gagement of specific stakeholders and partners at each step of the process described above is
the best guarantee of the instructions being clear and enabling you to defend a coherent nation-
al position during the negotiations.
A guide to global health diplomacy 181
Global health diplomacy is a burgeoning field that combines the priorities of global health with
those of foreign affairs. Health challenges of various kinds have acquired an urgency that is unprec-
edented in the long history of international health activities. Developments in the field of health are
affecting the way in which normative concepts and international legal rules are applied in diplo-
matic negotiations. Global health diplomacy involves a number of disciplines, ranging from public
health, law and international affairs to management and economics. Understanding and using
concepts from different disciplines consistently is therefore essential.
The ABC of Diplomacy is a glossary of alphabetically ordered keywords produced by the Swiss
Federal Department of Foreign Affairs. It explains frequently used terms, and provides information
about the laws and customs governing international relations:
https://www.eda.admin.ch/dam/eda/en/documents/publications/GlossarezurAussenpolitik/
ABC-Diplomatie_en.pdf
The institutional repository of the Global Health Centre at the Graduate Institute of International
and Development Studies contains two resources that explain commonly used concepts:
Æ
A glossary of terms used in global health negotiation: a working tool (2013), by Martin
Jacques, Ilona Kickbusch and Michaela Told
https://repository.graduateinstitute.ch/record/296833?ln=en
Æ
Discussing a definition of global health (2013) by Samantha Battams and Stephen A. Matlin
https://repository.graduateinstitute.ch/record/288069?ln=en
ANNEX 1 | GLOSSARY
182 Global Health Centre | February 2021
A few years ago, the online portal Middle East Medical published an article outlining a former
American ambassador’s views on global health diplomacy, from which it is worth quoting the fol-
lowing excerpts:
Scientists and diplomats approach problems differently. Scientists see a problem, a pattern
or an anomaly, do research to collect data and evidence, and, if the evidence is strong
enough, publish the results – the solution to the problem — in a peer-reviewed journal.
For diplomats, who don’t read peer-reviewed medical or scientific journals in the first
place, even an elegant proof is merely the beginning of a solution. Diplomats, if we are
good at our jobs, put our priorities onto other people’s agendas. This means making a
judgment about whether the problem the scientist’s research has set out to solve is
genuinely a priority for our own program or for the policy maker we are trying to influence.
It also implies understanding the context in which the policy-maker is operating and how
to present or explain our health priority so that it fits into his or her wider agenda.
27
Below we present a compilation of key terms, based on the glossary prepared for the participants
in an online course on global health diplomacy organized by the Global Health Centre at the Grad-
uate Institute of International and Development Studies:
Civil society: Refers to the process through which individuals negotiate, argue, struggle against or
agree with one another and with the centres of political and economic authority, and through
which voluntary associations, movements, parties, unions and individuals are able to act publicly.
The precise scope of the term varies but most common usage excludes private sector businesses
and formal local government organizations. (Kickbusch et al., 2013)
Club-type health diplomacy: Refers to diplomatic relations and negotiations among a group of
leaders who know one another well and can employ personal charm and persuasion.
COVID-19 diplomacy / pandemic diplomacy: Multi-stakeholder and multilevel negotiations to end
the COVID-19 pandemic more quickly by shaping and managing the global policy environment at
many venues.
Crisis diplomacy: Interactions between States (and other actors) under a heightened threat of
systemic change.
27 Kolker J, Abdelghany A (2018). The role of diplomacy in global health. In: Middle East Medical [website] (https://www.
middleeastmedicalportal.com/the-role-of-diplomacy-in-global-health/, accessed 11 February 2020).
A guide to global health diplomacy 183
Determinants of health: Determinants of health refer to the social, economic and physical environ-
ment and to individual characteristics and behaviours, all of which can affect people’s well being
and health. Whether people are healthy or not is determined largely by their circumstances and
environment. Access to health care and the quality of the services provided are also considered to
be determinants of health. Trends in recent years warrant a distinction to be made between com-
mercial and political determinants. Commercial determinants include “strategies and approaches
used by the private sector to promote products and choices that are detrimental to health” (Kick-
busch, Allen & Franz, 2016). Looking at health through the lens of political determinants means
analysing how different power constellations, institutions, processes, interests and ideological po-
sitions affect health within different political systems and cultures and at different levels of gover-
nance. In addition, other health determinants are dependent on political action (Kickbusch, 2015).
Digital health diplomacy / Twitter health diplomacy: The use of the Internet and new information
and communication technologies to help achieve diplomatic objectives. (However, other definitions
have also been proposed.) The above definition focuses on the interplay between Internet and di-
plomacy, ranging from Internet-driven changes in the environment in which diplomacy is conduct-
ed to the emergence of new topics on diplomatic agendas such as cybersecurity and privacy, along
with the use of Internet tools to practise diplomacy. Digital diplomacy is part of public diplomacy; it
is still mostly centred on the use of social media tools such as Twitter, Facebook, Instagram and
Snapchat, but it is also about creating engaging online content that stimulates people to partici-
pate in complex conversations about foreign policy, the role of governments and the common good.
Global governance for health: Global institutions and processes of governance that have a direct
and indirect impact on global health. It also includes other institutions associated with global
health that may not necessarily have health as part of their explicit agendas: for example, organi-
zations working in the areas of climate change, intellectual property rights, trade and education.
Global health: Health issues that transcend national boundaries and call for action on the global
factors that determine the health of people (Kickbusch, 2006).
Global health diplomacy: The multilevel and multi-stakeholder negotiation processes that shape
and manage the global policy environment for health in both health and non-health forums. Such
diplomacy deals in particular with health issues and determinants that cross national boundaries
and need to be tackled through global agreements. It brings together the disciplines of public
health, international affairs, management, law and economics (Kickbusch et al., 2007).
Global health governance: The conscious creation, shaping, steering, strengthening and use of
international and transnational institutions and regimes (of principles, norms, rules and deci-
184 Global Health Centre | February 2021
sion-making procedures) to organize the promotion and protection of health on a global scale. Such
governance is about institutions focused on global health, including conventional structures in-
volved in such work at the multilateral and bilateral level, and also innovative bodies, such as
public–private partnerships with representatives from different stakeholders.
Global health security: Reducing collective vulnerability to global public health threats, both imme-
diate and gradual. These threats transcend borders and may be caused by infectious agents that
emerge naturally at the human–animal interface, but they may also be caused by chemicals, toxins
and radiation, or be deliberately caused by acts of terrorism. At the individual level, health security
must include protection and provision measures such as access to safe and effective medicines,
vaccines and medical care. Increasing personal health security thus means providing individuals
with more sustained – and therefore secure – access to quality medical goods and services.
Global public goods of health: In an increasingly interconnected world, many public goods (that is,
goods which generate benefits shared by all and from which no one can be excluded) can no longer
be defined in exclusively national terms. Global public goods generate benefits – such as a safer
world, protection against the impacts of climate change, and improved health – that are vital to the
well-being of those living now and to the survival of future generations. Examples of global public
goods for health include shared scientific knowledge (such as the sequencing of the human ge-
nome), the eradication of smallpox, global surveillance systems for influenza and other diseases,
the WHO International Health Regulations and support for the development of new vaccines.
Governance for global health: The institutions and mechanisms established at the national and
regional level to contribute to global health governance and/or to governance for global health,
such as national or regional strategies on global health. It may also cover governance at the level
of local communities.
Humanitarian diplomacy: The International Federation of Red Cross and Red Crescent Societies de-
fines humanitarian diplomacy as “persuading decision-makers and opinion leaders to act, at all times,
in the interests of vulnerable people, and with full respect for fundamental humanitarian principles”.
Instruments of global health: International law, treaties, agreements, conventions, protocols, dec-
larations, strategies, action plans and codes that concern global health.
Multilateralism in global health diplomacy: “Multilateralism” is the term used to describe cooper-
ation among States: multilateralism in global health diplomacy is an approach based on the prem-
ise that, by working together, countries can find solutions to global health problems without re-
nouncing their sovereignty.
A guide to global health diplomacy 185
Private sector: The private sector is the part of the economy that is owned by private groups, usu-
ally as a means of enterprise for profit, rather than being owned by the State.
Science diplomacy: The use of scientific collaboration among nations to address the common
problems facing humanity and to build constructive international partnerships. It is both a compo-
nent of health and environmental diplomacy and a field in its own right.
Vaccine diplomacy: All aspects of global health diplomacy that relate to the development, manu-
facture and delivery of vaccines as public health goods. Among the key features of vaccine diplo-
macy are its potential as a humanitarian intervention and its proven role in helping to mediate the
cessation of hostilities and ceasefires during vaccination campaigns.
Whole-of -government / whole-of-society approach: These approaches call for collaboration, plan-
ning and dialogue across the entire government and society. They involve working together on pub-
lic health issues with non-traditional partners, including NGOs, the private sector and civil society.
186 Global Health Centre | February 2021
A guide to global health diplomacy 187
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Building Leadership for Health (by Graham Lister)
Æ
Global health diplomacy: https://www.building-leadership-for-health.org.uk/global-health-dii-
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Federation of Medical Students’ Associations.]
Chatham House
Æ
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European Union
Æ
Global health: https://ec.europa.eu/health/international_cooperation/global_health_en
206 Global Health Centre | February 2021
Gavi, the Vaccine Alliance:
Æ
Homepage: https://www.gavi.org/
Global Financing Facility for Women, Children and Adolescents
Æ
Homepage: https://www.globalfinancingfacility.org/ [The Global Financing Facility is helping
governments in low- and lower-middle-income countries to transform the way in which they
prioritize and finance health and nutrition.]
