 My name is Catherine Bliss and I'm a senior fellow and deputy director within the Global Health Policy Center here at CSIS and on behalf of the Global Health Policy Center along with the CSIS Africa program, the America's program, the Freeman Chair in China Studies, the Russia and Eurasia program and the Wadwani Chair in US India Studies. It is my pleasure to welcome you to this morning's seminar on emerging practices in global health cooperation which focuses on the increasingly influential roles of Brazil, China, India, Russia and South Africa within the global health landscape. Now it was almost exactly ten years ago this week that Goldman Sachs analyst Jim O'Neill coined the term brick to refer to the emerging economies he believed were poised to surpass the G7 in terms of economic growth in the coming years. And although at the time the term brick was just kind of a convenient name to refer to those economies as a group, the governments themselves found that they had common interests beyond the basic questions of economic growth and global economic and financial governance and began to work to coordinate their positions on a variety of issues through formal and informal mechanisms. Now in 2011 the brick alliance or association officially incorporated South Africa formalizing the bricks moniker. And in July of this year health ministers from the bricks met in China for the first time to exchange views on global health challenges and to affirm their commitment to promote the bricks as a forum for coordination, cooperation and consultation on relevant matters related to global health. Now the Beijing Declaration released at the conclusion of that meeting outlines a broad agenda focused on reform of the World Health Organization, the promotion of universal access to healthcare within the bricks themselves and in cooperation with other countries along the development path and an emphasis on the importance of honoring flexibilities within the trips agreement to ensure widespread access to medicines and vaccines. Now as many of you know because many of you have attended events here in recent months, CSIS has been carrying out analysis related to the bricks and global health for about the past year and a half. Building on international influence in the or international interest in the influence of the bricks within global governance schemes, generally we have asked a series of questions related to global health specifically. What is the history of each country's engagement in the global health arena? What philosophy or ideology guides each nation's global health outreach and cooperation? What is the relationship between each country's domestic health conditions and its international work on health? What kinds of legislation and bureaucratic arrangements support the government's work on global health? What are the most relevant regional and bilateral partners? And looking toward the future, what are the implications for the United States and other perhaps more traditional actors in the global health field and what are the opportunities for partnership and cooperation? Now in November of 2010 we published a preliminary report called Key Players in Global Health in which researchers from our regional programs here at CSIS offered initial assessments of each of the country's motivations, ideologies and practices in the global health arena. That publication also included analyses by colleagues within the CSIS Europe Program and the Chair in Korea Studies as well as from Chatham House in London and those authors considered the prospects that South Korea and France might incorporate health as a key element of their respective G20 summits that they would host in November of 2010 and November of 2011. Between May and November of this year CSIS worked with independent research organizations in each country to plan co-hosted workshops to deepen understanding of some of the issues and to develop common agendas for investigation and analysis. On May 19th in Moscow we co-hosted a session on Russia's leadership on global health with the Higher School for Economics International Organizations Research Institute. On May 24th we co-hosted with the China Institute of International Studies a discussion on the potential for U.S. and China collaboration on health in Sub-Saharan Africa. On August 25th we co-hosted with the South African Institute for International Affairs a session on South Africa's regional, south-south and international relations on health. And on November 7th CSIS and the Center for International Relations on Health at Brazil's Fiocruz in Rio de Janeiro co-hosted a session on the ways in which emerging forms of trilateral cooperation are influencing global health practices. Now a collection of papers from the May 24th Beijing conference entitled China's Emerging Global Health and Foreign Engagement in Africa has recently been released and reports from the Russia, South Africa and Brazil workshops should be available soon. So today we wrap up this first phase of work on the BRICS with a seminar featuring experts on health policy, development, foreign policy and the changing nature of international relations related to global health and overseas assistance. Many of our speakers participated as hosts, local experts or visiting speakers in Moscow, Beijing, Johannesburg and the Rio conferences. Others bring their expertise as observers and practitioners of global health cooperation to their roles today. So we've planned today's discussion around two sessions. In the first we have asked three panelists to consider the relationships between the BRICS countries and the multilateral institutions that are most important to them for health including the World Health Organization, the World Trade Organization and TRIPS issues and the G20 among others. In the second, four experts will offer their perspectives on the importance of South-South cooperation, trilateral cooperation and regional relationships to the BRICS