Global health diplomacy is an emerging field in global health and international diplomacy. As boundaries become blurred between global health and multilateral diplomacy, there is a growing call for health experts and development experts to become adept in international relations issues and for trained diplomats to become knowledgeable about global health issues. In this article, I briefly define global health diplomacy, review possible fundamental principles and discuss unresolved challenges.

Antecedents of Global Health Diplomacy

Experts trace global health diplomacy to multiple origins. The earliest origins involve trade and exchange of gifts between nation states. As the understanding of the role of personal health in national economic development became better understood, negotiations over access to health services became paramount in bilateral relationships. Preserving access to basic health services even in times of war and natural disasters is a well known concept in international relations. Even in the most intractable conflict situations, there is a reasonable expectation that access and “respect” for health services should be maintained.

The work of early religious missionaries in developed and developing countries created “respect” for health services. The observance of intermittent pause in hostilities during major conflicts to evacuate the dead, the dying and the wounded created additional respect for health services.  Almost by rote, the restoration of basic health services is often one of the first orders of business in post conflict situations. Negotiating for access to health services during crisis or conflict situation is complex. Maintaining fragile peace in the midst of conflict while the sick, the wounded and vulnerable populations receive medical attention is even more complex.

It is not surprising that health programs have become extremely important over the last fifty years in bilateral and multilateral development initiatives. Donor and host nations negotiate on technical and financial support for health programs. In the last decade, the emergence and influence of high profile and media savvy public/private/civil society alliances on health contributed to the increased attention on global health issues by policy makers around the world. In addition, the emergence of transnational health threats such as HINI influenza, SARS and HIV/AIDS helped concentrate global attention on health issues and assisted in galvanizing action at the highest levels of government and the private sector.    
 
Definition of Global Health Diplomacy

The definition or basic understanding of global health diplomacy (GHD) is constantly evolving. I am not aware of any universally accepted definition. A well known definition is that of the University of California at San Francisco, United States Global Health program. It defines global health diplomacy as “political change activity that meets the dual goals of improving global health and maintaining and improving international relations abroad, particularly in conflict areas and resource-poor environments.” This definition focuses on the relationship between health assistance, economic inequities in recipient countries and “enlightened self-interest of collaborating nations.”

A global health diplomacy book series defines GHD as “negotiations that shape and manage the global policy environment for health in health and non health fora...” This negotiation focused definition places emphasis on technical preparation in law, management, public health and international relations. Implicit in this definition is that GHD is part of a complex process of international relations with multiple institutions at play.

Another definition of GHD focuses on the role of the public health community in addressing transnational health threats within the framework of national and international Military oriented security structures. In this format, as noted by Laurie Garret and David Fidler, global health diplomats cannot operate in isolation. Global health diplomats cannot operate in isolation and have to immerse themselves within the nuts and bolts of existing national and international structures responsible for addressing health and non-health global threats.

From a developing country perspective, global health diplomacy revolves around bilateral and multilateral relationships. It provides an avenue for a developing country to articulate its national health priorities and to contextualize these priorities within the framework of existing or future diplomatic and development initiatives. It is highly unlikely that developing countries will subscribe to a Military-oriented focus on global health diplomacy since these countries primarily seek to extend healthcare coverage to individuals and families in need. 

Based on my extensive involvement in the global response against HIV/AIDS where I noted first hand the need for senior policy makers to become familiar with public health issues, I define GMD from the perspective of an interconnected broad disciplinary approach. I define Global Health Diplomacy as the deliberate introduction, participation and support for individuals trained jointly in global health, international relations and international development at all levels of bilateral diplomacy and multilateral development to ensure a prominent role for global health in all policies and programs. In this definition, health experts, diplomats and international development experts jointly train to become global health diplomats. Training is critical in establishing a viable cohort of global health diplomats that are verifiably familiar with key concepts, nuances and practices in global health, international relations and international development.

