Oslo Ministerial Declaration – global health: a pressing foreign policy issue of our time

• increase awareness of our common vulnerability in the face of health threats by bringing health issues more strongly into the arenas of foreign policy discussions and decisions, in order to strengthen our commitment to concerted action at the global level;
• build bilateral, regional and multilateral cooperation for global health security by strengthening the case for collaboration and brokering broad agreement, accountability and action;
• reinforce health as a key element in strategies for development and for fighting poverty, in order to reach the Millennium Development Goals;
• ensure that a higher priority is given to health in dealing with trade issues and in conforming to the Doha principles, affirming the right of each country to make full use of TRIPS flexibilities in order to ensure universal access to medicines;
• strengthen the place of health measures in conflict and crisis management and in reconstruction efforts.

For this purpose, we have prepared a first set of actionable steps for raising the priority of health in foreign policy in an Agenda for Action. We pledge to pursue these issues in our respective regional settings and in relevant international bodies. We invite Ministers of Foreign Affairs from all regions to join us in further exploring ways and means to achieve our objectives.

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Foreign policy taking up the challenges of global health: a background note
Why this initiative?

At the invitation of the Norwegian Foreign Minister Jonas Gahr Støre and his French colleague Foreign Minister Philippe Douste-Blazy, foreign ministers from Brazil, Indonesia, Senegal, South Africa and Thailand formed the Global Health and Foreign Policy Initiative in September 2006.

Globalisation is rapidly changing the perception of foreign policy and international relations. New actors are gaining influence and the speed of communication and growing interdependence is giving rise to new relationships, networks and alliances. This is creating new opportunities and new challenges. 

The Initiative will build the case for why global health should hold a strategic place on the international agenda. It will do this in two ways: by exploring how foreign ministers and foreign policy could add value to health issues of international importance, and by showing how a health focus could harness the benefits of globalisation, strengthen diplomacy and respond to new thinking on human security.

In its work to date, the Initiative has outlined the broad linkages between global health and foreign policy and identified a set of basic premises and shared values to guide its work. Using this as a foundation, ten priority areas were chosen where a stronger, more direct involvement of foreign policy could make a tangible contribution to protecting and promoting health, as well as offer new scope for foreign policy. In Oslo on 20 March 2007, the seven ministers agreed to an ambitious and progressive agenda for action that details its future work in each of the priority areas.

Health matters in foreign policy

During the late 19th and early 20th centuries, health and foreign policy were linked by quarantine restrictions to prevent the spread of disease from country to country. International agreements were designed to help avoid the consequences of trade disruptions. The early 21st century, however, has seen an unprecedented convergence of global health and foreign policy. Health is deeply interconnected with the environment, trade, economic growth, social development, national security, human rights and dignity. In a globalised and interdependent world, the state of global health has a profound impact on all nations – developed and developing. Ensuring public health on a global scale is of benefit to all countries. Powerful synergies arise when national interest coincides with the need for concerted regional and global action. 

While national security focuses on the defence of the state from external attack, national health security relates to defence against internal and external public health risks and threats. These are risks and threats that by their very nature do not respect borders, as people, animals and goods travel around the world faster than ever before. The responsibility of protecting against health threats must therefore be based on the shared commitment and the capacity of countries. Global health security is only as strong as its weakest link.

It is well recognised that health is a fundamental right of every human being and that health is a key element of any strategy aimed at promoting development and combating poverty. Poverty and hunger are major causes of ill health. Health is a main component of the Millennium Development Goals (MDGs), which point to the interconnectedness of the structural causes of poverty and under-development.

But the relevance of foreign policy to global health is not only about national health security on the one hand and development and the MDGs on the other. Foreign policy must engage in health in new ways. For example, health can be a good entry point to initiate dialogue across borders, thus contributing to building trust between parties. In armed conflict there are ten or more civilian deaths for every combat death, but the “indirect” or “excess” death toll from war-induced violence, injury, disease and malnutrition is rarely the subject of political attention.

Armed conflict often leads to the breakdown of health services, with disastrous consequences for people’s health and livelihood. Natural disasters cause high casualties, severe damage to health infrastructure, and loss of health workers. Treating the old and new health problems of people who have been internally displaced is virtually impossible. Re-establishing health services should be a primary focus during the reconstruction phase, post-conflict and in the aftermath of a disaster. Natural disasters generate other challenges for foreign policy including managing the flow of humanitarian aid.