emerging global health activities. Following the presentations we will have time for questions and comments from the audience and I hope that you will be able to stay for both sessions as your schedules permit. Now it is my pleasure to introduce the chair and moderator of our first session. Dr. Judith Twig is professor at Virginia Commonwealth University and senior associate within the CSIS Russia and Eurasia program. Judy is an internationally recognized expert on issues related to health and Russia and she chaired the public health working group of the civil society summit during the US Russia presidential summit in Moscow in July of 2009. More recently she took the lead for CSIS in organizing the May 2011 seminar with the higher economics school in Moscow and she has been a vital member of the CSIS BRICS group over the past two years. So Judy, let me turn to you. Thank you very much, Catherine. As Catherine said, this first panel is dedicated to discussing the engagement of the BRICS countries with international organizations and Catherine has asked the panelists to address three distinct issues in their remarks. The first is the importance of multilateral relationships to the engagement of the BRICS countries on global health issues. The second is an assessment of the priority relationships, the priority organizations, the priority associations within the multilateral arena. And the third question addresses the themes or the topics that the BRICS countries are most engaged with through multilateral channels. So we'll have three speakers. We've asked them each to give remarks of about 20 minutes and that will leave us plenty of time for questions and discussion afterwards. And I'll introduce each of the panelists as they speak. Our first panelist is Dr. Peter Fori. He is the specialist technical advisor with the AIDS Foundation of South Africa. His research focuses on issues concerning global health governance, political epidemiology, and the political economy of global development. Dr. Fori? Thank you. He also normally has quite a soothing baritone voice, but I seem to have brought a vicious South African virus with me. I'll be speaking with a voice that is not my own and I'll also treat you to a rather severe African accent. So good luck to us all. Thank you very much for the invitation to speak here today. Right. Thank you very much to the CSIS for this invitation to speak here today. Global health is not an issue that has traction in South Africa. As a member of BRICS, it's not an arena of struggle that seems to be exploiting after the end of apartheid. Although it is extremely necessary, it's interesting that the afrobarometer data indicates that South Africans don't really deem AIDS a particularly interesting topic or something that they think about when they make electoral decisions. So it will be interesting as we move forward in South Africa as the latest or the newest BRICS member to see whether that issue finds a place on the official agenda going into the future. So I'll focus mostly on the SN BRICS and I'll put my cards on the table. I'm a skeptic, probably I don't think South Africa belongs in the BRICS conglomerate. We don't seem to fit the profile of the other countries there, Mexico certainly seems to be an obvious one, but not so much South Africa. That's if you believe the metrics. If you think about it ideologically, maybe we do belong there, but those are the kinds of issues that I'll address later on. My bottom line is in the second half of the presentation, namely that South Africa and BRICS I think can use health issues and HIV and AIDS in particular as a filter through which they can project their soft power globally or internationally and certainly in the multilateral arena. And that's not really happening, it hasn't happened and it's not on any agenda. Probably mostly due to the shambolic nature of South African foreign policy making itself, but if we can sort that out, it would be possible I think to do something quite constructive in the multilateral arena around HIV and AIDS and the kind of evolving AIDS diplomacy in particular which is an appendix to a health diplomacy in particular. You see my affiliation there, I'll be moving to the University of Stalingbos next February, so that's a temporary affiliation and then my email address at the bottom would be an easier place to get hold of me as of very soon. So, in this presentation I'll have a quick glance at the BRICS on the whole. This presentation is probably a bit of a framing exercise as well, I hope, because it is fairly broad, although I pull it together towards the end. I'll then talk about the global South and its affinity for multilateralism with the BRICS being an idea within an evolving Southern solidarity shift towards multilateral global politics. Then I'll express my surprise, really that South Africa now is officially a member of that grouping and I'll talk about the place of global health within this evolving multilateral order where the BRICS want to play an important role. I'll then talk about, reflect on the deal crisis of global health deficits in the developing world and the global financial crisis, so there are two crises happening here at the same time and I'll make the case or I'll try to that we shouldn't lose this crisis, we should make the most of these deal crises because there are opportunities for learning and transformation, which I don't think the global South or South Africa are using. The global South probably can benefit from here just using health diplomacy, if you don't have enough resources that certainly a focus on health would make it easier again to project ourselves and our soft power internationally and AIDS diplomacy in particular would be an area that we know most about in South Africa and then right at the end I'll come to the three questions that Judy noted in her introduction. So there's a family photo, that's the BRICS nations, it certainly is impressive on paper, a third of