Understanding how domestic health policy is integrated into foreign policy in South Africa: a case for accelerating access to antiretroviral medicines

South Africa, as an emerging middle-income country, is becoming increasingly influential in global health diplomacy (GHD). However, little empirical research has been conducted to inform arguments for the integration of domestic health into foreign policy by state and non-state actors. This study seeks to address this knowledge gap. It takes the form of an empirical case study which analyses how South Africa integrates domestic health into its foreign policy, using the lens of access to antiretroviral (ARV) medicines.  To explore state and non-state actors’ perceptions regarding how domestic health policy is integrated into foreign policy. The ultimate goal of this study was to achieve better insights into the health and foreign policy processes at the national level.  Employing qualitative approaches, we examined changes in the South African and global AIDS policy environment. Purposive sampling was used to select key informants, a sample of state and non-state actors who participated in in-depth interviews. Secondary data were collected through a systematic literature review of documents retrieved from five electronic databases, including review of key policy documents. Qualitative data were analysed for content. This content was coded, and the codes were collated into tentative categories and sub-categories using Atlas.ti v.7 software.  The findings of this work illustrate the interplay among social, political, economic and institutional conditions in determining the success of this integration process. Our study shows that a series of national and external developments, stakeholders, and advocacy efforts and collaboration created these integrative processes. South Africa’s domestic HIV/AIDS constituencies, in partnership with the global advocacy movement, catalysed the mobilization of support for universal access to ARV treatment nationally and globally, and the promotion of access to healthcare as a human right.  Transnational networks may influence government’s decision making by providing information and moving issues up the agenda.

Related papers:

title: Framing global health: The governance challenge
abstract: With the emergence of global health comes governance challenges which are equally global in nature. This article identifies some of the initial limitations in analyses of global health governance (GHG) before discussing the focus of this special supplement: the framing of global health issues and the manner in which this impacts upon GHG. Whilst not denying the importance of material factors (such as resources and institutional competencies), the article identifies how issues can be framed in different ways, thereby creating particular pathways of response which in turn affect the potential for and nature of GHG. It also identifies and discusses the key frames operating in global health: evidence-based medicine, human rights, security, economics and development.

title: Global health diplomacy: An integrative review of the literature and implications for nursing
abstract: Abstract
 
 The increasing interconnectedness of the world and the factors that affect health lay the foundation for the evolving practice of global health diplomacy. There has been limited discussion in the nursing literature about the concept of global health diplomacy or the role of nurses in such initiatives. A discussion of this concept is presented here by the members of a Task Force on Global Health Diplomacy of the American Academy of Nursing Expert Panel on Global Nursing and Health (AAN EPGNH). The purpose of this article is to present an integrative review of literature on the concept of global health diplomacy and to identify implications of this emerging field for nursing education, practice, and research. The steps proposed by Whittemore and Knafl (2005) were adapted and applied to the integrative review of theoretical and descriptive articles about the concept of global health diplomacy. This review included an analysis of the historical background, definition, and challenges of global health diplomacy and suggestions about the preparation of global health diplomats. The article concludes with a discussion of implications for nursing practice, education, and research. The Task Force endorses the definition of global health diplomacy proposed by Adams, Novotny, and Leslie (2008) but recommends that further dialogue and research is necessary to identify opportunities and educational requirements for nurses to contribute to the emerging field of global health diplomacy.

title: Global Health Diplomacy, ‘Smart Power’, and the New World Order
abstract: Both the theory and practice of foreign policy and diplomacy, including systems of hard and soft power, are undergoing paradigm shifts, with an increasing number of innovative actors and strategies contributing to international relations outcomes in the ‘New World Order’. Concurrently, global health programmes continue to ascend the political spectrum in scale, scope and influence. This concatenation of circumstances has demanded a re-examination of the existing and potential effectiveness of global health programmes in the ‘smart power’ context, based on adherence to a range of design, implementation and assessment criteria, which may simultaneously optimise their humanitarian, foreign policy and diplomatic effectiveness. A synthesis of contemporary characteristics of ‘global health diplomacy’ and ‘global health as foreign policy’, grouped by common themes and generated in the context of related field experiences, are presented in the form of ‘Top Ten’ criteria lists for optimising both diplomatic and foreign policy effectiveness of global health programmes, and criteria are presented in concert with an examination of implications for programme design and delivery. Key criteria for global health programmes that are sensitised to both diplomatic and foreign policy goals include visibility, sustainability, geostrategic considerations, accountability, effectiveness and alignment with broader policy objectives. Though diplomacy is a component of foreign policy, criteria for ‘diplomatically-sensitised’ versus ‘foreign policy-sensitised’ global health programmes were not always consistent, and were occasionally in conflict, with each other. The desirability of making diplomatic and foreign policy criteria explicit, rather than implicit, in the context of global health programme design, delivery and evaluation are reflected in the identified implications for (1) international security, (2) programme evaluation, (3) funding and resource allocation decisions, (4) approval systems and (5) training. On this basis, global health programmes are shown to provide a valuable, yet underutilised, tool for diplomacy and foreign policy purposes, including their role in the pursuit of benign international influence. A corresponding alignment of resources between ‘hard’ and ‘smart’ power options is encouraged.