Drivers of change 

New technology has transformed communication and access to information. Rapid acceleration of knowledge and discovery in the life sciences, in areas such as genomics, biotechnology, nanotechnology and so on, means there are new opportunities and new risks to be managed.

The relentless spread of HIV/AIDS in many parts of the world represents a destructive threat to entire societies. Other new and re-emerging infectious diseases (avian influenza, SARS, XDR-TB, malaria, polio, plague, dengue fever and so forth) do not respect geographical borders and can only be tackled successfully if nations work together.

The global health arena is unrecognisable from what it looked like even a decade ago. Civil society now represents a major force for change. New partnerships and alliances are emerging that include multiple stakeholders, networks and movements, within countries and across borders and regions. At the same time there remains space for new structures.

The main actors involved in global health (governments, regional organisations, NGOs, foundations, private-public partnerships, the World Bank, the IMF, and the UN and its agencies, specifically WHO, UNICEF, UNAIDS, and UNDP) are all influenced by different views, resource flows, principles, objectives and interests – and they are independent from one another. This raises two key governance questions: How will the money be spent and on what? Who will set the global health agenda?

In spite of many positive developments and results, there is evidence of an increase in the social inequalities in health both between and within countries. The Commission on Social Determinants of Health is addressing these issues and is due to report in 2008.

The MDGs have been partly responsible for revitalising interest in global health and a whole range of activities are being implemented, but progress has been slow. The slow progress has been attributed to broken health systems, the human resources for health crisis, and persisting inequities in access to interventions that could keep people alive and well. If nothing changes, many countries will not attain the health-related MDGs by 2015.

Countries that succeed in meeting the MDGs will experience benefits far beyond the MDGs. The well-functioning health systems that are needed to reduce maternal, newborn and child mortality and to combat HIV/AIDS, TB and malaria will also help countries cope with other major health concerns such as sexual and reproductive health, newly emerging infectious diseases, accidents and injuries, and chronic non-communicable diseases.

Basic premises and shared values

The work of the Initiative is guided by the acknowledgement that globalisation requires new forms of governance in order to ensure sustainable development, social and economic equity, justice, peace and security.

It recognises the need for cooperation and collaboration, a respect for national sovereignty, a sense of shared responsibility, and the attributes of transparency, trust, accountability and fairness.

The Initiative is based on the recognition that life is the most fundamental of human rights, and that life and health are the most precious assets.

Every country needs a robust and responsive health system (this includes a health workforce, infrastructure and supplies), a health research system, and a health information system to provide all citizens opportunities to be healthy and to participate fully in the shared responsibilities for global health security.

There are both technical and political dimensions to protecting and promoting global health and human security. This means that health issues do not only belong to ministries of health and the WHO, especially when they are cross-cutting in nature. New mechanisms in addition to the traditional development model are required.

Lack of access to health knowledge and to essential medicines, vaccines and other products is one of the key factors limiting human development.

A focus on people’s health and well-being must become part of the collective consciousness of policy makers at the highest level, at the national as well as the international level, and within all relevant international bodies.

Health-impact assessments of all foreign, trade, and defence policies would do much to advance the cause of health across governments.

The road ahead will require alliance building and networking and at times will require difficult political decisions to be taken. Change is needed – a long-term, forward-looking view is required.

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Foreign policy taking up the challenges of global health: agenda for action

Adopted by the Ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa, and Thailand in Oslo on March 20, 2007.

In today’s era of globalisation and interdependence there is an urgent need to broaden the scope of foreign policy. In our time, the pursuit of pure self-interest of nations might undermine the solutions that respond to the challenges of growing interdependence. We must encourage new ideas, seek and develop new mechanisms for partnerships, and develop new paradigms of cooperation. This new reality creates a need to find shared values that are embodied in the relations between countries.

Protecting the most fundamental opportunity for life for the world’s citizens provides both a lens through which to enhance the goals and responsibilities of diplomacy and a call to bring a more active collaboration between foreign ministries, health ministries, and other functions of government around health security issues.

No country can isolate itself from cross-border risks and threats to their national health security. Foreign policy actions in security, trade, conflict and crisis, environment, and human rights have a strong bearing on whether we can achieve national as well as global health security.

Access to basic needs for human survival–—water, food, shelter, protection, and freedom from disease—concerns people of all nations. Unless these needs are met, our health and survival are threatened. Food security and health security are common concerns and should be viewed through the same lens. Often a public health threat in one country requires a concerted response that calls for many foreign policy makers to work together. In a very real sense, the development of all nations is a prerequisite to ensure global health security.