the world's population, combined GDP that's not insignificant, combined foreign reserves that's not insignificant, especially given recent global geopolitical developments with the stated goal to reform financial institutions and to become more involved I think is what the document says but there's a need of willingness and expression of interest in becoming projecting oneself in the global arena. Multilateralism is particularly seductive to countries in the global South simply because we do not have any ambitions for global dominance, some of us more than others, certainly China, certainly Russia, but the other three I don't think have ambitions for projecting on the global stage in terms of becoming superpowers. So multilateralism is a good accommodation of states who are not really small states but have some kind of traction, some kind of capital and in South Africa's case a kind of a moral high ground I think still capitalizing on the spirit of Nelson Mandela to be a player in the global political economy in particular. So the BRICS is seen as an alternative to the status quo which is dominated by the global North and it provides a beautiful opportunity to use as I state their lovely old fashioned post-colonial discourses. You made us poor, you sustain the development of underdevelopment internationally it's excellent for apportioning blame. It can provide a good forum, a good opportunity to become more assertive for more commerce in the global South in particular and as stated in the goals of BRICS to become more assertive in changing the rules of the financial game although the BRICS haven't been particularly active in that over the last year and in Basel III. So I would say that the BRICS as an idea to me and again maybe this is slightly cynical is an opportunity for realism dressed up as idealism using the language of the old Marxists. So it's a bit of a, it's promiscuous I think in terms of the discourses that BRICS enables and that makes it very seductive particularly given the pension for multilateralism in the global South these days. What complicates that is the fact that BRICS is not a monolith. Yes I think we are bound in the BRICS countries by our quest for soft power. Two members of course are also I think quite explicitly interested in hard power but there are also factors that divide us quite explicitly. South Africa is an odd outlier if you look at the metrics economically, geographically and demographically we simply don't belong there. There's history of tensions, recent tensions between key participants in the BRICS project India and China, recent wars. There are very explicit selfish impulses with China and South Africa wanting to be co-emperors of African resources. And South Africa ironically enough of course acting as a colonial power on the rest of the African continent and not particularly well liked for that. Russia and China seem to have global ambitions the others do not yet to that large extent. India is criticised for needing to be left by the United States and there are competing multilateralism. There's IBSA which seems to be an interesting forum where countries that are more alike in terms of those metrics and of course the G20 that might attract more attention than the BRICS nation themselves. So the BRICS is new, it's unsettled, it's not particularly well focused at the moment. So there is scepticism. I want to say a bit more about South Africa and its presence in the BRICS and the metric show that we do not belong there but I think ideologically and pragmatically it makes sense for South Africa to be there. So it depends how you argue it. South Africa especially under Tabu and Birki as president was quite strong in putting forth a post-colonial position in the global south in particular and wanting to play that kingmaker almost in terms of solidarity amongst nations in the global south. Fortunately we are unable to get our foreign policy right. We've been spectacularly bad at it. The bad health policy that we had until about three years ago I think overshadowed the really shoddy nature of South African foreign policymaking. Of course in 1994 we used to be a pariah state. The prodigal returns as a middle power becomes then very quickly what the Washington Post in 2008 called a rogue democracy. It simply is no sense to how we vote in the UN and in the UN Security Council. Or is there maybe there's some kind of agenda going on there. South Africa seems to be quite willing to give the middle finger to the priorities of the global north and the members of the P5 in particular but it's not particularly well expressed in formal foreign policy documents but we do protect ourselves as a champion of multilateralism in our brand for southern solidarity. We pretend to wanting to be everything for the rest of Africa but we're not. We're very selfish but we are a regional giant. So we went through a lot of phases in terms of foreign policymaking. We haven't really settled and I think it's useful to remember that South Africa as a global player really is only 17 years old in its new iteration and we very much are the adolescent. We've moved from that pariah and practicing the diplomacy of circumvention to Mandela's wonderful idealistic but unpredictable foreign policymaking and his flip-flop policies on Taiwan, China certainly was illustrative here. I spoke to people at the Department of Foreign Affairs a few years ago. It said that you can't criticize Mandela but he was a nightmare to work with in terms of foreign policymaking because he would decide on the day. He really normally would make good decisions but not always. And Beki of course, difficult to follow Mandela's footsteps but very much an African nationalist much clearer sense of what he wants to do globally but certainly global health not present there as a mainstay of his foreign policymaking. He desperately of course tried to have a conversation about the social determinants of health but then was seduced by crazy