title: Framing health and foreign policy: lessons for global health diplomacy
abstract: Global health financing has increased dramatically in recent years, indicative of a rise in health as a foreign policy issue. Several governments have issued specific foreign policy statements on global health and a new term, global health diplomacy, has been coined to describe the processes by which state and non-state actors engage to position health issues more prominently in foreign policy decision-making. Their ability to do so is important to advancing international cooperation in health. In this paper we review the arguments for health in foreign policy that inform global health diplomacy. These are organized into six policy frames: security, development, global public goods, trade, human rights and ethical/moral reasoning. Each of these frames has implications for how global health as a foreign policy issue is conceptualized. Differing arguments within and between these policy frames, while overlapping, can also be contradictory. This raises an important question about which arguments prevail in actual state decision-making. This question is addressed through an analysis of policy or policy-related documents and academic literature pertinent to each policy framing with some assessment of policy practice. The reference point for this analysis is the explicit goal of improving global health equity. This goal has increasing national traction within national public health discourse and decision-making and, through the Millennium Development Goals and other multilateral reports and declarations, is entering global health policy discussion. Initial findings support conventional international relations theory that most states, even when committed to health as a foreign policy goal, still make decisions primarily on the basis of the 'high politics' of national security and economic material interests. Development, human rights and ethical/moral arguments for global health assistance, the traditional 'low politics' of foreign policy, are present in discourse but do not appear to dominate practice. While political momentum for health as a foreign policy goal persists, the framing of this goal remains a contested issue. The analysis offered in this article may prove helpful to those engaged in global health diplomacy or in efforts to have global governance across a range of sectoral interests pay more attention to health equity impacts.

title: Health Diplomacy and the Enduring Relevance of Foreign Policy Interests
abstract: Harley Feldbaum and Joshua Michaud consider the important interplay between foreign policy and global health interests, and introduce a series on Global Health Diplomacy beginning this week in PLoS Medicine.

title: Governance challenges in global health.
abstract: In this article in the Global Health series, the authors argue for a coordinated (i.e., a governed) international response to a variety of health issues that affect people worldwide.

title: Understanding how and why health is integrated into foreign policy - a case study of health is global, a UK Government Strategy 2008–2013
abstract: BackgroundOver the past decade, global health issues have become more prominent in foreign policies at the national level. The process to develop state level global health strategies is arguably a form of global health diplomacy (GHD). Despite an increase in the volume of secondary research and analysis in this area, little primary research, particularly that which draws directly on the perspectives of those involved in these processes, has been conducted. This study seeks to fill this knowledge gap through an empirical case study of Health is Global: A UK Government Strategy 2008–2013. It aims to build understanding about how and why health is integrated into foreign policy and derive lessons of potential relevance to other nations interested in developing whole-of-government global health strategies.MethodsThe major element of the study consisted of an in-depth investigation and analysis of the UK global health strategy. Document analysis and twenty interviews were conducted. Data was organized and described using an adapted version of Walt and Gilson’s policy analysis triangle. A general inductive approach was used to identify themes in the data, which were then analysed and interpreted using Fidler’s health and foreign policy conceptualizations and Kingdon’s multiples streams model of the policymaking process.ResultsThe primary reason that the UK decided to focus more on global health is self-interest - to protect national and international security and economic interests. Investing in global health was also seen as a way to enhance the UK’s international reputation. A focus on global health to primarily benefit other nations and improve global health per se was a prevalent through weaker theme. A well organized, credible policy community played a critical role in the process and a policy entrepreneur with expertise in both international relations and health helped catalyze attention and action on global health when the time was right. Support from the Prime Minister and from the Foreign and Commonwealth Office was essential. The process to arrive at a government-wide strategy was complex and time-consuming, but also broke down silos. Significant negotiation and compromise were required from actors with widely varying perspectives on global health and conflicting priorities.ConclusionsAs primarily an exploratory study, this research sheds significant light on the global health policymaking process at the level of the state. It provides a useful and important starting point for further hypothesis driven empirical research that focuses on the integration of health in foreign policy, how and why this happens and whether or not it makes an impact on improving global health.

title: Reforming the health sector in developing countries: the central role of policy analysis.
abstract: Policy analysis is an established discipline in the industrialized world, yet its application to developing countries has been limited. The health sector in particular appears to have been neglected. This is surprising because there is a well recognized crisis in health systems, and prescriptions abound of what health policy reforms countries should introduce. However, little attention has been paid to how countries should carry out reforms, much less who is likely to favour or resist such policies. This paper argues that much health policy wrongly focuses attention on the content of reform, and neglects the actors involved in policy reform (at the international, national sub-national levels), the processes contingent on developing and implementing change and the context within which policy is developed. Focus on policy content diverts attention from understanding the processes which explain why desired policy outcomes fail to emerge. The paper is organized in 4 sections. The first sets the scene, demonstrating how the shift from consensus to conflict in health policy established the need for a greater emphasis on policy analysis. The second section explores what is meant by policy analysis. The third investigates what other disciplines have written that help to develop a framework of analysis. And the final section suggests how policy analysis can be used not only to analyze the policy process, but also to plan.

title: Interviews : an introduction to qualitative research interviewing
abstract: PART ONE: INTRODUCTION Interviewing as Research PART TWO: CONCEPTUALIZING THE RESEARCH INTERVIEW The Interview as a Conversation Postmodern Thought, Hermeneutics, Phenomenology, and Dialectics Qualitative Research in Science and in Practice PART THREE: THE SEVEN STAGES OF AN INTERVIEW INVESTIGATION Thematizing and Designing an Interview Study Ethical Issues in Interview Inquiries The Interview Situation The Quality of the Interview From Speech to Text The 1,000-Page Question Methods of Analysis The Plurality of Interpretations The Social Construction of Validity Improving Interview Reports PART FOUR:  Conversations about Interviews

title: Qualitative data analysis: conceptual and practical considerations.
abstract: Qualitative inquiry requires that collected data is organised in a meaningful way, and this is referred to as data analysis. Through analytic processes, researchers turn what can be voluminous data into understandable and insightful analysis. This paper sets out the different approaches that qualitative researchers can use to make sense of their data including thematic analysis, narrative analysis, discourse analysis and semiotic analysis and discusses the ways that qualitative researchers can analyse their data. I first discuss salient issues in performing qualitative data analysis, and then proceed to provide some suggestions on different methods of data analysis in qualitative research. Finally, I provide some discussion on the use of computer-assisted data analysis.