The most effective response to global health challenges depends on alliances, cooperation, and partnerships that reflect a respect for national sovereignty and a sense of shared responsibility. They must also be transparent, trustworthy, accountable, and fair. Collaboration can come in all different forms, including South-South, North-North, and South-North cooperation.

Foreign Ministers have identified areas where the kinds of policy positions they adopt can make a significant difference to prospects for global health security. This paper proposes a shared agenda for Foreign Ministers’ action. The agenda is organised around three main themes: “Capacity for global health security”, “Facing threats to global health security”, and “Making globalisation work for all”. Each theme identifies specific actions. But the challenges are all inter-linked. Some have a broad cross-cutting impact and respond to a range of challenges, while others are more specific.

 

Capacity for global health security

1 Preparedness and foreign policy

Preparedness is a cross-cutting theme. For most govern-ments it starts with an emphasis on being ready to respond to health risks and threats to national health security. But increasingly it includes global mechanisms and other measures that enable countries to make an informed and coordinated response. Preparedness is based on a capacity to identify health risks and threats, including those that may be outcomes of the foreign policies practised by individual nations.

Points for collaborative action by foreign ministers:

1.1 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. Use all available evidence in the analysis, share the findings, and ensure open access to the analytical process.

1.2 Engage in developing a roadmap for what remains to be done in large-scale disasters and emergencies where foreign ministers have special responsibilities, including the movement of people and equipment across borders. Make use of global instruments such as the International Health Regulations and humanitarian law.

1.3 Support national disaster planning and development of critical national capacity for emergency pre-paredness, including the capacity to coordinate relief efforts through the development of local relief networks.

1.4 Strengthen the capacity of the UN Secretary General to assume a coordinating role in facilitating actions related to foreign policy in preparedness, planning, and action for global health security. Work in close cooperation with UN Specialized Agencies, Programmes, and Funds.

1.5 Identify critical gaps in capacity for effective imple-mentation of the International Health Regulations with a specific focus on better national and transnational surveillance, outbreak investigation, and disease control.

2 Control of emerging infectious diseases and foreign policy

Efforts should be based on an understanding of the cross-cutting impacts of communicable disease, including pandemic influenza. These efforts must build on a commitment to fairness and mutual trust, such as in sharing information.

Points for collaborative action:

2.1 Commit to the early and full implementation of the International Health Regulations. Call for improved data and accountability mechanisms as well as the rapid scale up of national capacity. Emphasise the need to share information related to any health risk of international importance.

2.2 Exchange experiences and best practices on preventive and emergency response measures toward the outbreak of pandemics.

2.3 Identify gaps in implementation, ensuring the availability of essential medicines, vaccines, and equipment, not only domestically but also within countries that need assistance, including failing states and countries in conflict and crisis.

2.4 Support and facilitate WHO’s leadership role and the work of the Global Outbreak Alert and Response Network (GOARN).

2.5 Support the mobilisation of adequate resources for global infectious disease control, including domestic spending, ODA spending, and dedicated spending for joint action to improve global health security, through trusted and transparent partnership mechanisms.

3 Human resources for health and foreign policy

The current global shortage and maldistribution of trained health workers, particularly nurses, represents a major barrier to preparedness and to national and global health security. The shortage of human resources is influenced by the global economy, incentives for migration, and global negotiation on services. Such influences go beyond the health sector and can only be modified through political action at the national, regional, and global level. At the same time, human resources for health is situated within the broader health development and systems agenda with financing and stewardship issues as key related matters.

Points for collaborative action:

3.1 Support the development of a global framework for tackling the global shortage of health workers, with monitoring and accountability mechanisms, including for tracking recruitment from countries with weak capacity. Facilitate the use of the Diaspora in country of origin and examine the possibility of establishing multilateral and/or bilateral mechan-isms that would ensure that the movement of health professionals is mutually beneficial to both sending and receiving countries.

3.2 Encourage the development of national broad plans for human resources for health, including the use of alternative models for care. These should reflect the standards set by the WHO, for use as reference points and drivers of alignment and accountability globally, such as through the Global Health Workforce Alliance (GHWA) and related initiatives.

3.3 Respond to the need to train more health workers and encourage regional and international exchanges at academic institution level as well as the exchange of technical expertise within the Ministries of Health of the region, centres of excellence, and beyond through facilitating strong collaboration and partnerships, including South-South and regional collaboration.

3.4 Support health research, the ethical conduct of research and research capacity building in countries with inadequate capacity. Facilitate better access for researchers from these countries to innovation and to global knowledge networks.