Global Fund to Fight AIDS, Tuberculosis and Malaria
Æ
Homepage: https://www.theglobalfund.org/en/
Global Health Council
Æ
Homepage: https://globalhealth.org/
Graduate Institute of International and Development Studies
Æ
Global Health Centre: https://graduateinstitute.ch/globalhealth
Henry J. Kaiser Family Foundation
Æ
Global health policy: https://www.kff.org/global-health-policy/ [This covers mainly the role of
the United States.]
Institute for Health Metrics and Evaluation
Æ
Homepage: http://www.healthdata.org/ [See in particular the report Financing global health
2018: countries and programs in transition (2019).]
Joint United Nations Programme on HIV/AIDS
Æ
Homepage: https://www.unaids.org/en
Organisation for Economic Co-operation and Development
Æ
Health: https://www.oecd.org/health/
UHC2030
Æ
Homepage: https://www.uhc2030.org/ [This multi-stakeholder platform promotes collabora-
tion on the strengthening of health systems and on achieving universal health coverage.]
United Nations
Æ
Health: https://www.un.org/en/sections/issues-depth/health/
Æ
Sustainable Development Goals Knowledge Platform: https://sustainabledevelopment.un.org/
A guide to global health diplomacy 207
Women in Global Health
Æ
Homepage: https://www.womeningh.org/
World Bank
Æ
Health: http://www.worldbank.org/en/topic/health
World Health Organization
Æ
Homepage: https://www.who.int/en/ [This includes links to all six WHO regional offices.]
Æ
Governance: http://apps.who.int/gb/gov/ [This gives an overview of all governance-related
processes at WHO, including documentation, records and the rules of procedure of the
governing bodies.]
Æ
WHO Framework Convention on Tobacco Control: https://www.who.int/fctc/en/
208 Global Health Centre | February 2021
A guide to global health diplomacy 209
ANNEX 3 | LIST OF BOXES
Box 1 Negotiating at the World Health Organization 27
Box 2 Negotiating health at the G7 and G20 32
Box 3 Decolonizing global health diplomacy 44
Box 4 Science diplomacy meets health diplomacy:
recent examples of building alliances for health 60
Box 5 China’s Belt and Road Initiative and its relevance to health 67
Box 6 Humanitarian diplomacy and health 70
Box 7 Health and human rights 77
Box 8 Women as global health diplomats 82
Box 9 Negotiating health at the World Trade Organization 90
Box 10 The governance model of Gavi, the Vaccine Alliance 97
Box 11 The governance model of the Global Fund to Fight AIDS,
Tuberculosis and Malaria 100
Box 12 What are the characteristics of health negotiations at the United Nations? 106
Box 13 Global health diplomacy in Africa 119
Box 14 Preparing a national strategy on global health 129
Box 15 Competencies required to conduct global health negotiations 163
Box 16 City diplomacy for global health 172
Box 17 Preparing for negotiations in Geneva 178
210 Global Health Centre | February 2021
A guide to global health diplomacy 211
CASE STUDIES
212 Global Health Centre | February 2021
A guide to global health diplomacy 213
CASE STUDY 1 | NEGOTIATIONS
FOR THE WORLD HEALTH
ASSEMBLY RESOLUTION ON PRICE
TRANSPARENCY (2019)
Full title: Negotiations leading to the adoption of World Health Assembly resolution WHA72.8 on
improving the transparency of markets for medicines, vaccines and other health products
Author: Catherine Saez
Introduction
On 28 May 2019, Member States at the Seventy-second World Health Assembly adopted a resolu-
tion aimed at improving the transparency of markets for medicines, vaccines and other health
products, including medical devices, diagnostics, assistive products, cell-and-gene-based therapies
and other health technologies (WHO, 2019a).
28
Described by many as a landmark decision, this resolution was agreed on after intense negotiations
that included several night sessions. The language of the final version was slightly less ambitious
than that of the original proposal submitted in February 2019 by Italy, which was joined by nine co
sponsors at the opening of the Seventy-second World Health Assembly in May. Nevertheless, for
the first time a WHO resolution was adopted that explicitly urges countries to publicly share infor-
mation on the net prices of health products.
Only three countries dissociated themselves from the resolution: Germany, Hungary and the United
Kingdom (Fletcher, 2019).
The resolution called for transparency on the prices actually paid for health products in national and
global markets, and for more data on the R&D cost for medicines, the cost of clinical trials and the
patent status of medicines. It was prompted by the need to tackle the huge disparity in medicine
prices between countries. As pointed out by proponents of the resolution, some medicines are,
paradoxically, more expensive in low-income countries than in high-income ones (Saez, 2019a).
28 Citations in the text of this case study are to the references in the list at the end of the case study, not to those in Annex 2.
214 Global Health Centre | February 2021
The issues at stake: high prices, disparities and lack of transparency
Access to medicines and health products is to a great extent conditioned by pricing. The 2019 Med-
icine Price Index noted that “one of the biggest disparities across the world when it comes to access
to care is the price of medicine” (Medbelle, 2019). With the rise of noncommunicable diseases, par-
ticularly in low- and middle-income countries, and the ageing of the world’s population, the global
health burden is increasing. New life-saving therapies, often protected by patents, are marketed at
prices that put a great strain on the resources of health-care systems, even in affluent countries.
The problem of medicines being unaffordable is not a new one for low- and middle-income coun-
tries. It was first brought to international attention by the HIV/AIDS epidemic, in which millions of
people in such countries were left without access to medicines. A new factor, however, is the rising
discomfort felt in high income countries over the prices of new medicines, triggered by the high
cost of the novel life saving treatment for hepatitis C marketed by Gilead in 2014. Some high in-
come countries began to question the high prices charged for new drugs and the transparency of
pricing negotiations with the pharmaceutical industry.
DISPARITIES IN MEDICINE PRICES BETWEEN COUNTRIES
Many low-income countries are expected to increase their gross domestic product (GDP) in the
coming years, thereby losing their eligibility for aid from donor agencies. These countries will have
to negotiate the prices of medicines directly with pharmaceutical companies.
The lack of transparency in the prices paid to the pharmaceutical industry for medicines, both
branded and generic, leads to significant pricing disparities between countries. In its 13th General
Programme of Work, WHO (2019b) noted, “In many contexts, the principal cause of financial hard-
ship is out-of-pocket payments for the purchase of medicines.” As pointed out in the WHO Guide-
line on Country Pharmaceutical Pricing Policies, “[u]p to 90% of the population in developing coun-
tries purchase medicines through out-of-pocket payments, making medicines the largest family
expenditure item after food” (WHO, 2015).
According to the Global Health Observatory (WHO, 2020), out-of-pocket spending accounted for
around 32% of global health expenditure in 2015.
A guide to global health diplomacy 215
However, there are substantial disparities between countries, as may be seen in the figure below:
Out-of-pocket expenditure (%) in 2015
90
80
70
60
50
40
30
20
10
0
Yemen
Myanmar
Cameroon
Pakistan
India
Egypt
Guatemala
Philippines
Viet Nam
Greece
China
Brazil
Portugal
Spain
Italy
Austria
Bulgaria
Argentina
Sweden
Ireland
Norway
Germany
United States
Vanuatu
France
Tuvalu
Similarly, data from the World Bank (2016) point to large disparities in health expenditure between
countries, as shown in the next figure:
Health expenditure in 2016 (% of GDP)
18
16
14
12
10
8
6
4
2
0
United States
Tuvalu
Brazil
France
Germany
Sweden
Norway
Austria
Portugal
Spain
Italy
Greece
Bulgaria
Argentina
Ireland
Myanmar
Guatemala
Viet Nam
Yemen
China
Cameroon
Egypt
Vanuatu
India
Philippines
Pakistan
216 Global Health Centre | February 2021
A study carried out by Health Action International (Hawlik & Delavière, 2016) found that the hospi-
tal prices of medicines in four EU Member States (Austria, France, Latvia and Spain) did not cor-
relate with GDP per capita: the prices of the five medicines examined (for cancer, rheumatic diseas-
es and hepatitis C) were higher in Latvia and Spain than in Austria and France, despite the first two
countries having a lower GDP per capita.
Such disparities have been noted by numerous studies, including one by Iyengar et al. (2016), who
found great variations between countries in the prices of two novel hepatitis C medicines and
concluded, “Poorer countries may be paying higher adjusted prices than richer countries.”
The 2019 Medicine Price Index (Medbelle, 2019) compared the prices of 13 prevalent pharmaceuti-
cal compounds across 50 countries, regardless of whether the medicines were covered by a health-
care system or paid for by patients out of their pocket. Both brand-name and generic versions of
medicines for common conditions were included in the study, which found that the deviation from
the median price ranged from +306.82% in the United States to −93.93% in Thailand.