people on the fringes and then was so conceited that he couldn't escape from that and became the victim of that. So we had to disentangle ourselves from all of that we've really befuddled our presence in terms of global health views we haven't been able to return to a sensible conversation about the social determinants of health and the political economy thereof globally which I think would be really useful and that towards the end of this I would argue is where AIDS can come in we can reclaim that moral high ground and have a serious conversation about global inequities global unfairness, social injustice I don't even want to mention the current guy Jacob Zuma Shambolic chaotic foreign policy no norm entrepreneurial flair whatsoever and eminently inward looking and the recent drama around the issuing of a visa for the Dalai Lama's visit I think is a clear illustration of that I don't know if you're aware of that recent drama essentially the Department of Home Affairs just waited until the Dalai Lama gave up he did put in an application for a visa the presidency refused to comment on it and they just didn't issue it until he withdrew his application and then they said, oh we would have approved it and then it kind of went away so there's no planning there's no strategy really in terms of foreign policymaking and only recently did it come out that yes, South Africa was playing a Chinese game around the Dalai Lama didn't want to upset Beijing within this context in all of this global health is new global health I think the importance of it is the fact that since the end of the Cold War when we moved from international health to global health has been multilateralised and that is a point that I will make a little bit later as well it fits the profile of foreign policymaking and activity that the BRICS countries as well as South Africa hold dear we have multilateralised the way in which global health is managed and it fits nicely with the modus operandi of countries serious, large countries in the global south the fact however is that there is a multitude of actors, multitude of agendas and it's difficult to see whether there's any kind of pattern all of this is fairly new I mean I don't have to tell this audience this kind of history but over the last 150 years or so first there was an international conference on cholera in 1851 and since then we have quite actively, globally multilateralised the way in which global health is managed eventually the World Health Organisation established almost as an afterthought in 1946 with some successes leading to a sense that we have conquered nature by the 1950s, early 1960s and it was only by the 1990s that we rediscovered our sense of common fear our common insecurity is the pathogens and the issues around global health in the absence of certainty with the emergence of new pandemics and HIV and AIDS in particular all of that drove the multilateralisation of responses to global health international and governmental organisations were set up transnational civil society became more and more important multilateralisation of health issues was the name of the game after 9-11 most of this became issues focusing on surveillance surveillance became very important after 9-11 and that flowed into the surveillance of pathogens as well the almost militarisation of the management of global health threats internationally however at the same time a few countries started to play an alternative role and you recognise their names because they're all in Brics, Brazil was quite instructive in terms of the rolling out of antiretroviral therapy quite a pioneer then after 1996 India was a leader in the manufacture of generic drugs and the South Africans were quite successful in the Doha round early on when it was still going to make room for those generic drugs and their parallel importation into poor countries so interesting things have happened in this new multilateral global health management system there are a few and sorry but these notes are all going to be available but I'm aware of the time and they are really just an 8-min mark for me, they're for my benefit not for yours but there have been fascinating developments over the last few decades in particular and again I don't need to tell you this especially after 1978 with the the health for all where health became a human right it seems as though a perfect storm has been coming multilateralisation of global health the setting up of multilateral institutions the establishment of Brics a multilateral take on pathogen transfer internationally all of this has created a context certainly by the 1990s that was absolutely ready for a new way of seeing how we can govern all of these issues unfortunately once again the Brics countries I don't think have made great leeway in doing exactly that what we ended up with today and I've got about 5 slides yet can I have a time check am I doing alright one is the era of partnerships today it's certainly an interesting time to be alive and to be working in global health in 2000 the Gates Foundation was established by 2007 it's budget far surpassed that of the World Health Organization this emphasis on partnerships beyond this fixed Westphalian state centric view again emphasising the need for multilateralisation there was an emphasis on technological solutions still coming of course from the Gates Foundation looking at the survival of women and children in particular as multipliers in global health and development practices in general a new multilateral elite has come about the H8 or the Health 8 with those organisations listed there as key members so this goes some way in answering one of those questions that Judy mentioned which are those global actors that are important in a multilateral response to the challenges of managing or governing global health today the question however is and I think the Occupy Wall Street Occupy Washington movement is a sign of this that the more we multilateralise the more