title: Reconstructing South African identity through global summitry
abstract: This article will evaluate South Africa’s pursuit of global summitry as an expression of its own evolving national identity. Since its inception, South Africa’s multiculturalism has produced fragmentation and reconstitution of identity-based sovereignty. We argue that the contradictions which have featured in the historical processes of South African identity formation and reformation, whether from its position as a colonial bastion of white power or that of a beacon of African liberation, are both motivated by, and manifested through, its foreign policy activism in global summitry. This process lends meaning to contested domestic politics and helps shape regional and global affinities, affirming South Africa’s legitimacy as a representative of the African continent. Engaging in global summitry provides South Africa an opportunity to present a coherent purpose to audiences at home and abroad on key issues that emerge out of the country’s divided diversity.

title: Making health an imperative of foreign policy: The value of a human rights approach.
abstract: Health is increasingly seen as relevant to foreign policy; nevertheless, it remains subordinate to other interests. In particular, the interests of security and economics are often presented as more critical than health. This is due to a failure to sufficiently recognize the legal obligations that states have undertaken to ensure the human right to health. This article argues that health should be an imperative of foreign policy, equally valid, and prioritized in resource allocation. We suggest application of the human rights approach with attention to the legal duty of cooperation and the necessity of ensuring broad participation. We suggest that the human rights approach to health can contribute to achieving this result and is compatible with, and beneficial to, other foreign policy concerns. Finally, we conclude that the human rights approach to health requires that health be an imperative in foreign policymaking processes.

title: South Africa's Future Foreign Policy
abstract: A s T h e 1980s drew to a close I could not see much of the world from my prison cell, but I knew it was changing. There was little doubt in my mind that this would have a profound impact on my country, on the southern African region and the continent of which I am proud to be a citizen. Although this process of global change is far from complete, it is clear that all nations will have boldly to recast their nets if they are to reap any benefit from international affairs in the post-Cold War era. The African National Congress (anc) believes that the charting of a new foreign policy for South Africa is a key element in the cre ation of a peaceful and prosperous country. Apartheid corroded the very essence of life in South Africa. This is why the country's emerg ing political leaders are challenged to build a nation in which all peo ple?irrespective of race, color, creed, religion or sex?can assert fully their human worth; after apartheid, our people deserve nothing less than the right to life, liberty and the pursuit of happiness. This vision cannot be realized until South Africa can again par ticipate fully in world affairs. For four decades South Africa's inter national relations were dogged by the apartheid issue. By the end of the 1980s, South Africa was one of the most isolated states on earth. Recovering from this will be no easy task. Conscious of this difficul ty, the anc is involved in developing those policies which will be nec

title: ‘BRICS without straw’? A systematic literature review of newly emerging economies’ influence in global health
abstract: BackgroundSince 2010, five newly emerging economies collectively known as ‘BRICS’ (Brazil, India, Russia, China and South Africa) have caught the imagination, and scholarly attention, of political scientists, economists and development specialists. The prospect of a unified geopolitical bloc, consciously seeking to re-frame international (and global) health development with a new set of ideas and values, has also, if belatedly, begun to attract the attention of the global health community. But what influence, if any, do the BRICS wield in global health, and, if they do wield influence, how has that influence been conceptualized and recorded in the literature?MethodsWe conducted a systematic literature review in (March-December 2012) of documents retrieved from the databases EMBASE, PubMed/Medline, Global Health, and Google Scholar, and the websites of relevant international organisations, research institutions and philanthropic organisations. The results were synthesised using a framework of influence developed for the review from the political science literature.ResultsOur initial search of databases and websites yielded 887 documents. Exclusion criteria narrowed the number of documents to 71 journal articles and 23 reports. Two researchers using an agreed set of inclusion criteria independently screened the 94 documents, leaving just 7 documents. We found just one document that provided sustained analysis of the BRICS’ collective influence; the overwhelming tendency was to describe individual BRICS countries influence. Although influence was predominantly framed by BRICS countries’ material capability, there were examples of institutional and ideational influence - particularly from Brazil. Individual BRICS countries were primarily ‘opportunity seekers’ and region mobilisers but with potential to become ‘issue leaders’ and region organisers.ConclusionThough small in number, the written output on BRICS influence in global health has increased significantly since a similar review conducted in 2010 found just one study. Whilst it may still be ‘early days’ for newly-emerging economies influence in global health to have matured, we argue that there is scope to further develop the concept of influence in global health, but also to better understand the ontology of groups of countries such as BRICS. The BRICS have made a number of important commitments towards reforming global health, but if they are to be more than a memorable acronym they need to start putting those collective commitments into action. Keywords BRICS, global health, influence, newly emerging economies, Brazil, Russia, India, China, South Africa.