The OECD has determined an indicator of pharmaceutical spending as a share of total health spend-
ing – expressed in both US dollars per capita and as a share of GDP – for a number of countries
(OECD, 2020), as may be seen in the figure below:
Pharmaceutical spending
Total, % of health spending, 2018 or latest available
40
35
30
25
20
15
10
5
0
Denmark
Norway
Netherland
Sweden
Iceland
Luxembourg
United Kingdom
United States
Austria
Finland
Ireland
Fance
Israel
Switzerland
Costa Rica
Germany
Belgium
Portugal
Australia
Malta
Canada
Czech Republic
Italy
Estonia
Slovenia
Spain
Japan
Cyprus
Poland
Croatia
Korea
Mexico
Lithuania
Romania
Slovak Republic
Greece
Latvia
Hungary
Russia
Bulgaria
A guide to global health diplomacy 217
DISPARITIES DRIVEN BY A LACK OF TRANSPARENCY
The authors of a 2019 study on confidentiality agreements in the pharmaceutical industry observed
how the significant increase in health spending associated with very expensive novel treatments
was prompting countries to negotiate discounts with manufacturing companies. The lack of trans-
parency arising from such confidentiality agreements prevented fair access to essential health
products and made the pharmaceuticals market difficult to regulate (Iunes et al., 2019).
A number of countries set reference prices for prescription drugs on the basis of official list prices,
which are higher than the actual prices paid after negotiations with manufacturers.
As observed in the above-mentioned study by Health Action International (Hawlik & Devalière,
2016), “Opacity of the actual prices of medicines across the EU makes it challenging to assess price
equity and affordability. It is impossible to access data on the true prices of medicines after negoti-
ation with the manufacturer.”
Efforts to tackle high medicine prices before the Seventy-second
World Health Assembly
The problem of high medicine prices has been discussed in various international forums over the
years. However, the lack of transparency in price negotiations with manufacturers has attracted
the most attention recently as studies such as those cited above have found large disparities world-
wide. High income countries have had to start rationing treatments because of their cost, with
some of them even considering using the flexibilities under the Agreement on Trade-Related As-
pects of Intellectual Property Rights (TRIPS Agreement), which were originally designed to help
developing and least developed countries access lower-priced generic versions of pharmaceuticals.
GLOBAL INITIATIVES HIGHLIGHTING THE NEED FOR TRANSPARENCY
A number of global initiatives have been launched to seek ways of facilitating access to medicines
and increasing transparency in their pricing. For example, the WHO Roadmap for Access to Medi-
cines, Vaccines and Other Health Products 2019–2023, presented at the Seventy-second World
Health Assembly in May 2019, stresses the importance of transparency, whether on the results of
clinical trials, the patent status of medicines and health technologies, the research and develop-
ment costs, or on pricing, procurement and reimbursement (WHO, 2019c).
218 Global Health Centre | February 2021
In May 2017, WHO held its first Fair Pricing Forum, during which it was pointed out that “in many
countries the published prices for medicines are not the actual prices paid”. Moreover, govern-
ments generally did not realize the bargaining power they had. They “could negotiate more effec-
tively if they shared information on prices and joined together to reduce transactional costs and
place more emphasis on price–volume negotiations”. It was suggested that governments should
agree to acknowledge where the published price was not the actual price paid in order to ensure
greater transparency on prices (WHO, 2017).
A second Fair Pricing Forum was held by WHO in April 2019. The participants again stressed the
importance of transparency on prices and explored ways of improving it. By that time, the draft
resolution on the transparency of markets for health products had been put forward by Italy, and
the then Director General of the Italian Medicines Agency, Luca Li Bassi, discussed the draft at the
Forum (WHO, 2019d).
Before that, in 2016, the report of the United Nations Secretary-General High-Level Panel on Access
to Medicines had similarly underlined the need for transparency in the cost of R&D, marketing,
production and distribution. In particular, the report noted, “Existing public databases of health
technology prices managed by international organizations and civil society groups, while laudable,
tend to be limited in scope and accuracy, in part because of discounts, mark-ups, taxes and region-
al pricing differences” (UN High-Level Panel on Access to Medicines, 2016).
Launched in 2014, the WHO Vaccine Product, Price and Procurement (V3P) Project aims to facilitate
the comparison of price information by providing countries with accurate and useful data on vac-
cine products and prices (WHO, n.d.). International organizations acting as procurement agencies,
such as UNICEF and PAHO, provide price and procurement resources for the V3P Project, as do a
number of countries including France, the Netherlands, Portugal, South Africa, Sweden and the
United States.
In 2017 the OECD proposed multi-country joint procurement as a way of tackling high prices and
information asymmetry between countries and global companies. The OECD recommends “en-
sur[ing] an adequate degree of transparency of the public procurement system in all stages of the
procurement cycle” and allowing free access for all stakeholders, including “potential domestic and
foreign suppliers, civil society and the general public” (OECD, n.d.).
REGIONAL EFFORTS TO INCREASE TRANSPARENCY
A well-known and widely cited example of regional efforts to increase pricing transparency for
medicines is the PAHO Strategic Fund, a regional technical cooperation mechanism that supports
A guide to global health diplomacy 219
the pooled procurement of essential medicines and strategic health supplies (PAHO, n.d.).
Some EU countries, such as the Netherlands, have voiced strong concerns about the prices of
medicines, and attempts have been made to organize joint negotiations with the pharmaceutical
sector on the prices of medicines.
Thus, in 2015, the Belgian and Dutch health ministers signed a declaration of intent to negotiate
prices jointly with the pharmaceutical sector. Belgium and the Netherlands were later joined by
Austria, Ireland and Luxembourg in what is now known as the Beneluxa Initiative. The Initiative
seeks to facilitate access to medicines, in particular newer expensive medicine, and achieve great-
er transparency on the cost build-up of pharmaceutical products and on pricing in different coun-
tries (Beneluxa Initiative, 2015).
Separately, the Valletta Declaration Group – established in 2017 by Cyprus, Greece, Italy, Malta,
Portugal and Spain, and later joined by Croatia, Ireland, Romania and Slovenia – is seeking to in-
crease the transparency of medicine prices and to facilitate joint procurement initiatives. France
has been granted observer status at the Group’s meetings.
World Health Assembly resolution WHA72.8
CONTENT
Although not legally binding, the resolution adopted by the Seventy-second World Health Assembly
in May 2019 was immediately hailed as a major success. Resolution WHA72.8 is the first interna-
tional agreement on increasing the transparency of markets for medicines. Spearheaded by Italy, it
gained overwhelming support from delegations, after long negotiations that removed the most
contentious provisions.
The resolution urges Member States in particular to:
Æ
Take measures to publicly share information on the net prices
29
of health products;
Æ
Take steps to support the dissemination of, and access to, information on the costs arising from
clinical trials on human subjects, regardless of their outcomes or whether the results will sup-
port an application for marketing approval; and
29 Net prices are the amount received by manufacturers after subtraction of all rebates, discounts and other incentives.
220 Global Health Centre | February 2021
Æ
Work collaboratively to improve the reporting of information by suppliers on registered health
products, such as reports on sales revenues, prices, units sold, marketing costs, and subsidies
and incentives.
The resolution, moreover, requests WHO in particular to:
Æ
Support Member States in collecting and analysing information on economic data across the
value chain for health products;
Æ
Support Member States, especially low- and middle-income countries, in developing and imple-
menting their national policies relevant to the transparency of markets for health products;
Æ
Support research on and monitor the impact of price transparency on the affordability and
availability of health products, including its effect on differential pricing;
Æ
Analyse the availability of data on inputs throughout the value chain, including data on clinical
trials and price information;
Æ
Continue convening the Fair Pricing Forum every second year; and
Æ
Continue supporting efforts to determine the patent status of health products.
A report on the progress made in implementation of the resolution is expected to be delivered to the
Seventy-fourth World Health Assembly, through the Executive Board at its 148th session in 2021.
COSTS RELATED TO RESEARCH AND DEVELOPMENT, MARKETING AND CLINICAL
TRIALS EXCLUDED FROM TRANSPARENCY OBLIGATIONS
Several versions of the draft resolution were in circulation among Member States, both before and
during the Seventy-second World Health Assembly in May 2019, because numerous informal meet-
ings and negotiating sessions were convened by proponents to try to find common ground in ad-
vance of the Health Assembly.
The NGO Knowledge Ecology International, which followed the discussions closely, published six
preliminary versions of the draft proposal.
A number of compromises were made after consideration of the original proposal: elements of the
text had to be removed or tweaked as delegates sought to find language on which most of them
A guide to global health diplomacy 221
could agree. For example, the original proposal submitted by Italy in February 2019 (KEI, 2019a):
Æ
Made the information on R&D and clinical trial costs, marketing, grants, tax credits, sales reve-
nues, prices and quantities a condition of registration for drugs and vaccines;
Æ
Urged Member States to establish minimum standards for transparency regarding information
from clinical trials;
Æ
Requested WHO to collect and analyse data on health technologies of public health importance,
including the actual manufacturing costs of specific drugs, vaccines and health technologies; and
Æ
Urged Member States to avoid measures in trade agreements that could limit the transparency
of information from clinical trials, legitimate disclosures of manufacturing know how for drugs
and vaccines, or the reporting of data on pharmaceutical, vaccine and health technology prices,
revenues and other relevant medical or economic information.
The draft resolution put forward by Italy, Greece, Egypt, Malaysia, Portugal, Serbia, Slovenia, South
Africa, Spain, Turkey and Uganda (KEI, 2019b):
Æ
Urged Member States to undertake measures to publicly share information on prices and the
reimbursement cost of medicines, vaccines, cell and gene-based therapies and other health
technologies;
Æ
Urged Member States to require that all the results from clinical trials on human subjects be
reported publicly, including the costs incurred in undertaking each trial and the direct funding,
tax credits or other subsidies received from governments; and
Æ
Urged Member States to require that the following information be made public for medicines,
vaccines, cell and gene-based therapies: annual reports on sales revenues, prices and units
sold; annual reports on marketing costs incurred for each registered product or procedure; the
R&D cost directly associated with each clinical trial used to support the registration of a product
or procedure; and all grants, tax credits or any other public sector subsidies and incentives re-
lating to the initial regulatory approval.