Fundamental Principles of Global Health Diplomacy

It is important to deal upfront with contradictions of GHD. The fundamental principles of international diplomacy may clash with the cherished ideals of global health. Global health experts value openness and transparency.  They also place a high premium on social justice, equity, mutual respect and the need to make public health goods available to those in need. They also embrace demographic, social and economic differences among target populations. These virtues may not be applicable all the time in traditional diplomacy where national interests are paramount and strategic interests may evolve. Military options are never off the table in bilateral and international diplomacy but unthinkable among global health purists. Global health thrives on out-of-box thinking and action while bilateral diplomacy and multilateral development activities are hide-bound in traditions and processes.

Fundamental principles of global health diplomacy should include:

a) Ethical participation and decision making;
b) Human rights concerns and enforcements;
c) Rule of law and clear process for settling disputes;
d) Social determinants of health and how to mitigate its impact;
e) Shared bilateral and international interests and priorities;
f) Centrality of target populations and sensitivities to local customs, religions and social mores;
g) Research as part of efforts to expand the frontiers of the field; 
h) Training and field experience for all practitioners;
i) An understanding of political, policy making, advocacy and implementation issues in global health;
j) Globalization and international trade issues;
k) Integration and mainstreaming of policies and programs in the relationship between global health, bilateral diplomacy and multilateral development;
l) Public/Private/Civil Society partnerships and alliances 

Challenges in Global Health Diplomacy

The first challenge is to further develop the field of GHD as a discipline. It is important to establish a widely accepted definition of GHD, determine core competences and define short and long term training needs. Short term training needs may include developing executive education programs for global health experts, diplomats and development experts on global health diplomacy from rich and poor nations; developing short term immersion courses for senior executives and experts that are already engaged in the field; and, planning for extensive briefing sessions for senior policy makers in the public and private sector. Longer term training needs will include making decisions regarding entry qualifications, certifications/standards and exploring the feasibility of advanced degree programs. In addition, it would be necessary over time to encourage scholarly work through peer reviewed journals and high level professional magazines. 

The second challenge is how to harmonize the divergent orientation of public health experts, trained diplomats and development experts. In this regard, we can learn from the experiences and insights of three individuals that became celebrated global health diplomats.  Peter Piot, the former head of UNAIDS; Koffi Annan, the former UN Secretary General; and, James Wolfensohn, the former head of the World Bank have done more in the last 15 years than most people in shaping what we know today as global health diplomacy. Each of them came from vastly different backgrounds but provide crucial support for health programs at the highest political levels. Peter Piot skillfully developed a global political agenda against HIV/AIDS. Kofi Annan almost single handedly brokered the establishment of a new global financing mechanism for health, the Global Fund against AIDS, Tuberculosis and Malaria. James Wolfensohn during his tenure made the World Bank a major “health agency” playing critical roles in the financing and implementation of global health programs.

The third challenge is how best to ensure that global health diplomacy retains a significant focus on the needs of target populations around the world. Understanding the needs of target populations remains a major issue in global health. Global health diplomats need to remain attuned to the needs of vulnerable populations.

The fourth challenge is how to ensure that global health diplomacy does not create additional tensions between donor and host nations. A trained and motivated cadre of global health diplomats should bridge the gap between donor and host nations. By focusing on accountability issues on both sides and the priorities of potential target populations, it is possible to douse tensions that currently exist between donor and host nations. Global health diplomats will also need to work closely with civil society organizations in donor and host nations. 

The final challenge is how to maintain the current non partisan support of policy makers on global health issues over the long term.  This support is can change as shown by the hesitation of policy makers regarding commitments to health care as the global economic crises unfolded. Global health diplomats must be comfortable in the policy making environment. They should be skilled communicators in their interaction with policy makers. They must be both trusted advisers and problem solvers.

Conclusion

Global health diplomacy is an emerging field in bilateral diplomacy and multilateral development. It is a niche that is likely to grow as transnational health threats grows and as the world becomes increasingly interdependent. Global health diplomacy faces the challenge of defining the field, establishing acceptable contours of training and practice and making its presence felt in bilateral diplomatic and multilateral development efforts.

By Dr. Chinua Akukwe

Former Chairman of the Technical Advisory Board of the Africa Center for Health and Human Security, George Washington University, Washington, DC. He is the Executive Chairman of the Africa Union Africa Diaspora Health Initiative, Washington, DC.