title: Business as usual? The role of BRICS co- operation in addressing health system priorities in East and Southern Africa
abstract: There has been increased interest in whether “South-South” co-operation by 
Brazil, Russia, India, China and South Africa (BRICS) advances more equitable 
initiatives for global health. This article examines the extent to which 
resolutions, commitments, agreements and strategies from BRICS and Brazil, 
India and China (BIC) address regionally articulated policy concerns for health 
systems in East and Southern Africa (ESA) within areas of resource mobilization, 
research and development and local production of medicines, and training and 
retention of health workers. The study reviewed published literature and 
implemented a content analysis on these areas in official BRICS and ESA regional 
policy documents between 2007 and 2014. The study found encouraging signals 
of shared policy values and mutuality of interest, especially on medicines access, 
although with less evidence of operational commitments and potential 
divergence of interest on how to achieve shared goals. The findings indicate that 
African interests on health systems are being integrated into south-south BRICS 
and BIC platforms. It also signals, however, that ESA countries need to 
proactively ensure that these partnerships are true to normative aims of mutual 
benefit, operationalize investments and programs to translate policy 
commitments into practice and strengthen accountability around their 
implementation.

title: The Treatment Action Campaign's Struggle for AIDS Treatment in South Africa: Coalition-building Through Networks
abstract: The Treatment Action Campaign (TAC), South Africa's – and probably the world's – most prominent AIDS activist movement, emerged in the context of state-supported AIDS denialism and government resistance to evidence-based responses such as antiretroviral treatment. TAC's forceful campaigns against denialism and in favour of the provision of antiretroviral drugs are widely lauded and even credited with the dramatic policy turnaround in South Africa. This study draws on extensive interviews with TAC leaders and members to provide a detailed historical narrative of the emergence and impact of TAC, while employing a range of theoretical approaches to help explain its influence. It describes how TAC's founders drew on their experiences and networks from the anti-apartheid struggle to build the movement and construct new local and international support networks in order to gain influence. It concludes that TAC succeeded in leveraging ‘networks of influence’ (which also included scientists, bureaucrats and politicians) to contribute to the formation of a moral consensus on treatment access and the construction of an inclusive coalition that pursued policy change.