The adopted resolution (WHA72.8):
Æ
Does not request the disclosure of R&D costs;
222 Global Health Centre | February 2021
Æ
Only asks that the costs arising from clinical trials on human subjects be disseminated if already
publicly available or voluntarily provided;
Æ
Does, however, request enhanced availability of the results of clinical trials regardless of out-
comes or whether the results will support an application for marketing approval;
Æ
Does not request the disclosure of manufacturing costs; and
Æ
Does not seek to prevent measures in trade agreements that limit the transparency of informa-
tion from clinical trials, legitimate disclosures of manufacturing know-how for drugs and vac-
cines, or the reporting of data on pharmaceutical, vaccine and health technology prices, as
envisaged in the original Italian proposal.
NEGOTIATIONS
As the heavy financial burden of new medicines started to be felt by high-income countries, they
became more vocal and joined developing countries in the quest for solutions to bring prices down.
At the meeting of the WHO Executive Board in January 2019, Romania, on behalf of the EU Member
States, advocated a holistic approach, including fair pricing and transparency. Portugal mentioned
in particular the price of hepatitis C and cancer medicines and emphasized how a lack of transpar-
ency “prevail[ed] throughout the pharmaceutical chain”. Italy called for an instrument to tackle the
problem of access to health products, and expressed interest in a WHO resolution on transparent
pricing of medicines at the forthcoming World Health Assembly – the first time that such a resolu-
tion was proposed. There were calls for price transparency from a number of other countries too,
including Bangladesh, the Plurinational State of Bolivia and Chile (Saez, 2019b).
In early February 2019, Italy submitted a draft proposal to improve the transparency of markets for
medicines, vaccines and other health-related technologies. On 29 April, a draft resolution on the
same topic was put forward by 10 Member States for discussion at the Seventy-second World
Health Assembly to be held between 20 and 28 May; those Member States were Italy, Greece,
Malaysia, Portugal, Serbia, Slovenia, South Africa, Spain, Turkey and Uganda. There followed in-
tense negotiations with other Member States before the opening of the World Health Assembly.
On 20 May 2019, the first day of the Seventy-second World Health Assembly, a side event on access
to medicines, vaccines and health products (focusing on how to ensure transparency of markets
and affordable and quality products with a view to achieving universal health coverage) was orga-
nized by Italy and the Republic of Korea, with the co-sponsorship of Costa Rica, Greece, Indonesia,
A guide to global health diplomacy 223
Mexico, Mongolia, the Netherlands, Portugal, Saudi Arabia, Spain and Viet Nam (Saez, 2019c).
The draft resolution had not yet been presented at the World Health Assembly, and the room at this
side event was overflowing, with many health ministers attending. The speakers emphasized the
high prices of medicines, the secrecy surrounding R&D costs, and the negotiated prices obtained
by some countries.
In particular, a representative of the Cypriot Ministry of Health referred to “unethical practices” by
the pharmaceutical industry. Cyprus had a small population and no negotiating power and was
being asked to pay prices much higher than those granted to other countries. A study conducted in
Cyprus had examined all the products approved by the European Medicines Agency (EMA) since
2011, finding that the industry tended to wait about four years before releasing newly EMA-ap-
proved products in Cyprus, reserving those products for richer northern European countries first.
The then Director General of the Italian Medicines Agency, Luca Li Bassi, observed that it would be
interesting to see whether differential pricing was actually occurring according to countries’ GDP,
citing the example of a pneumococcal vaccine that cost twice as much in Lebanon as in Greece. He
called for more comprehensive information to be made available to support better-informed policy
decisions. Countries were the biggest investors in the pharmaceutical industry and should be able
to shape the market.
Armando Bartolazzi, Italy’s Undersecretary of State for Health at the time, noted that transparency
was recognized as a solution to the problem of there being an increasing number of highly effective
but unaffordable medicines.
Bruno Bruins, Minister for Medical Care of the Netherlands, argued that countries should be more
transparent on the price they were willing to pay, while Sarangerel Davaajantsan, Minister of
Health of Mongolia, said that the price of medicines would decrease if transparency were to be
legalized, as it might create competition between suppliers.
Confidential rebates and discounts kept the list prices high, impairing the effectiveness of external
reference pricing, said Soonman Kwon from the Graduate School of Public Health at Seoul Nation-
al University, while Nikos Raptis, Special Adviser to the Greek Minister of Health, added that the
non disclosure clauses which countries had to sign were a way for the pharmaceutical industry to
“divide and conquer”.
In the audience, Anban Pillay, Deputy Director-General for National Health Insurance at the Nation-
al Department of Health of South Africa, called upon countries to follow his country’s example.
224 Global Health Centre | February 2021
South Africa had enacted a law preventing non-disclosure contracts and requiring information from
pharmaceutical companies, such as the price of the active ingredients in their products.
The side event was followed by intense rounds of negotiations between Member States over the
next few days. By 23 May, the discussions had not resulted in consensus, and a drafting group was
set up in view of the fact that the draft resolution was rapidly being riddled with comments and
caveats: there had been almost 100 proposed additions, deletions and amendments. As the plena-
ry discussion, scheduled for 24 May, drew closer, it remained uncertain whether consensus would
ever be reached (Saez, 2019d).
Countries with a strong pharmaceutical industry proposed revisions and amendments to the draft
text. While Germany and the United Kingdom continuously requested revisions, other countries,
including Japan, Switzerland and the United States, sought amendments to specific sections, in
particular those dealing with the disclosure of R&D and clinical trial costs.
The EU Member States were divided, with some co-sponsoring the draft resolution but others openly
making known their opposition to it. Some countries, such as Germany and the United Kingdom, ar-
gued that the draft text had been prepared too hastily and that it should have gone through the WHO
Executive Board in January before being submitted for consideration to the World Health Assembly.
Little progress had been achieved by 24 May. Further negotiations were conducted behind closed
doors, and the formal plenary session that had been scheduled for that date, a Friday, was delayed
until the following Monday (27 May). During the session of 24 May, some Nordic countries, notably
Finland and Norway, expressed their support for the resolution. Similarly, the United States and
Switzerland spoke out in favour of the proposed provisions calling for the publication of list prices
of medicines sold and purchased in national markets. They were, however, against the disclosure
of R&D and clinical trial costs for drugs at the time of regulatory approval, even if the funding came
from public sources (Saez, 2019a).
On 27 May, after a full day of negotiations and yet another postponement of the plenary session
tasked with examining the draft resolution (now postponed to the final day of the World Health
Assembly), the prospect of agreement was brought closer as the number of co-sponsors increased
to 19. The newcomers included the Republic of Korea and Malta. Moreover, Brazil, Ecuador, Nor-
way, the Netherlands, Switzerland and Thailand expressed their support in principle for the resolu-
tion (Saez, 2019e).
While a dedicated core team of some 30 delegates – led by Italy and drawn from, among others,
Brazil, Japan, Norway, Spain, Sweden, Switzerland, Thailand, the United Kingdom and the United
A guide to global health diplomacy 225
States – continued working late into the night on Monday, 27 May, some countries, such as Ger-
many, had by then left the negotiating table. Turkey was reported to have withdrawn its previous
co-sponsorship of the draft resolution – a move linked by some observers to the objections raised
by Germany.
According to sources inside the room, a critical moment occurred when France changed its position
and, breaking ranks with Germany, the United Kingdom and the United States, decided to support
the inclusion of a reference to the costs of clinical trials.
The opening of the last session of Committee A on 28 May, the last day of the World Health Assem-
bly, during which the draft resolution was to be discussed, was delayed slightly as the United
Kingdom tried in vain to gain support for postponing the discussion until the next meeting of the
WHO Executive Board in January 2020 (Fletcher, 2019).
The draft resolution was approved by Committee A with overwhelming support. However, Germany,
Hungary and the United Kingdom, though not blocking the adoption as such, chose to “dissociate”
themselves from the resolution. The United Kingdom complained mainly about the resolution not
having been reviewed by the WHO Executive Board. Julian Braithwaite, the British Permanent
Representative to the UN and other international organizations in Geneva, noted that the United
Kingdom was concerned about the disruptive effect which price transparency could have on differ-
ential pricing agreements granted to low- and middle-income countries. He criticized the process
as having been rushed through, without sufficient time given for careful consideration of potential-
ly far-reaching implications.
Those concerns were echoed by the German delegate, who pointed out that the transparency of
prices was a very complex issue and that the potential implications for health-care systems should
have been better assessed.
Other actors: The World Health Organization, civil society
and public–private partnerships
WORLD HEALTH ORGANIZATION
At the close of the Seventy-second World Health Assembly, WHO Director-General Tedros Adha-
nom Ghebreyesus described the resolution as a “landmark agreement to enhance the transparency
of pricing for medicines, vaccines and other health products”.
226 Global Health Centre | February 2021
WHO has long been advocating greater transparency in the pricing of pharmaceuticals. The Orga-
nization is currently working on updating the 2015 WHO Guideline on Country Pharmaceutical
Pricing Policies, with the new version expected to be published in 2020. The updated version will
include “evidence-informed recommendations for the promotion of price transparency of pharma-
ceutical products” (WHO, 2019e).