we vest governance capacity in multilateral institutions the more it excludes traditional democratic practice voices have been going up in the global south for many decades for greater say in how the world is governed and how issues are governed and if something as important something as dramatic as global health is managed multilaterally then where do you talk to where do you go if you are unhappy what about governance who is accountable to whom in a global context very soon after the multilateralisation became so prominent it became clear that we needed to respond to the problem of duplication different multilateral organisations were working in silos there was a lot of waste this was discussed at the Monterey meeting in 2002 and of course led to the Paris declaration and the process of aligning overseas development assistance so all of this illustrates that global health in itself has become a push for the institutionalisation of various aspects of governance of again pathogens and responses to them the last decade has been dramatic in terms of the establishment of institutions the writing of rules the international health partnership established in 2007 adding to the age 8 a range of new actors important to multilateral global health governance focusing in particular on health systems strengthening and of course the creation of the BRICS and the G20 will only increase the complexity of managing all of this what looks like chaos to many people so if we have been frantic starting slowly in the mid-1800s with a conference on cholera and over the last 20 years and especially since November 1989 going not overboard but certainly becoming frantic in terms of institutionalising creating multilateral institutions creating new ways of governing loads of health global health maybe AIDS can help to make sense maybe AIDS can be a galvaniser for countries belonging to BRICS certainly other countries in the global south in terms of their place in the world we have all these institutions the ones mentioned there in the first dot point we have the health aid there's a lot of money available less than before of course but the stakes remain high how do we align our activities our spending we still have very little coordination between aid agencies we need to understand the political mechanisms that make things happen we need more discussions between countries that are served and countries that want to help now HIV and AIDS has been instructive in creating some sense out of that chaos in my own country there's been quite an interesting debate ended about 3-4 years ago only after 1998 in the establishment of a treatment action campaign there was a fascinating national narrative discussion huge differences going on in public health versus human rights responses to the epidemic and that debate was used quite cynically by the mberiki government as well as the detractors in establishing a foothold in terms of how health more generally should be managed in South Africa and that has led to a level of surprising sophistication in South Africa not only about HIV and AIDS but about gender issues about questioning sexual culture in South Africa difficult issues to have national conversations about but AIDS has been absolutely instrumental in doing that I'm convinced that we can use health issues broadly as well as HIV and AIDS to make the most of both the health crisis in the global south as well as the global financial crisis this is a spectacular time for learning it's a spectacular time for transformation and I think it provides an opportunity for the BRICS countries to find a way in to the conversation that the grown-ups are having at the big tables in multilateral institutions elsewhere it will be very difficult to deny a place at that table to a country that has 5.7 million HIV positive people and wishes to share its learnings about what it means to govern that I think it would be a mistake for BRICS to ignore global health as well as HIV and AIDS issues as an area of focus it can be a fascinating, useful filter through which to have its conversations for the global north I call that turning dread into capital turning the negative consequences of this epidemic into something that can be used constructively in the engagement certainly of countries like South Africa with the global north we've done it before South Africa did, as I said before, interesting things during the Doha round in 2001 2002 in changing the TRIPS agreement and allowing parallel importation of generic drugs so I think AIDS has not been used sufficiently in niche diplomacy or what we would call niche diplomacy even George W. Bush I don't know if this institution is a friend of George W. Bush but you'll find very few friends in the global south no one is blind to the fact that he's one great foreign policy success that was accepted without any great discussion by the global south was PEPFAR AIDS diplomacy or health diplomacy I think served him spectacularly well in that instance and I think South Africa by excellence can use AIDS diplomacy as a leitmotif to do a lot of other things as well and BRICS can do that also for instance we have a history of doing battle with large pharmaceutical companies that battle isn't over it's going to shift soon in terms of the medical technologies that become available we can build on the Doha around successes around TRIPS we can use AIDS as a motif around which to have serious talks about mending or changing global trade rules for greater fairness greater access to services health as well as otherwise we need to use HIV to have a serious conversation with the global north about stealing our medical personnel our nurses and our doctors we can play the moral high ground card to a large extent by using HIV and AIDS there are fascinating new transnational alliances forming and have been over the last 13 years around the issue of HIV and AIDS we shouldn't lose the capital globally that that has generated and maybe if we are