title: African perspectives in global health diplomacy
abstract: Health has been brought into foreign policy processes for several centuries, through diverse approaches that differ across countries and regions, albeit with both risks and benefits for public health. This paper explores, through a review and analysis of published literature in English, the perspectives that have informed African health diplomacy; particularly in Anglophone Sub-Saharan Africa. A thematic analysis of literature on health diplomacy in Africa pointed to common themes in African diplomacy on health, including: a liberation ethic; African unity and interdependence; and developmental foreign policy. Examples are provided that demonstrate how these perspectives have specifically informed negotiations on global health. The literature also highlights reasons for caution in raising health as an issue of global diplomacy, including: loss of sovereignty; the disguised role of private actors; a focus on development aid; and weak attention to underlying determinants of health. Nevertheless, the authors argue that a rising demand for African resources and the emergence of south-south alliances raise new possibilities for advancing African perspectives in global health diplomacy, particularly if supported by strengthened regional co-operation, greater policy coherence between health and other sectors within African countries, and by effective involvement of the public sector and civil society. JOURNAL OF HEALTH DIPLOMACY LOEWENSON, MODISENYANE AND PEARCEY  Effective engagement in global health is particularly important for African countries, who face major deficits in access to key determinants of health and some of the highest disease burdens globally, with significant costs to national economies and individual households (AU, 2010);  2010). Elements of globalization and widening global inequalities in wealth have particularly disadvantaged African countries and communities, undermining opportunities for human security (Labonté & Shrecker, 2008;  2007). At the same time, increased demand for the mineral and natural resources in the continent, increasing levels of social connectedness and the emergence of new global forces offer new leverage for African countries in global diplomacy (Vieira, 2012; Musiitwa, 2012). This paper explores the perspectives that have informed African diplomacy, particularly for Anglophone Sub-Saharan Africa, and the implications for what this means for African engagement in the field of global health diplomacy (GHD). Global health diplomacy as a field Diplomacy is a foreign policy process through which actors negotiate their interests in political interactions. Foreign policy seeks to: ensure a nation’s security from external threats; contribute to a country’s economic power and prosperity by promoting international trade and investment; support order and stability in countries; and promote and protect human dignity (Fidler, 2005). It has been described as an instrument in pursuit of power, survival and self-interest, with collective action an outcome only when interests converge (Gagnon, 2012). Health has been brought into foreign policy processes for several centuries, as a goal (as in the global responses to treatment access for people living with HIV); as a tool to secure economic or security interests of states (as in management of cross border health risks); and as an outcome in the collective negotiation of competing interests (such as on the international recruitment of health workers). Health has been a matter for international co-operation. It has thus been used as a tool of soft power in diplomacy; specifically to make a state look better in the eyes of others and to establish a state’s reputation (Fidler, 2005). ‘Soft power’ refers to the persuasive ability to attract or co-opt others to achieve desired outcomes through shared values, agenda, culture and legitimacy, as distinct to the use of threat or financial coercion (Nye, 2011). As globalization has intensified social interconnectedness and the transnational movement of capital, information, goods and services, greater attention has been paid to GHD. Cross border concerns such as HIV have precipitated the negotiation of global instruments such as the July 2000 UN Security Council (SC) Resolution 1308 on the responsibility of the Security Council in the maintenance of international peace and security: HIV/AIDS and international peacekeeping operations, and the 2005 revision of the World Health Organisation's (WHO) International Health Regulations (IHR) (Fidler, 2009; Cooper, et al., 2007). While containing public health risks to security and trade have remained dominant concerns, conceptualizing health as a human right and a human security issue has, since JOURNAL OF HEALTH DIPLOMACY LOEWENSON, MODISENYANE AND PEARCEY  Doha declaration protecting public health in the World Trade Organisation (WTO) Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS), or assert human rights such as the 2012 UN resolution on universal health coverage (Fidler 2009; UN 2012). Diverse perspectives in global health diplomacy GHD has obtained increasing prominence as a field. A Google Scholar search with the term yields 88 000 results, with the same number of results for the year 2012 alone, as in the whole decade spanning 1990-1999. In considering African engagement with GHD, it is important to note that it is not a monolithic field. Diverse paradigms and goals characterize health diplomacy, reflecting a diversity of political histories and philosophies, experience and interests in relation to globalization and internal challenges (GHSi, 2012). From as early as the 14th century, European foreign policy interactions sought to contain cross border health risks to trade, economic and security interests. This has remained the core of health diplomacy in Europe and North America over subsequent centuries. From the 1800s, health has also been raised as a humanitarian issue in Western foreign policy, with scientific and humanitarian collaborations even occurring between military and/or Cold War antagonists on vaccine development (Hotez, 2001). Post-World War Two, and with the independence of colonies, health as an instrument of soft power grew more prominent in Western foreign policy, including through the discourse on development aid (Kennedy, 1992; Van Straelen, 1993; Macro, 2005). Non-state actors (civil society, private corporations and private foundations) have had a rising presence in Western diplomacy. Some European countries have joined those in the south to assert common vulnerability, shared risk, and shared responsibility as a basis for collaboration across borders, such as France and Norway’s involvement in the 2007 Oslo Ministerial Declaration (Mogedal & Alverberg, 2010). At the same time, the ‘war on terror’ and the financial crisis of the 2000s have kept national security and economic interests at the core of US and European global diplomacy (Lee & Smith, 2009; Fidler, 2009; Zacher & Keefe, 2008). The decline of bipolar superpower competition in the 1990s, the growth of social media and the rise of Brazil, Russia, India, China and South Africa (BRICS) have enabled new forms of co-operation, the opening of new political/diplomatic spaces; and opportunities for interactions at the global level, such as through south-south co-operation. In turn, these developments have had an influence on the practice of GHD (Alcazar, 2008; Lee & Smith 2009; Fidler, 2009; Kennedy, 1992; Van Straelen, 1993; Macro, 2005). Countries in the south have strengthened their power in diplomacy, including at the global level, through regional economic and political arrangements such as Mercosur, Southern African Development Community (SADC) and the South Asian Association for Regional Cooperation (SAARC), and by engaging in alliances, such as the Non Aligned Movement, and more recently the BRICS and the India Brazil South Africa Dialogue Forum (IBSA) (Alden & Vieira, 2005). JOURNAL OF HEALTH DIPLOMACY LOEWENSON, MODISENYANE AND PEARCEY  Chinese diplomacy, as articulated by Jiang Zemin in 1996, is based on ‘Five Principles of Peaceful Coexistence’, that are (1) mutual respect for territorial integrity and sovereignty; (2) mutual nonaggression; (3) mutual non-interference in internal affairs; (4) equality and mutual benefit; and (5) peaceful coexistence. This is reported to have positioned China less as a ‘transformer’ of global systems than as using its growing influence to address national interests of accessing technology and raw materials to accelerate the country’s transition from manufacturer to innovator (Jiang, 2006). Cuba and Venezuela use public diplomacy within their own region, as well as globally, to protect their security and national interests. Public diplomacy refers to a government’s use of aid, culture, media and exchange programs to influence how they are seen by citizens in other countries. Both countries have used a critique of neoliberal globalisation and a discourse of unity, solidarity and shared interest to evoke a commonality with countries sharing similar colonial legacies (Castro, 1987; Bustamente & Sweig, 2008). Their critiques of inequality and injustice in globalisation are communicated through ideas, culture, art, and other approaches that have the power to influence public perceptions and generate symbolic capital. Other countries have used diplomacy to actively seek benefits from globalization, such as Thailand (on WTO agreements and public health) and Indonesia (on virus sharin

title: South Africa's Treatment Action Campaign: Combining Law and Social Mobilization to Realize the Right to Health
abstract: This article summarizes the experience and results of a campaign for access to medicines for HIV in South Africa, led by the Treatment Action Campaign (TAC) between 1998 and 2008. It illustrates how the TAC mobilized people to campaign for the right to health using a combination of human rights education, HIV treatment literacy, demonstration, and litigation. As a result of these campaigns, the TAC was able to reduce the price of medicines, prevent hundreds of thousands of HIV-related deaths, but also to force significant additional resources into the health system and towards the poor. The article asks whether the method of the TAC has a wider application for human rights campaigns and, particularly, whether the protection of the right to health in law, and the obligation that it be progressively realized by the State, provides an opportunity to advance human rights practice.

title: Global and Local Health Governance: Civil society, human rights and hiv/aids
abstract: From the outset in the mid-1980s the international response to hiv/aids has been characterised by an emphasis on the human rights aspects of the pandemic, and on recognition of the pivotal role of civil society actors (csos). But how the rights-based conception of hiv/aids and the international legitimation of csos play out at the local level depends not only on the vertical coordination between global and local levels but also on government–cso relations and the understanding of the pandemic in individual countries. South Africa and Cambodia provide comparative examples of ‘glocalised’ responses to hiv/aids. Both countries were among the hardest hit in their respective regions. But, while the South African government was slow to acknowledge the severity of epidemic, the Cambodian leadership quickly initiated a comprehensive response to it. The two cases illustrate how opportunity structures at the international and national levels created different local responses to hiv/aids, with significant consequences for the epidemic over time.