The WHO Roadmap for Access to Medicines, Vaccines and Other Health Products 2019–2023 calls
for global and regional collaboration to increase price transparency, facilitate dialogue between
public payers, government decision-makers and industry, and improve capacity for price negotia-
tion. It also suggests measures to assist countries with the selection of appropriate medicines,
vaccines, diagnostics and other health products; with transparent and fair pricing; and with the
implementation of policies to reduce costs for both governments and individuals while ensuring
quality, safety and efficacy and sustainable supply (WHO, 2019c).
In 2018, World Health Assembly decision WHA71(9) on the WHO global strategy and plan of action
on public health, innovation and intellectual property urged Member States to implement and take
into account the recommendations made by the expert panel that had reviewed the strategy. One
of the recommendations flagged as high priority was that Member States should support the WHO
Secretariat in promoting transparency in, and understanding of, R&D costs. Another high-priority
recommendation was that the WHO Secretariat should provide guidance to Member States on
promoting and monitoring transparency in medicine prices and on the implementation of pricing
and reimbursement policies.
In 2017, WHO held its first Fair Pricing Forum, which was followed by a second in 2019. Both events
provided a platform for discussing transparency as one of the means of achieving fair pricing.
CIVIL SOCIETY
Civil society was closely involved from the very start and strongly supported the draft resolution put
forward by Italy. Access to medicines and, in particular, the need to tackle high prices have been long
standing concerns for many civil society organizations, such as Médecins Sans Frontières, Health
Action International, Knowledge Ecology International, Oxfam and Medicus Mundi International.
Intense lobbying by civil society raised awareness of what was at stake in the discussions, before
and during the World Health Assembly. This lobbying, which was carried out either during the
World Health Assembly or at the national level, clearly influenced the negotiations.
A guide to global health diplomacy 227
On 9 May 2019, a group made up of 77 NGOs and 49 individuals, including prominent academics,
signed an open letter denouncing the profusion of brackets and proposed changes to the draft text
that had been made during informal negotiations. The open letter argued that a group of high in-
come countries was seeking to derail the initiative. Australia, Denmark, Germany, Sweden and the
United Kingdom were singled out as the main opponents of the draft resolution, but Austria and the
United States were also cited as seeking to dilute key parts of the text (Branigan, 2019).
On 23 May, in view of how little progress had apparently been made, Knowledge Ecology Interna-
tional and Médecins Sans Frontières, together with 44 other NGOs and 10 individuals, published an
open letter to delegates, urging them “to reach consensus on a strong WHO transparency resolu-
tion that addresses every topic in the original proposal, including prices, revenues, units sold, mar-
keting costs, clinical trial enrollment and outcomes, clinical trial costs, government R&D subsidies,
patent landscapes, manufacturing know-how, and future meetings, forums and activities that col-
lectively are designed to progressively expand and implement norms on transparency” (KEI, 2019c).
The open letter further called for the negotiating text to be released after every negotiating session,
with Member States’ positions identified for any brackets or alternative texts proposed.
France’s initial opposition to the draft resolution stirred a group of prominent civil society leaders,
including Nobel Prize laureate Françoise Barré-Sinoussi, into action. The group published an op-ed
in the leftist newspaper Libération calling on the French Government to support the resolution
without any reservations or ambiguities. The group noted that, in the United Kingdom, treatments
costing above £30,000 per quality-adjusted life year gained were not covered by the National
Health System. In France, unprecedented rationing had had to be introduced for medicines used to
treat hepatitis C, and cancer treatments had been delayed.
A group of German NGOs issued a similar petition to protest against Germany’s position during the
negotiations on the draft resolution. They called on the German Government to reconsider its stance.
In a separate development, 66 African NGOs based in South Africa, Uganda and Zimbabwe sought
to influence Germany’s negotiating position by addressing an open letter to Jens Spahn, the Ger-
man Minister of Health. They urged the German Government to display solidarity with the people
most at risk of acute suffering and even death because of lack of access to medicines. The same
letter was addressed to French Health Minister Agnès Buzyn and to Matthew Hancock, Secretary
of State for Health and Social Care of the United Kingdom.
228 Global Health Centre | February 2021
PUBLIC–PRIVATE PARTNERSHIPS
During the discussions on the draft Roadmap for Access to Medicines, Vaccines and Other Health
Products 2019–2023 at the Seventy-second World Health Assembly, the Drugs for Neglected Dis-
eases Initiative, which works with private sector partners, emphasized that transparency on the
costs of R&D was a central element of its policy: “We put as much information into the public do-
main as possible, including all clinical trial data, our actual R&D costs and related financing flows,
including the in-kind contributions from our partners where they provide them.”
PHARMACEUTICAL INDUSTRY
The pharmaceutical industry did not express its views openly during the negotiations at the Seventy
second World Health Assembly. The industry has traditionally been against the disclosure of R&D and
clinical trial costs, arguing that such figures are difficult to compile. Moreover, so it is argued further,
such costs are influenced by multiple factors, and prices are only one aspect of access to medicines.
As the industry came under pressure from high-income countries protesting about the unprece-
dentedly high prices of new medicines, some companies defended themselves by pointing out that
medicines such as the new hepatitis C drugs offered a cure for life, thereby saving health-care
systems a lot of money.
Commenting on the draft Roadmap for Access to Medicines, Vaccines and Other Health Products at
the meeting of the WHO Executive Board in January 2019, the International Federation of Pharmaceu-
tical Manufacturers and Associations (IFPMA) voiced concerns about what it described as a narrow
approach to pricing that focused on price transparency, rather than taking into account the broader
context. The IFPMA also warned about possible unintended consequences of price transparency on
pharmaceutical companies’ ability to offer preferential pricing to developing countries and argued
that those consequences should be examined before embarking on discussions on transparency.
Speaking on the same topic at the Seventy-second World Health Assembly, the IFPMA pointed out
that sharing information on the prices of medicines could drive prices up in less developed coun-
tries – namely, if developed countries were to see what the latter were paying and demand greater
price parity.
With regard to reporting on R&D costs, the IFPMA argued that medicine prices should reflect the
therapeutic value of medicines and the positive outcomes experienced by patients and society,
rather than considering the “cost input” of individual medicines. However, the Federation acknowl-
edged the need for more information to be made available.
A guide to global health diplomacy 229
At the close of the World Health Assembly, the IFPMA concluded that improving the affordability
of, and access to, medicines and vaccines was a multidimensional challenge requiring collabora-
tive and holistic solutions from all stakeholders, including the pharmaceutical industry. In particular,
it was important to reduce the out-of-pocket payments that patients had to make; tackle inefficien-
cies in supply chains; combat counterfeit medicines; improve procurement practices; and make
differential pricing possible for low- and middle-income countries.
Lessons learned – What now?
The negotiations leading to the adoption of the resolution on improving the transparency of phar-
maceutical markets were tortuous, but their successful conclusion was aided by the strong support
of some high-income countries, whose interests are now divided between protecting their pharma-
ceutical industries and ensuring the sustainability of their health systems.
Eventually only Germany, Hungary and the United Kingdom dissociated themselves from the reso-
lution. According to observers, a number of high-income countries, including Australia, Belgium,
Bulgaria, Canada, Denmark, the Netherlands, Poland, Sweden and Switzerland, objected to certain
passages of the draft, leading to a weakened text in the final version.
Once the transparency of R&D costs had been removed from consideration, Japan, the Netherlands,
Switzerland and the United States were able to rally the resolution’s other proponents. Only a small
number of countries were opposed to the disclosure of clinical trial costs.
Both Germany and the United Kingdom have a strong pharmaceutical industry (notably GlaxoSmith-
Kline and AstraZeneca in the latter), but they also depend on negotiations with the industry to
maintain their health-care systems. Germany was recently dubbed the leader of the European
pharmaceutical industry.
The strong lobbying by civil society also helped tilt the balance of the negotiations. During the
Seventy second World Health Assembly, Germany complained about the campaign mounted by
civil society – in particular, that negotiators were being put under pressure by the publication of
leaked information on their perceived positions.
Following the resolution’s adoption, France and Italy approved new regulations requiring pharma-
ceutical companies to disclose public contributions received for R&D on new drugs. However, by
the end of 2019 those initiatives had stalled owing to procedural issues in France and to the forma-
tion of a new government in Italy.
230 Global Health Centre | February 2021
The WHO report to be presented at the 148th session of the Executive Board in January 2021 is
expected to shed some light on the implementation of the resolution at the national level.
Reference list
Abbreviations used in the in-text citations are given in square brackets after the full name of the au-
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September 2020).
A guide to global health diplomacy 231
Knowledge Ecology International [KEI] (2019a). Improving the transparency of markets for drugs,
vaccines and other health-related technologies [draft text of resolution as submitted by Italy to
WHO] (https://www.keionline.org/wp-content/uploads/italy-draft-resolution-transparen-
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Saez C (2019c). Several ministers of health speak up for drug market transparency, lower prices at
WHA side event. Health Policy Watch. 20 May (https://www.healthpolicy-watch.org/several-min-
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accessed 14 September 2020).
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Saez C (2019e). Negotiators agree on game-changing WHA resolution for medicine price
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Secretary-General’s High-Level Panel on Access to Medicines (http://www.unsgaccessmeds.
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GD.ZS?end=2016&start=2000, accessed 14 September 2020).
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WHO/Immunization, vaccines and biologicals [website]. Geneva: World Health Organization
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A guide to global health diplomacy 233
World Health Organization. (2015). WHO guideline on country pharmaceutical pricing policies.
Geneva: World Health Organization (https://apps.who.int/iris/handle/10665/153920, accessed 14
September 2020).
