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The integration of health into foreign policy: Health is Global

Author(s) Michelle Gagnon1.
Affiliation(s) 1Norlien Foundation and University of Calgary, Norlien Foundation and University of Calgary, Calgary, Canada.
Country - ies of focus Canada
Relevant to the conference tracks Governance and Policies
Summary This study explored the global health diplomacy phenomenon by focusing on how and why health is integrated into foreign policy. To elucidate a deeper and clearer understanding of this phenomenon, the research used a case study design that incorporated literature and document review and interviews with twenty informants to conduct an in-depth analysis of the United Kingdom’s (UK) Health is Global: A UK Government Strategy 2008-13.
Background Over the last decade or so, precipitated primarily by a growing concern about the need to strengthen global health security and deliver on the Millennium Development Goals, foreign policymakers have been paying more attention to health as a foreign policy concern and several countries have adopted formal global health policy positions and/or strategies. Health is Global represents the first example of a formal national global health strategy developed using a multi-stakeholder process. Briefer background case reviews of three nations that are leaders in global health diplomacy - Brazil, Norway and Switzerland, were also conducted to inform the analysis of the in-depth case. Policy analysis included categorizing data into five areas: context (why?), content (what?), actors (who?), process (how?) and impact (so what?). The Multiple Streams Model of Policymaking and Fidler’s health and foreign policy conceptualizations - revolution, remediation and regression - were used to analyze the findings.
Objectives The main objective of this study was to explore and better understand what global health diplomacy (GHD) is by focusing on the health and foreign policy nexus. Since little empirical research has been undertaken that focuses on GHD this study aimed to break new ground in this area. Specific objectives were to:
• understand how health as a concept is understood and positioned in the diplomatic and policy discourse at the state level.
• build theoretical understanding about global health diplomacy by exploring how and why nations integrate global health into foreign policy (e.g. what factors influence this process and what is the process itself that leads to this integration).
• build understanding about what the connection between health and foreign policy means for the craft of foreign policy and global health diplomacy.
• begin exploring whether whole-of-government strategies that aim to promote this integration make or have the potential to make a relevant difference to government policy, structures and processes and what that difference is or could be as perceived by the stakeholders involved.
• derive policy and decision making lessons for other nations that are potentially interested in developing similar policy coherence mechanisms.
While ascertaining the impact of national global health strategies was not the main objective of this thesis, the study provided an initial look at the impact of these policy instruments and processes. Such impacts include better collaboration across government actors leading to enhanced policy coherence and a more strategic focus on global health.
The central research question explored was: how and why is global health integrated into foreign policy? Sub-questions include: how is global health defined and understood in the diplomatic and policymaking processes? Which global health issue(s) have the most saliency with state actors and why? Who are the actors involved and what role and influence do they exert in the process? How and why does global health attract the attention of state actors and remain on the policy agenda? How have government diplomatic strategies or practices changed with respect to the adoption of a broad policy framework that embodies GHD? How are state foreign policy interests in global health understood by state actors?
Methodology This research adopted a case study design. The major element of the study consisted of an in-depth investigation and analysis of the UK global health strategy launched in 2008. This UK case was chosen because it represents the first instance in which a G8 country has articulated a national global health strategy that purports to integrate global health into foreign policy. Of the countries presently engaged formally in some form of GHD initiative, the UK global health strategy is also the most detailed and comprehensive. In addition to the UK case, document analysis and interviews were conducted for three other background case reviews, Norway, Switzerland and Brazil. Methodology included literature review, document analysis and semi-structured interviews. Purposive sampling was used to identify and recruit interviewees for semi-structured interviews. In keeping with the objective of the study and to help answer the main research question, state and non-state actors who had been directly involved in the process of the integration of health into foreign policy in each of the four countries were targeted for interviews. A total of twenty interviews were conducted, 14 for the UK case (seven with state actors and seven with non-state actors) and two each for the background cases (Norway: one state, one non-state; Brazil: two state; and Switzerland: one state and one non-state). Interviews took place between August 27, 2009 and March 24, 2010. A general inductive approach was used analyze the data. In this approach, both the research objectives and questions (deductive) and multiple readings and interpretations of the raw data (inductive) guide data analysis. The main mode of analysis is the development of categories from the raw data into a framework or model that captures key themes and processes. Data analysis encompassed three concurrent and iterative flows of activities: data reduction, data display and conclusion drawing/verification.
Results The primary reason that the countries examined have decided to focus more on global health is self-interest - to protect national and international security and their economic interests. Investing in global health was also seen as a way to enhance a state’s international reputation. In terms of self-interest, Brazil was an outlier, however. International solidarity and health as a human right have been the driving forces behind its long-term investment in development cooperation to date. Investing in health for normative reasons was also a prevalent, though weaker, theme in the UK, Swiss and Norwegian cases. The study highlighted the critical role that policy entrepreneurs who cross the domains of international relations and health play in the global health policymaking process. In regards to advancing a conceptual understanding of global health diplomacy, the findings propose that the whole-of-government global health policymaking process is a form of global health diplomacy. The research elucidated factors that underpin this process as well as lessons for other nations.
Conclusion This study was principally exploratory and as such aimed at advancing understanding of how and why health is integrated into foreign policy. Overall it:
• Helped to fill identified knowledge gaps through rigorous, primary research focused on understanding the global health diplomacy process from the perspectives of those who have been involved in it.
• Provided further empirical support and critical analysis to advance understanding of the key arguments for health in foreign policy, including global health security.
• Used a triangulated theoretical approach that incorporated the Multiple Streams Model of the policy process and Fidler’s three health in foreign policy conceptualizations to advance theoretical understanding of global health diplomacy.
• Proposed a more precise definition of the global health diplomacy process at the state level that is potentially a useful starting point for other countries that may embark on similar global health policymaking processes.
• Contributed to advancing theory about global health diplomacy by elucidating some of the key factors that can lead to a successful global health diplomacy process.
• Contributed some initial perspectives on what constitutes success of state level global health policymaking processes and outcomes.
• Surfaced a number of areas for further in-depth research such as that which compares global health diplomacy processes within the state with those between states and institutions at the international level (e.g. WHO). More specifically, a number of research topics could be pursued in each of the areas that make up the policy analysis circle – context, content, process, actors and impact. Further empirical research into the key arguments that underpin health in foreign policy, how this discourse is potentially shifting in the current world economic environment, and in particular, how and why health diplomats make trade-offs in their advancement of these arguments is another area for further inquiry. Other research topics could include a more in-depth look at the role of researchers and research evidence in the global health diplomacy process at the state level and knowledge translation practices that help facilitate the use of evidence in global health policymaking.
• This study provided significant insight to the global health policymaking process at the state level that could inform similar processes that other countries might be considering embarking on.

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