title: The impacts of AIDS movements on the policy responses to HIV/AIDS in Brazil and South Africa: A comparative analysis
abstract: Brazil and South Africa were among the first countries profoundly impacted by the HIV/AIDS epidemic and had similar rates of HIV infection in the early 1990s. Today, Brazil has less than 1% adult HIV prevalence, implemented treatment and prevention programmes early in the epidemic, and now has exemplary HIV/AIDS programmes. South Africa, by contrast, has HIV prevalence of 18% and was, until recently, infamous for its delayed and inappropriate response to the HIV/AIDS epidemic. This article explores how differing relationships between AIDS movements and governments have impacted the evolving policy responses to the AIDS epidemic in both countries, including through AIDS programme finance, leadership and industrial policy related to production of generic medicines.

title: The BRICS – a paradigm shift in global health?
abstract: To what extent does the Brazil, Russia, India, China and South Africa (BRICS) bloc constitute a paradigm shift in global health and development? This paper interrogates the concept of paradigm shift with the help of a framework familiar to scholars working in the field of International Relations. It distinguishes between the BRICS' material capabilities, institutions and ideas, and assesses the extent to which the BRICS contribution represents ‘a potentially transformative’ source of new resources and innovation for global health and development. It has been argued that the BRICS bloc champions a qualitatively different development discourse from industrialised countries that has made possible a progressive set of development practices. The BRICS discourse and praxis gives weight to the claim that a paradigm shift in global health is underway. However, the extent to which such discourse will be effective in improving global health will depend on the bloc making greater use of institutions and further deploying its material capabilities.

title: Turning dread into capital: South Africa’s AIDS diplomacy
abstract: BackgroundIn much of the world, President George W. Bush was not admired for his foreign policy and diplomacy. It is therefore ironic that Bush’s single most uncontested foreign policy triumph was an instance of what has now become known as “health diplomacy”. In 2003 Bush launched the President’s Emergency Plan for AIDS Relief, a five-year $15 billion initiative to fight HIV/AIDS, mostly in Africa. The president’s pragmatic health diplomacy may well save his foreign policy legacy. This article argues that a middle power such as South Africa should consider a similar instrumental AIDS diplomatic strategy, to rehabilitate its public health as well as foreign policy images.DiscussionThis article reflects on the emergence and contemporary practice of health diplomacy. In particular, it explores the potential of niche areas within health diplomacy to become constructive focal points of emerging middle powers’ foreign policies. Middle powers often apply niche diplomacy to maximise their foreign policy impact, particularly by pursuing a multilateral agenda. The literature on middle powers indicates that such foreign policy ambitions and concomitant diplomacy mostly act to affirm the global status quo. Instead, this paper argues that there may well be niches within health diplomacy in particular that can be used to actually challenge the existing global order. Emerging middle powers in particular can use niche areas within health diplomacy in a critical theoretical manner, so that foreign policy and diplomacy become a project of emancipation and transformation, rather than an affirmation of the world as it is.SummaryThe article first describes the emergence and contemporary practice of health diplomacy; this is followed by a discussion of niche diplomacy, in particular as it applies to the foreign policy agendas of emerging middle powers. It then reviews South African foreign policy and diplomacy, before situating these policies within the context of emerging mechanisms of south-south multilateralism. The article concludes by synthesizing these elements and advocating for a South African AIDS diplomacy, emphasizing its potential to galvanize a global project of emancipation.

title: Access to Medicines, BRICS Alliances, and Collective Action
abstract: On December 6, 2005, shortly before the World Trade Organization (“WTO”) Ministerial Conference in Hong Kong, WTO member states agreed to accept a protocol of amendment to the Agreement on Trade-Related Aspects of Intellectual Property Rights (“TRIPs Agreement”). This amendment sought to provide a permanent solution to implement paragraph 6 of the Doha Declaration on the TRIPS Agreement and Public Health (“Doha Declaration”). If ratified, the new article 31bis of the TRIPs Agreement will allow countries with insufficient or no manufacturing capacity to import generic versions of on-patent pharmaceuticals. To facilitate the supply of essential medicines to countries with insufficient or no manufacturing capacity, article 31bis(3) creates a special arrangement not only for the affected countries, but also for those belonging to a regional trade agreement. Such an arrangement allows less developed countries to aggregate their markets to generate the purchasing power needed to make the development of an indigenous pharmaceutical industry attractive.

title: Mobilising Brazil as 'Significant Other' in the Fight for HIV/AIDS Treatment in South Africa: the Treatment Action Campaign (TAC) and its global Allies
abstract: This chapter focuses on emergent actor in Africa: Brazil. By focusing on the first decade of the 21st century and the fight against HIV/AIDS in South Africa, the role of Brazil is examined. This is done through the lens of the Treatment Action Campaign (TAC)-the most prominent HIV/AIDS organisation in South Africa and also a global actor-which vigorously battled the South African government that refused to establish a universal HIV/AIDS treatment programme. The chapter examines theoretically whether the concepts of 'global civil society' and 'transnational activist network' help us understand what we witness in the case of the global HIV/AIDS movement, or whether different interpretations of these concepts may in fact cloud our understanding of such phenomena and the powers at play.  Brazil; global civil society'; HIV/AIDS treatment; South Africa; transnational activist network; Treatment Action Campaign (TAC)