Facing threats to global health security

4 Conflict (pre, during, and post conflict, and as peace is being built)

As part of efforts to promote peace and security, women, children, and men whose lives are under threat must be helped to survive and maintain good health. Lack of access to health services can in itself have a destabilising effect. The need to preserve life and health is a useful starting point for peace building “before logic breaks down” into full conflict. Access cannot be preserved unless health workers and health infrastructure are protected.

Points for collaborative action:

4.1 Recognise that health can be a good entry point to initiate dialogue across borders and to spearhead the resolution of conflict, with the sincere intention of serving the public interest and building trust and legitimacy.

4.2 Recognise the potential in the presence of “global knowledge networks”, which cut across borders and are maintained in spite of conflict. They can be building blocks in peace building efforts, but need to maintain their own integrity and independence.

4.3 Support the evolution of a more consistent approach for monitoring suffering in conflict and war. There should be a regular watch on life and health issues and in particular on the indirect consequences of war and conflict on people’s health, with a special focus on women as care givers and girls and women threatened by rape and other forms of violence.

4.4 Further develop the case for a health focus in post-conflict reconstruction. This is necessary to set out clearer principles for better health security as a means for re-establishing peace, trust, and legitimacy of government, and to advocate for a strong focus on health issues in the work of the recently established UN Peace Building Commission, in cooperation with the WHO. Such efforts must respect the basic imperatives and principles that guide a neutral “humanitarian space” reserved for non-state actors.

5 Natural disasters and other crises

Many of the same principles exist for natural disasters and other emergencies as for situations of conflict, but there is not the same early warning and time for “diplomacy”. One challenge is to make a neglected crisis visible and not let action be driven by media attention. In a globalised world, there will be a mix of nationals affected by crisis. Foreign ministers and ministries in countries tackling a crisis will be involved in dealing with expatriates that have been affected, as well as dealing with offers of emergency support. Other foreign ministers will be involved in relief efforts and the repatriation of victims.

Points for collaborative action:

5.1 Support the work of the Office for the Coordination of Humanitarian Affairs (OCHA) and the Central Emergency Response Fund (CERF), facilitating early and effective assistance to vulnerable groups in emergencies.

5.2 Ensure that priority is given to restoring a functioning health system (workforce, infra-structure, and supplies) in the aftermath of a crisis.

5.3 Monitor the equitable distribution of aid, specific needs of care givers and marginalised groups, and any shortfalls in the ulfilment of pledges of funding.

6 Response to HIV/AIDS

A high prevalence of HIV infection is not only a threat to personal health, but also to national and global health security, because of the way AIDS undermines human capacity in essential services. The global response to HIV/AIDS has mobilised a dynamic multi-stakeholder, multi-sector movement, with common purpose, inclusive leadership, and linked community and global action.

Points for collaborative action:

6.1 Take up the challenges that HIV/AIDS presents to trade, human rights, peace building, and humani-tarian action through a health lens to drive forward a broader agenda for change.

6.2 Commit to the international agreements and political declarations linking and monitoring these commitments, and call for speeding up their implementation. Initiate voluntarily monitoring the actions taken by the countries involved in the Global Health and Foreign Policy Initiative.

6.3 Call for improved and disaggregated data collection on HIV/AIDS in all countries.2 Raise awareness among diplomats and ambassadors about the impact of HIV/AIDS on economies, institutional capacity, gender, and human rights in order to bring these issues into country-level policy dialogue as appropriate.

7 Health and the environment

Human health and the environment are both outcomes of complex systems that exist in dynamic balance. Given the severity of health threats related to climate change, biosecurity, and biosafety, the linkage between global health and environment should be considered.

Points for collaborative action:

7.1 Make the links between environment policies and global health visible in foreign policy engagements and exploit the synergistic potential of related policy processes.

7.2 Recognise that the potential of biotechnologies to help developing countries achieve the Millennium Development Goals (MDGs) should not be eclipsed by otherwise legitimate security concerns: establish robust governance mechanisms to prevent misuse of the biological sciences, without hindering their positive contribution to development.

7.3 Engage with WHO and the UN Environment Programme on their joint “Health and Environment Linkages Initiative” in order to strengthen the dialogue between governments and civil society in the use of health and environment impact assessments.

7.4 Give further attention to the potentially very severe consequences to health of climate change and support appropriate foreign policy action at relevant regional and global meetings.