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234 Global Health Centre | February 2021
A guide to global health diplomacy 235
CASE STUDY 2 | THE POLITICAL
DECLARATION OF THE HIGH-LEVEL
MEETING ON UNIVERSAL HEALTH
COVERAGE (2019)
Full title: The Political Declaration of the High-Level Meeting on Universal Health Coverage (2019):
Negotiating the most comprehensive agreement ever reached on global health*
Authors: Satoshi Ezoe, Tamar Tchelidze, Nathita Premabhuti, Marcelo A.C. Costa
* This case study was written by the authors in their personal capacity; it does not reflect their respec-
tive organizations’ views and positions.
Introduction
On 23 September 2019, world leaders at the United Nations General Assembly High-Level Meeting
on Universal Health Coverage unanimously approved the Political Declaration of the High-Level
Meeting on Universal Health Coverage (UN, 2019a),
30
described by UN Secretary-General António
Guterres as “the most comprehensive agreement ever reached on global health” (UN, 2019b). This
historic agreement reiterates a number of key principles, including the importance of health for
implementation of all the goals and targets of the 2030 Agenda for Sustainable Development.
World leaders recommitted themselves to achieving universal health coverage by 2030 and to scal-
ing up global efforts to build a healthier world for all.
The high-level meeting and its political declaration were the result of a series of concerted
multi-stakeholder efforts. This case study looks at the relevant processes from the point of view of
health diplomats in New York who were closely involved in the planning and negotiations that led
to this landmark agreement.
30 Citations in the text of this case study are to the references in the list at the end of the case study, not to those in Annex 2.
236 Global Health Centre | February 2021
The problem
As defined by WHO, universal health coverage is when “all people receive the health services they
need, including public health services designed to promote better health …, prevent illness …,
and to provide treatment, rehabilitation and palliative care … of sufficient quality to be effective,
while at the same time ensuring that the use of these services does not expose the user to financial
hardship” (WHO, 2019a).
As a result of several advocacy campaigns and intergovernmental negotiations, universal health
coverage was included in the Sustainable Development Goals (SDGs) adopted at the UN General
Assembly in 2015, specifically as SDG target 3.8, “Achieve universal health coverage, including fi-
nancial risk protection, access to quality essential health care services and access to safe, effective,
quality and affordable essential medicines and vaccines for all” (UN, 2015).
31
However, according to the 2019 global monitoring report on universal health coverage, global prog-
ress since the previous report in 2017 has been less than satisfactory. Alarmingly, at least half of
the world’s population still lack access to essential health services. Every year, more than 900 mil-
lion people spend at least 10% of their household income on health care, and out-of-pocket expens-
es on health drive some 100 million people into poverty. If the current trend continues, at least
one-third of the world’s population will still have no access to essential health services in 2030
(WHO, 2019a).
The context
Global health matters are discussed mainly at the governing bodies of WHO, particularly the World
Health Assembly, which is convened under the auspices of Member States’ health ministers. How-
ever, there has been an increasing tendency for the Heads of State and Government to discuss
prominent health issues at the UN General Assembly, the primary role of which is to tackle matters
related to peace and security, human rights and development. The first example of this trend was
the General Assembly Special Session on HIV/AIDS held in 2001, which was a watershed in the
sense that the global response to AIDS was now put on the political agenda of the Heads of State
31 The associated indicators were defined in 2017 as shown below:
Æ
SDG indicator 3.8.1: “Coverage of essential health services (defined as the average coverage of essential services based
on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, non commu-
nicable diseases and service capacity and access, among the general and the most disadvantaged population)”; and
Æ
SDG indicator 3.8.2: “Proportion of population with large household expenditures on health as a share of total household
expenditure or income” (UN, 2017).
A guide to global health diplomacy 237
and Government (UN, 2001). That special session has been followed by high-level meetings at the
General Assembly on noncommunicable diseases (2011, 2014 and 2018), antimicrobial resistance
(2016) and tuberculosis (2018).
While these meetings – and the declarations endorsed at them – helped to draw policy-makers’
attention to a number of major health issues, it was recognized increasingly that health-related
discussions in New York, particularly those on universal health coverage, required a more coherent
and integrated approach for the following reasons:
Æ
The 2030 Agenda for Sustainable Development emphasized the integrated, indivisible and in-
terlinked nature of the SDGs, and called for a holistic rather than piecemeal approach;
Æ
The international community’s renewed commitment to primary health care and to the strength-
ening of health systems in order to ensure health for all put the focus on universal health cov-
erage as an umbrella concept under which all health issues related to SDG 3 could be tackled
(WHO, 2019b); and
Æ
The interrelated and increasingly complex topics dealt with at the UN, such as climate change,
financing for development and nuclear disarmament, required a more focused approach to
health as opposed to holding high-level meetings on individual health issues about once a year.
Accordingly, the General Assembly decided, in 2017, to convene a high-level meeting in 2019 on
universal health coverage and to proclaim 12 December as International Universal Health Coverage
Day (UN, 2018a, 2018b). The two resolutions, both adopted on 12 December 2017, were put for-
ward by Thailand, which was then chairing the Foreign Policy and Global Health Initiative.
On 13 and 14 December 2017, the first Universal Health Coverage Forum was held in Tokyo, bring-
ing together high-level representatives of various countries and international agencies – including
the UN Secretary-General and the heads of WHO, the World Bank and UNICEF – to generate mo-
mentum for the promotion of universal health coverage (MoFA Japan, 2017). The outcome docu-
ment (MoFA Japan et al., 2017), which included such aspirations as extending essential health
coverage to an additional 1 billion people by 2023, was to feed into the Political Declaration of the
High-Level Meeting on Universal Health Coverage in 2019.
In December 2018, the General Assembly unanimously adopted a resolution setting out the scope,
modalities, format and organization of the high-level meeting on universal health coverage, which
was to be convened on Monday, 23 September 2019, the first day of the high-level week (UN,
2019c). The resolution, co-facilitated by Thailand and Hungary, called upon all Member States to
238 Global Health Centre | February 2021
participate in the meeting at the highest level and to commit to achieving universal health coverage
by 2030. Moreover, the General Assembly in the same resolution decided that the meeting should
approve “a concise and action-oriented political declaration, agreed in advance by consensus
through intergovernmental negotiations”. At this point, the stage was set for the meeting in Sep-
tember and the Member States had to start negotiating a political declaration that would merit
endorsement by world leaders.
The players and their roles
PRESIDENT OF THE GENERAL ASSEMBLY
The President of the General Assembly was tasked with organizing the high-level meeting and with
submitting to the General Assembly the political declaration to be approved at the meeting as
mandated by the General Assembly (UN, 2019c). The President was also tasked with organizing an
interactive multi-stakeholder hearing as part of the preparations for the meeting. In her capacity as
President of the 73rd session of the General Assembly, H.E. Ms María Fernanda Espinosa Garcés
demonstrated strong commitment and led the preparatory arrangements, including the appoint-
ment of the Permanent Representatives of Thailand and Georgia as co facilitators for the negotia-
tions on the political declaration. The actual convening of the high-level meeting was taken on by
the President of the 74th session of the General Assembly, H.E. Mr Tijjani Muhammad-Bande.
CO-FACILITATORS
H.E. Mr Vitavas Srivihok and H.E. Mr Kaha Imnadze, the Permanent Representatives of, respective-
ly, Thailand and Georgia to the UN, were appointed by the President of the General Assembly as co
facilitators to conduct informal consultations with the Member States aimed at producing the po-
litical declaration that was to be approved at the high-level meeting (PGA, 2019a). They led the
drafting of the political declaration, incorporating inputs from various stakeholders, and steered the
negotiations between the Member States.
GROUP OF FRIENDS OF UNIVERSAL HEALTH COVERAGE AND GLOBAL HEALTH
On International Universal Health Coverage Day in 2018, the Group of Friends of Universal Health
Coverage and Global Health was launched. H.E. Mr Koro Bessho, Permanent Representative of
Japan to the UN, was appointed its Chair (UHC2030, 2019a). The Group was established as an open
platform that Member States could use to build momentum towards the high-level meeting in
September 2019, and to raise awareness of the importance of universal health coverage among
A guide to global health diplomacy 239
diplomats in New York, most of whom have expertise not in health matters but in security, human
rights or development. The Group started off with just a few members (including Brazil, France,
Ghana, Hungary, Japan, South Africa and Thailand), but by the start of the negotiations on the
political declaration its membership had grown to more than 50.
FOREIGN POLICY AND GLOBAL HEALTH INITIATIVE
A group of Member States under the Foreign Policy and Global Health Initiative, which was
launched by the Oslo Ministerial Declaration of 2007 (MoFA Brazil et al., 2007), has been proposing
draft resolutions on global health and foreign policy to the General Assembly since 2008.
32
It was
thanks to the 2012 version of the “Global health and foreign policy” resolution, presented by France,
that universal health coverage was first discussed at the General Assembly (UN, 2013). In 2017,
Japan, a long-standing proponent of universal health coverage, suggested to Thailand, which then
held the chairmanship of the Foreign Policy and Global Health Initiative, that the forthcoming
“Global health and foreign policy” resolution should, among other things, call for a high level meet-
ing on universal health coverage. After negotiations led by Thailand and supported by other propo-
nents of universal health coverage, it was unanimously decided through the new resolution to hold
such a high-level meeting in 2019 (UN, 2018a).