title: Civil Society Leadership in the Struggle for Aids Treatment in South Africa and Uganda
abstract: This thesis is an attempt to theorise and operationalise empirically the notion of ‘civil society leadership’ in Sub-Saharan Africa. ‘AIDS leadership,’ which is associated with the intergovernmental institutions charged with coordinating the global response to HIV/AIDS, is both undertheorised and highly context-specific. In this study I therefore opt for an inclusive framework that draws on a range of approaches, including the literature on ‘leadership’, institutions, social movements and the ‘network’ perspective on civil society mobilisation.This framework is employed in rich and detailed empirical descriptions (‘thick description’) of civil society mobilisation around AIDS, including contentious AIDS activism, in the key case studies of South Africa and Uganda. South Africa and Uganda are widely considered key examples of poor and good leadership (from national political leaders) respectively, while the Treatment Action Cam- paign (TAC) and The AIDS Support Organisation (TASO) are both seen as highly effective civil society movements. These descriptions emphasise ‘transnational net- works of influence’ in which civil society leaders participated (and at times actively constructed) in order to mobilise both symbolic and material resources aimed at exerting influence at the transnational, national and local levels. They endeav- oured to influence both AIDS policy and the course of the epidemic directly. I conclude that these networks played a key role in the effectiveness of both TAC and TASO.These qualitative case studies are complemented by econometric analyses. At the continental level, I attempt to measure the impact of civil society mobilisation on the performance of national governments through a cross-country regression analysis applied to 42 Sub-Saharan African states. This analysis fails to show a strong relationship between the presence of AIDS NGOs and HAART and PMTCT coverage (controlling for a range of factors) — potentially supporting my hypothesis that civil society mobilisation is only effective in certain circumstances. At the local level, a second set of regression models using household survey data investigates whether TAC’s mobilisation in Cape Town impacted appreciably on HIV prevention efforts. They show a significant relationship between contact with TAC and not endorsing false conspiracy beliefs about AIDS as well as condom use, indicating that TAC’s impact is not restricted to the national policy level.

title: Assessing the Foreign Policy and Global Health Initiative: The Meaning of the Oslo Process
abstract:  The Foreign Policy and Global Health Initiative (FPGHI) is one of the most well-known efforts aimed at increasing health’s importance in foreign policy. The FPGHI and its Oslo Ministerial Declaration gained prominence by reflecting health’s rise as a foreign policy issue that was under way before the FPGHI’s launch in 2006.  The FPGHI emphasized ‘global health security’ to frame the link, proposed health as a ‘defining lens’ for foreign policy and developed an ambitious agenda. It has stimulated interest on global health and foreign policy in the United Nations General Assembly.  Assessing the FPGHI’s importance is difficult because it has not provided regular information about its activities or critically analysed its performance. External assessments are also lacking. On the available information, the FPGHI’s impact appears limited, and other initiatives, processes, mechanisms and actions have had more impact in elevating health in foreign policy.  The FPGHI does not appear to be a promising venue in which to address the increasingly difficult environment health faces within foreign policy processes because of fiscal crises in many countries and geopolitical shifts in the distribution of power. Clarifying and deepening the meaning of the Oslo process would require more information and insight on how it has managed the dilemmas presented by pursuing health objectives in foreign policy.

title: Reflections on a new Democratic South Africa’s role in the Multilateral Trading System
abstract: The paper argues that South Africa’s participation in the World Trade Organization since the birth of its democracy in 1994 was informed by its domestic development challenges. It claims that South Africa’s values were derived from its long struggle against apartheid and its transition to a new democracy. South Africa’s political leadership in the Doha negotiations was also strengthened by its deep democratic institutions and consultative processes. South Africa’s values, articulated by Nelson Mandela, reflected a deep commitment to multilateralism and consensus building, fairness and justice, inclusiveness, and a concern to support and promote development, within South Africa, and also in developing countries, especially the African continent. The paper discusses how and why South Africa’s unique value system enabled it to play a significant role in the Doha Round. The paper concludes that South Africa is both part of the group of major emerging developing countries and a crucial bridge to a smaller group of developing countries, particularly in Africa.

title: Driving a decade of change: HIV/AIDS, patents and access to medicines for all
abstract: Since 2000, access to antiretroviral drugs to treat HIV infection has dramatically increased to reach more than five million people in developing countries. Essential to this achievement was the dramatic reduction in antiretroviral prices, a result of global political mobilization that cleared the way for competitive production of generic versions of widely patented medicines.Global trade rules agreed upon in 1994 required many developing countries to begin offering patents on medicines for the first time. Government and civil society reaction to expected increases in drug prices precipitated a series of events challenging these rules, culminating in the 2001 World Trade Organization's Doha Declaration on the Agreement on Trade-Related Aspects of Intellectual Property Rights and Public Health. The Declaration affirmed that patent rules should be interpreted and implemented to protect public health and to promote access to medicines for all. Since Doha, more than 60 low- and middle-income countries have procured generic versions of patented medicines on a large scale.Despite these changes, however, a "treatment timebomb" awaits. First, increasing numbers of people need access to newer antiretrovirals, but treatment costs are rising since new ARVs are likely to be more widely patented in developing countries. Second, policy space to produce or import generic versions of patented medicines is shrinking in some developing countries. Third, funding for medicines is falling far short of needs. Expanded use of the existing flexibilities in patent law and new models to address the second wave of the access to medicines crisis are required.One promising new mechanism is the UNITAID-supported Medicines Patent Pool, which seeks to facilitate access to patents to enable competitive generic medicines production and the development of improved products. Such innovative approaches are possible today due to the previous decade of AIDS activism. However, the Pool is just one of a broad set of policies needed to ensure access to medicines for all; other key measures include sufficient and reliable financing, research and development of new products targeted for use in resource-poor settings, and use of patent law flexibilities. Governments must live up to their obligations to protect access to medicines as a fundamental component of the human right to health.