Making globalisation work for all

8 Health and development

Health is key to development and combating poverty. Hunger is a major cause of ill health. Structural causes of poverty and hunger are interwoven, and part of a nexus of policies where foreign policies also play an important part. Global partnership for overcoming both structural and economic barriers to development and health is fundamental for reaching the MDGs and reducing vulnerabilities to neglected and emerging infectious diseases.

Points for collaborative action:

8.1 Use the shared interest in global public health as rationale for giving health top priority in the national and international cross-sectoral development agenda. Push for development cooperation models that match domestic commitment and reflect the requirements of those in need and not one that is characterised by charity and donors’ national interests.

8.2 Strengthen the efficiency of global health initiatives through improved governance and better co-ordination of multiple, competitive donors and aid providers (UN agencies, international financial institutions, regional mechanisms, G8, donor countries, private foundations, together with the coalitions and alliances that bring them together).

8.3 Improve national and regional research capacity and the management capacity of public health systems, taking into account the special needs of the developing countries and using a variety of modalities including twinning, exchange programmes and institutional collaboration, transfer of technology, regional centres of excellence, etc, fostering regional and South-South collaboration based on shared interests.

8.4 Promote modalities and means to enhance the capacity for national and regional production of essential medicines and equipment and for building capacity for national regulation of pharmaceuticals and commodities, quality control, and supply chain management.

8.5 Honour existing financial commitments and initiate innovative financing mechanisms in order to generate additional resources for financing global health investments such as the international drug facility (UNITAID).

8.6 Work together with the IMF and the World Bank to overcome macroeconomic constraints to effective health investment at country level.

9 Trade policies and measures to implement and monitor agreements

International trade policies and agreements need to be placed within the context of protecting and promoting health and wellbeing. A universal, rule-based, open, non-discriminatory, and multilateral trade system, including trade liberalisation, can support global health security, such as enabling the implementation of the International Health Regulations. Ensuring equal and universal access to essential medicines is one example with major relevance for global public health.

Points for collaborative action:

9.1 Affirm the interconnectedness of trade, health, and development, including both trade and health policies in the formulation of all bilateral, regional, and multilateral trade agreements.

9.2 Reaffirm commitment to the Doha Declaration on TRIPS and Public Health and foster the full implementation of the TRIPS flexibilities.

9.3 Explore the feasibility of a voluntary monitoring mechanism outside WTO for the use of TRIPS flexibilities to overcome price and access barriers and examining the implication of other trade agreements, in particular bilateral trade agreements that may limit the use of these flexibilities.

9.4 Encourage WTO members to accelerate national acceptance procedures in order to ensure the entry into force of the amendment of the TRIPS Agreement. 9.5 Explore and leverage multiple and innovative approaches to reduce price and improve access to essential medicines, together with the application of TRIPS flexibilities.

10 Governance for global health security

Improved governance requires review and adaptation to new realities. It could be better achieved through effective national structures, stronger regional collaboration, broader stakeholder participation and clearer contracts and accountability at the international level. In several respects, health offers a platform for exploring the new challenges of governing interdependence. Governance for health is an aspect of deepening global democracy within regional and global institutions. New mechanisms and alliances are increasingly important but need to have their actions better coordinated. Dealing with cross-border issues, such as the vast differences in access to health care, as well as the movement of people, pharmaceuticals, and commodities, represents situation-specific governance challenges and requires attention on a case-by-case basis.

Points for collaborative action:

10.1 Support policies for global health security in the various foreign policy dialogue and action arenas, such as the UN, G8, arenas for economics and trade issues, and within regional and bilateral arenas.

10.2 Establish broader and more coherent national leadership for global health issues, reflecting the interdependency of health and foreign affairs.

10.3 Recognise and affirm the WHO Secretariat and the World Health Assembly as the main arenas for global health governance,3 with expanded engagement from foreign ministries in the WHA delegations and assistance to the WHO Director General in bringing relevant global health issues into relevant foreign policy arenas.

10.4 Recognise the role of the private sector, knowledge networks, and civil society organisations in the evolution of global public health policy as well as in action that will improve global health security and engage them more effectively in governance, policy dialogue, and implementation of relevant actions.

10.5 Maximise opportunities for joint working to achieve priority health outcomes within regions and across national borders, including a focus on parity of negotiating powers and the building of capacity that is available to all.

10.6 Contribute to financing global health in ways that do not undermine existing commitments to development financing. Continue efforts to conceive of and bring to fruition innovative and sustainable financing mechanisms and their effective use. Initiate a mechanism to track resource flows for international cooperation directed at specific and agreed global health security purposes, particularly the control of infectious and neglected diseases.

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