MEMBER STATES
During the negotiations on the political declaration, Member States negotiated either individually
or coordinated their positions as part of groups. The main groups in these negotiations were the
Group of African States, the European Union and the CANZ (Canada, Australia and New Zealand)
group. The Group of 77, which is the largest coalition of developing countries in the UN, did not
negotiate as a group at the time, although it had done so during the negotiations leading to the two
high-level meetings on tuberculosis and noncommunicable diseases in 2018. It appears that the
Group of 77 countries were unable to agree on a common position because of the broader scope of
the political declaration on universal health coverage. Two other groups worth mentioning in this
connection are the Group of Seven
33
and the Group of 20
34
, both of which have taken up universal
health coverage in recent years (G7, 2016, 2019; G20, 2019). Other groups and individual Member
States also contributed significantly to the negotiations, forming coalitions on an ad hoc basis.
32 The Member States taking part in the Foreign Policy and Global Health Initiative are Brazil, France, Indonesia, Norway, Senegal,
South Africa and Thailand.
33 The G7 consists of Canada, France, Germany, Italy, Japan, the United Kingdom, and the United States of America. The EU is
regularly represented at G7 summits.
34 The G20 consists of the G7 countries (plus the EU), along with Argentina, Australia, Brazil, China, India, Indonesia, Mexico, the
Republic of Korea, the Russian Federation, Saudi Arabia, South Africa and Turkey.
240 Global Health Centre | February 2021
WORLD HEALTH ORGANIZATION
Ever since his inauguration, WHO Director-General Tedros Adhanom Ghebreyesus (2017) has made
it clear that universal health coverage is a “top priority” for the Organization. As the UN technical
agency on health, WHO played a central role in providing technical support throughout the negoti-
ations, as it had already done for previous high-level meetings on health topics at the General As-
sembly. WHO served as a technical secretariat during the negotiations: its tasks included replying
to Member States’ requests for technical clarification and ensuring the technical integrity of the
political declaration. Moreover, WHO assisted the President of the General Assembly in organizing
the multi-stakeholder hearing in April 2019 as well as the high-level meeting itself.
INTERNATIONAL HEALTH PARTNERSHIP FOR UNIVERSAL HEALTH COVERAGE 2030
The International Health Partnership for Universal Health Coverage 2030 (UHC2030) is a multi-stake-
holder partnership established in 2017 to facilitate equitable and sustainable progress towards
universal health coverage.
35
It played an instrumental role in the preparations for the high level
meeting by bringing together multiple stakeholders (including civil society, the private sector, phil-
anthropic institutions and academia) through a series of consultations. These resulted in the com-
pilation of a set of “Key Asks” that were presented to the co-facilitators of the negotiations and to
Member States through briefings given by the Group of Friends of Universal Health Coverage and
Global Health, and also through the multi-stakeholder hearing in April (UHC2030, 2019b). There are
seven Key Asks in all: (1) “Ensure political leadership beyond health”; (2) “Leave no one behind”; (3)
“Regulate and legislate”; (4) “Uphold quality of care”; (5) “Invest more, invest better”; (6) “Move
together”; and (7) “Gender equality and women’s rights as drivers of health”.
Tools and approaches
The drafting of the political declaration was led by the co-facilitators and involved broad and inclu-
sive consultations with the UN Member States, WHO, civil society, academia, the private sector
and other stakeholders. The main approaches employed to ensure an inclusive and effective pro-
cess leading to a meaningful consensus-based declaration were as follows:
MULTI-STAKEHOLDER ENGAGEMENT
One important input for the declaration was the Key Asks presented by the multi-stakeholder plat-
35 See https://www.uhc2030.org/.
A guide to global health diplomacy 241
form UHC2030 (2019b). Stakeholders were given the opportunity to contribute to the six Key Asks
before these were submitted for the co-facilitator’s consideration as part of the development of the
zero draft of the declaration. Stakeholders were also able to voice their views during the briefings
of the Group of Friends of Universal Health Coverage and Global Health, and at the interactive
multi-stakeholder hearing convened by the President of the General Assembly on 29 April 2019. At
the hearing, it was proposed to include the area of gender equality and women’s rights as the
seventh Key Ask; this proposal was duly accepted.
GROUP OF FRIENDS OF UNIVERSAL HEALTH COVERAGE AND GLOBAL HEALTH
ESTABLISHED AS A PLATFORM IN NEW YORK
The Group of Friends convened a series of briefings in New York that brought together UN agencies
(including WHO, which gave a briefing on the relevant resolutions and discussions in Geneva), ex-
perts and civil society organizations. The Group also organized a briefing to launch the Key Asks
prepared by UHC2030. These briefings were instrumental in helping diplomats in New York to play
an informed and constructive role in the negotiations on the political declaration.
LIAISON BETWEEN GENEVA AND NEW YORK
At WHO headquarters in Geneva, as a basis for formulating a draft declaration, Thailand and Japan
jointly led the development of a resolution entitled “Preparation for the high-level meeting of the
United Nations General Assembly on universal health coverage”, which was adopted by the Exec-
utive Board in January 2019 (WHO, 2019c) and by the World Health Assembly in May 2019 (WHO,
2019d). The Permanent Representatives of Thailand and Georgia to the UN in New York, who had
been appointed co-facilitators of the negotiations on the political declaration, paid a visit to Geneva
in May 2019 to brief WHO Member States on the status of the negotiations in New York and to
consult technical experts at WHO headquarters with a view to ensuring coherence between the
negotiation processes in the two cities.
ALIGNING THE DECLARATION WITH RELEVANT INITIATIVES
During the drafting of, and the negotiations on, the political declaration, the co-facilitators sought
to ensure that the declaration was aligned with relevant initiatives and outcomes. These included:
(a) the Astana Declaration, endorsed at the Global Conference on Primary Health Care that was
held in Astana (now Nur Sultan), Kazakhstan, in October 2018 (WHO, 2019b); (b) the Global Action
Plan for Healthy Lives and Well-being for All, launched at the UN General Assembly in September
2019 to strengthen collaboration among multilateral organizations with a view to helping countries
242 Global Health Centre | February 2021
achieve swifter progress on the health-related SDGs;
36
and (c) the G20 Osaka Leaders’ Declaration
(adopted at the G20 Summit held in Osaka, Japan, in June 2019), which includes commitments on
universal health coverage. The Astana Declaration was invoked in paragraph 13 of the political
declaration, which states that “primary health care is the cornerstone of a sustainable health sys-
tem for universal health coverage and health-related Sustainable Development Goals”. The propos-
al to include a reference to the Global Action Plan for Healthy Lives and Well-being for All was ini-
tially not supported by some Member States, but such a reference did finally appear in paragraph
77, where the agreed wording from the G20 Osaka Leaders’ Declaration was used. Some concepts
from the G20 Osaka Leaders’ Declaration were also incorporated into the political declaration – for
example, “healthy and active ageing” (paragraph 30) and collaboration between finance and health
authorities (paragraph 39).
Outcomes and challenges
Drawing on the inclusive and carefully sequenced processes in both Geneva and New York that had
brought together a range of multi-stakeholder views, the co-facilitators developed a zero draft of the
political declaration, which was circulated among Member States in late May 2019, initiating a series
of negotiations. More than 10 informal consultations had been held by the end of July; these were
supplemented by small-group and bilateral meetings to deal with specific concerns. Following the
negotiations, the final draft was placed under silence procedure on 24 July.
37
The silence was broken
twice over contentious issues in early August (PGA, 2019b, 2019c, 2019d). However, thanks to the
skill and perseverance of the two co-facilitators – who organized a final ambassadorial meeting on 4
September as well as several informal bilateral discussions – the final draft of the political declara-
tion could be placed under silence procedure again on 10 September (PGA, 2019e). By the end of the
silence period two days later, the political declaration had been agreed upon by consensus.
The Political Declaration of the High-Level Meeting on Universal Health Coverage reaffirms various
relevant agreements and stresses the central role of universal health coverage for implementation
of the 2030 Agenda for Sustainable Development. Moreover, it lays down the commitment by world
leaders to achieve universal health coverage by 2030. The main points of the declaration were
summarized by the International Health Partnership for UHC2030 as “Key targets, commitments
and actions” (UHC2030, 2019c) with reference to the “Key Asks” that the Partnership had compiled
36 See https://www.who.int/sdg/global-action-plan.
37 The silence procedure is used in most intergovernmental negotiations at the UN to agree upon a proposal by consensus. A draft
version of the text of the proposal is circulated among participants and if no amendments or objections are proposed – that is,
if no one breaks the silence – before a specified deadline, the text is considered to have been agreed upon by all participants.
A guide to global health diplomacy 243
in advance of the high-level meeting. Some of the highlights of the political declaration are outlined
below:
1. KEY TARGETS
Among the most important targets of the political declaration – targets that were intensely debated
during the negotiations – are: providing all people with quality essential health services by 2030;
reversing the trend that is seeing out-of-pocket health expenditure rise to catastrophic levels; and
eliminating impoverishment due to health related expenses by 2030. Achieving agreement on
those targets became possible thanks to a technical briefing given by experts from WHO headquar-
ters, convened by the co-facilitators. Those Member States, including Japan, that were keen on
setting meaningful and ambitious numerical targets had asked for various technical clarifications,
including trends and estimates. Other key targets are summarized in Figure 1.