title: For-profit policies and equitable access to antiretroviral drugs in resource-limited countries
abstract: Unaffordable prices continue to obstruct access to antiretroviral drugs in income-constrained countries. This article explores the fitness of a multi-pronged, incentive-bound, WHO-mediated voluntary license strategy for attuning research, innovation, profit and equitable access to antiretrovirals in under-served markets. The potential of the model was investigated by examining: the predictable effect on current regulatory practices (trade-related aspects of intellectual property rights [TRIPS] and TRIPS-plus measures); the expected benefits, either in terms of equity or safeguarding of the generic and brand name manufacturer’s interests; the interplay dynamics with drug trading policies of deeply concerned countries (China, India, countries in the EU, USA, Brazil, South Africa and Thailand); and the suitability for helping plants for generic antiretrovirals, including home plants in Sub-Saharan Africa, undertake research and development partnerships encompassing innovation, technological catch-up, exploit...

title: Understanding global health governance as a complex adaptive system
abstract: The transition from international to global health reflects the rapid growth in the numbers and nature of stakeholders in health, as well as the constant change embodied in the process of globalisation itself. This paper argues that global health governance shares the characteristics of complex adaptive systems, with its multiple and diverse players, and their polyvalent and constantly evolving relationships, and rich and dynamic interactions. The sheer quantum of initiatives, the multiple networks through which stakeholders (re)configure their influence, the range of contexts in which development for health is played out – all compound the complexity of this system. This paper maps out the characteristics of complex adaptive systems as they apply to global health governance, linking them to developments in the past two decades, and the multiple responses to these changes. Examining global health governance through the frame of complexity theory offers insight into the current dynamics of governance, and while providing a framework for making meaning of the whole, opens up ways of accessing this complexity through local points of engagement.

title: AIDS Drugs For All: Social Movements and Market Transformations
abstract: 1.  global markets and transnational social movements Appendix A. A brief history of AIDS and the AIDS treatment movement Appendix B. Key dates 2. Industry structure and movement opportunities 3. Drugs = life: framing access to AIDS drugs 4. Movement coherence and mobilization 5. Advocacy strategies to address costs 6. Institutions to stabilize the market 7. Lessons for other campaigns 8.  implications for research and policy.

title: Global health diplomacy: how foreign policy can influence health
abstract: Ilona Kickbusch argues that public health experts need to work with diplomats in order to achieve global health goals

title: Global Health Governance Challenges 2016 - Are We Ready?
abstract: The year 2016 could turn out to be a turning point for global health, new political realities and global insecurities will test governance and financing mechanisms in relation to both people and planet. But most importantly political factors such as the global power shift and "the rise of the rest" will define the future of global health. A new mix of health inequity and security challenges has emerged and the 2015 humanitarian and health crises have shown the limits of existing systems. The global health as well as the humanitarian system will have to prove their capacity to respond and reform. The challenge ahead is deeply political, especially for the rising political actors. They are confronted with the consequences of a model of development that has neglected sustainability and equity, and was built on their exploitation. Some direction has been given by the path breaking international conferences in 2015. Especially the agreement on the Sustainable Development Goals (SDGs) and the Paris agreement on climate change will shape action. Conceptually, we will need a different understanding of global health and its ultimate goals - the health of people can no longer be seen separate from the health of the planet and wealth measured by parameters of growth will no longer ensure health.

title: New BRICS Bank a Building Block of Alternative World Order
abstract: In 1990, right after the Berlin Wall fell, NPQ published our Spring edition, titled “The New World Disorder,” about the nationalistic chaos and up-in-theair sensibility of that fraught new historical moment. 
 
 
 
Nearly a quarter of a century later, the regime of globalization that had supplanted the Cold War world of blocs is itself coming apart at the seams. Even Henry Kissinger these days says “the world order is crumbling.” 
 
 
 
Will this New World Disorder 2.0 revert to a system of conflicting blocs, as during the Cold War, or will we be mature enough to save the interdependence of plural identities that is the foundation of a new global civilization? 
 
 
 
In this section our contributors offer their perspectives on what the future holds.

title: The Real New World Order
abstract: Many thought that the new world order proclaimed by George Bush was the promise of 1945 fulfilled, a world in which international institutions, led by the United Nations, guaranteed international peace and security with the active support of the world's major powers. That world order is a chimera. Even as a liberal internationalist ideal, it is infeasible at best and dangerous at worst. It requires a centralized rule making authority, a hierarchy of institutions, and universal membership. Equally to the point, efforts to create such an order have failed. The United Nations cannot function effectively independent of the major powers that compose it, nor will those nations cede their power and sovereignty to an international institution. Efforts to expand suprana tional authority, whether by the U.N. secretary-general's office, the European Commission, or the World Trade Organization (wto), have consistently produced a backlash among member states. The leading alternative to liberal internationalism is "the new medievalism," a back-to-the-future model of the 21st century. Where liberal internationalists see a need for international rules and institutions to solve states' problems, the new medievalists proclaim the end of the nation-state. Less hyperbolically, in her article, "Power Shift," in the January/February 1997 Foreign Affairs, Jessica T. Mathews describes a shift away from the state?up, down, and sideways?to supra-state, sub-state, and, above all, nonstate actors. These new players have multiple allegiances and global reach.