Figure 1: Political declaration: outcome targets
Global targets National targets
[24] Accelerate efforts towards the achievement of UHC by
2030
Æ
Progressively cover 1 billion additional people by 2023
and all people by 2030
Æ
Reverse the trend of catastrophic out- of-pocket health
expenditure and eliminate impoverishment due to
expenses by 2030
[42] Expand services, strengthen health systems, and
mobilize resources, noting that an additional 3.9 trillion USD
in by 2030 could prevent 97 million premature deaths and
add 3.1 and 8.4 years of life expectancy in low- and
middle- income countries
[60] Address the shortfall of 18 million health workers and
the call for the creation of 40 million health worker jobs by
2030.
[40] Optimize budgetary allocations on health, broaden
fiscal space, and prioritize health in public spending, with
emphasis on primary health care, and note the World
Health Organization recommended target of an additional
1% of GDP or more.
Source: Political Declaration of the Hight-Level Meeting on Universal Health Coverage
2. KEY COMMITMENTS
The political declaration incorporates all seven “Key Asks” compiled by the International Health
Partnership for UHC2030, with a strong emphasis on: the importance of political commitment; de-
veloping and implementing evidence-based policies and programmes; national ownership; tackling
244 Global Health Centre | February 2021
health inequities so as to leave no one behind; engaging stakeholders; and increasing investment,
notably through enhanced collaboration between health and finance authorities. The declaration
recognizes the urgent need for health systems to be strengthened, and the pivotal role of primary
health care in achieving universal health coverage. Moreover, the declaration calls for social justice
and social protection mechanisms to be upheld so that health-care systems are truly comprehen-
sive and people-centred.
3. CONTROVERSIAL AREAS
There were three main controversial areas that required focused attention and consultations during
the negotiation process:
Sexual and reproductive health and rights
One of the most contentious topics during the negotiations was sexual and reproductive health and
rights, which many Member States felt strongly about in different ways, as has happened before in
other UN forums. When a difficult issue comes up during negotiations at the UN, a well-tried ap-
proach is to use agreed language from earlier documents adopted unanimously by the Member
States. In this case, however, it proved difficult to agree on which agreed language to use. One
possible approach was to use the outcome document of the 2019 session of the UN Commission on
the Status of Women (UN-Women, 2019). Wording from that document appeared in the zero draft
of the political declaration, but it was contested by some Member States on the grounds that the
source text might not be a consensus-based document and that the context was different. Another
possible approach was to use the language from the World Health Assembly resolution on prepa-
ration for the high-level meeting (resolution WHA72.4), which referred to “sexual and reproductive
health”; however, some Member States felt that this was insufficient, as there was no mention of
rights. Either approach would have been equally valid, but after extensive consultations and at-
tempts at persuasion that went on until the very last minute, the Member States, as suggested by
the co-facilitators, finally agreed to settle the matter by using agreed language from the SDGs –
specifically from SDG targets 3.7 and 5.6 (UN, 2015) – in paragraph 68 of the political declaration.
Migrants
The issue of migrants was another controversial area that required extensive consultations, as in
some other UN forums. Some Member States felt that there was no need to refer to migrants in the
political declaration, while others considered this to be essential. Similarly, some Member States
felt it was necessary and relevant to invoke the Global Compact for Safe, Orderly and Regular Mi-
gration, while others disagreed, pointing out that the Global Compact had not been universally
A guide to global health diplomacy 245
agreed upon by the UN Member States. Finally, as suggested by the co facilitators, Member States
agreed to base paragraph 70 of the political declaration on agreed language from the “Global
health and foreign policy” resolution adopted by the General Assembly in December 2017 (UN,
2018a). The final text of that paragraph refers generally to leaving no one behind, including mi-
grants among other vulnerable groups of people.
Intellectual property and price transparency
The question of how to strike a balance between ensuring that medical products are affordable and
protecting intellectual property in order to incentivize innovation is a perennial subject of debate in
health-related negotiations, not least in the negotiations on the political declaration. Furthermore,
the issue of increasing transparency in the pricing of high-priced medical products, which was
discussed at great length during the Seventy-second World Health Assembly in May 2019, was
taken up in these negotiations. With regard to intellectual property, the co-facilitators decided to
incorporate into paragraph 51 of the declaration the language agreed on during the negotiations
for the Political Declaration of the High-Level Meeting of the General Assembly on the Fight against
Tuberculosis in 2018 (UN, 2018c). As for price transparency, Member States finally chose to use the
agreed language from World Health Assembly resolution WHA72.8 (WHO, 2019e) in paragraph 50
of the political declaration, rather than reopening in New York the technical discussions on that
topic that had taken place in Geneva.
4. ACCOUNTABILITY AND FOLLOW-UP
The political declaration further focuses on identifying priority tasks for action, follow-up and ac-
countability at the national and global level, such as: setting national targets and strengthening
national monitoring and evaluation platforms; monitoring and enhancing the initiatives undertaken
to achieve universal health coverage through progress reports prepared by the Secretary-General;
and organizing a high-level review meeting on universal health coverage in 2023, intended to con-
solidate all health-related efforts. Relevant commitments on accountability and follow-up are sum-
marized in Figure 2.
246 Global Health Centre | February 2021
Figure 2: Political declaration: follow-up, accountability
Global follow-up National follow-up
[82] SG progress report in 75th session of General Assembly
(2020/21)
[82] SG report with recommandations on political
declaration implementation in 77th session og General
Assembly (2022/23)
[83] HLM on UHC in 2023 – scope and modalities to be
decided by 75th session of the General Assembly (by
September 2021)
[55] Strengthen the capacity of national government
authorities for strategic leadership and coordination,
focusing on intersectoral interventions, as well as
strengthen the capacity of local authorities
[79] Set measurable national targets and strengthen
national monitoring and evaluation platforms
[80] Upon Member State request, leverage the full potential
of the multilateral system, including WHO, the UN
development system, RCs and UN country teams, and other
relevant actors, to assist and support countries at the
national level to achieve UHC
Source: Political Declaration of the Hight-Level Meeting on Universal Health Coverage
Lessons learned and next steps
The key lessons learned throughout the planning and preparations for, negotiations on, and con-
vening of the high-level meeting are outlined below:
1. THE RIGHT AGENDA AT THE RIGHT TIME
Following the adoption of the SDGs in 2015 and a series of high-level meetings at the UN that fo-
cused on specific health issues (2001, 2006, 2011, 2014, 2016 and 2018), there was increasing
momentum for a comprehensive approach towards health to be discussed at the level of Heads of
State. The fact that the representatives of 165 Member States, including 57 Heads of State and
Government, registered in advance of the High-Level Meeting on Universal Health Coverage sug-
gests that the topic was very much seen as worthy of the international community’s attention.
Scheduling the meeting to take place on the first day of the UN General Assembly’s high-level week
also helped to ensure the participation of many senior State representatives.
2. LEADERSHIP AND COMMITMENT BY CHAMPIONS OF UNIVERSAL
HEALTH COVERAGE
The leadership and commitment of champions of universal health coverage were essential to the
successful outcome of the high-level meeting. Thailand and Georgia, the co-facilitators, and their
A guide to global health diplomacy 247
teams demonstrated great perseverance and skill throughout the negotiations. The UN Secre-
tary-General, the WHO Director-General and the President of the General Assembly made clear their
support for the agenda early on through their statements and actions, such as convening prepara-
tory meetings. Member States – including such champions of universal health coverage as Brazil,
Georgia, Japan and Thailand, and also the members of the Group of Friends of Universal Health
Coverage and Global Health – helped to steer the negotiations and convene the high-level meeting.
Experts from Thailand and Georgia (as the co-facilitators), the Office of the President of the General
Assembly, the Chair of the Group of Friends, and WHO (as the technical secretariat for the negotia-
tions) communicated daily on practical matters, which helped to move the process forward.
3. MULTI-STAKEHOLDER ENGAGEMENT
The “Key Asks”, compiled by the International Health Partnership for UHC2030 and based on exten-
sive consultations with civil society, the private sector, philanthropic institutions and academia,
were instrumental in ensuring that the views of a wide range of stakeholders were reflected in the
political declaration. In addition, the multi-stakeholder hearing convened by the President of the
General Assembly and the briefing held by the Group of Friends of Universal Health Coverage and
Global Health to invite the International Health Partnership for UHC2030 to present the “Key Asks”
helped to channel the voices of these stakeholders into the final negotiations.
4. PREPARING THE DIPLOMATS IN NEW YORK FOR THE NEGOTIATIONS
As the diplomats in New York are not necessarily experts in health matters, the Group of Friends of
Universal Health Coverage and Global Health was created as a platform for Member States to
deepen their understanding of universal health coverage and of the views of different stakeholders.
Briefings on relevant discussions at WHO headquarters and governing bodies in Geneva and on
multi-stakeholder consultations helped diplomats to prepare for, and constructively engage in, the
negotiations. There were also briefings, jointly convened by interested Member States and part-
ners, on such topics as the private sector’s role in health care, the funding of universal health cov-
erage and population ageing.
5. LIAISON BETWEEN GENEVA AND NEW YORK
Every effort was made to ensure coherence between the discussions in Geneva and New York,
which had different dynamics and priorities. This was achieved mainly through the preparatory
World Health Assembly resolution (WHA72.4; WHO, 2019d), the co-facilitators’ briefing in Geneva
and the engagement of experts from WHO headquarters. The technical foundations for the negoti-
ations were thereby laid, and it was possible to tackle some controversial issues such as price
248 Global Health Centre | February 2021
transparency. However, some topics – notably sexual and reproductive health and rights, and mi-
grants – proved more controversial in New York than in Geneva; these required focused mediation
and persuasion as described above. Diplomats taking part in future health negotiations in New
York should bear in mind their political nature, which is closely linked to broader developments at
the General Assembly.
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