successful at this by ourselves or within a forum like the BRICS we can come up with a new southern model of cooperation and multilateralization and I know the BRICS as an institution would find that again quite attractive very seductive so to go back to the three questions from Julian this is my last slide the first one was what is the importance of multilateral relationships to the engagement of the BRICS on global health issues I think it's extremely important the BRICS is all about multilateralism and if we look at the kinds of issues that have been multilateralized it's a natural fit I think multilateralism multilateralization is quite an interesting area of study and in South Africa speaking for my own country it's not really studied that much so I know the University of Toronto is very strong at looking at the G8, G20 and so on but it's an area where we can grow I think as the BRICS as a project the second question was what are the priority relationships organizations or associations within the multilateral arena I think in terms of global health they were the ones that were mentioned the Health 8 the Health 8 Plus certainly the G20 the G8 and BRICS seem to be constructive along with the World Trade Organization and then on what themes and topics the BRICS are most engaged through multilateral channels the short answer is that at the moment it's about global financial rules using the language again of post-colonial disgust you know about the development of underdevelopment that kind of cushy language of new Marxist analyses that we default to the conversation about global health isn't really happening yet at the level of BRICS I think it's an interesting time for that precise reason to be working in this area and maybe introduce it to the BRICS countries as an area where they can project themselves and their power soft or hard internationally that's it thank you our next speaker is Dr. Yan Zheng Huang who is a senior fellow for Global Health at the Council on Foreign Relations at the Council on Foreign Relations Dr. Huang directs the Emerging Powers and Global Health Governance Roundtable Series he's also on the faculty at the John C. Whitehead School of Diplomacy and International Relations at Seton Hall University where he's an associate professor and the director for Global Health Studies in fact at Seton Hall he developed the first academic concentration among United States Professional Schools of International Affairs that explicitly addresses the security and foreign policy aspects of health issues Dr. Huang thank you Judy for that generous introduction and actually I'm going to follow up the Peter's presentation actually by focusing on the three questions that Catherine raised I think these are all very important timely questions the first question is what is the importance of multilateral relationships to the engagement of the BRICS on Global Health issues and I'm going to actually reformulate a little bit because I think it raises the question why the BRICS countries engage multilateral institutions in Global Health Governance I will and according to some of the international relations scholars such as Helen Milner there's essentially the three logics on why countries engage in multilateralism the first logic is essentially follows the so-called principle agent model the second is the logic of hegemonic self-bounding and the third one is the normative logic of appropriateness and I would like to add the fourth one that is a pragmatic logic of opportunism so let's let me go this four logics one by one the first is the principle agent model basically the countries decide to join or participate in this multilateralist institutions because this is like a choice for state to delegate its policy control or decision making to an international institution when this case a multilateral institution they do not get this policy control because they may one of the reasons is because they do not have the knowledge or the ability to make the decisions as well as that international agent and of course in order for that delegation to occur the principle in this case the BRICS countries they must benefit from reducing the transaction cost or resolving a collective action problems and in this case we found indeed that is the case for example international organizations such as WHO provides the knowledge or ability international health policy making and also the cost of reaching agreements balancing the wide range of interests and building consensus actually significantly reduced when engaged in a kind of stable rule governed environment associated with the deepening multilateralism I'm going to use the China's example when actually I'm going to use China as the critical case for answering those questions but I'm also going to use some comparative cases the HIV AIDS crisis the 2003 SARS episode highlighted the role of multilateral organizations such as WHO addressing global health challenges so that explains why following the 2003 outbreak of SARS China began to adopt a more participatory approach to health within the multilateral international organizations so this is the first logic the second logic is essentially I would say the hegemonic self binding logic basically those powerful states or countries with ambitions doesn't include South Africa but does include countries like Russia China, particularly China they may choose to pursue multilateralism as a means of demonstrating to others that they are not going to abuse their overwhelming influence they want to show the international society the responsible stakeholder that's basically the actually the thesis of David Lake publication 2009 and in fact again we found that in the case of China beginning in the early 1990s as part of his search for effective approach to allay the fear of the rapidly rising power rapidly rising power Beijing actually increasingly turned to multilateralism in its foreign policy and that changes of course evidence is in growing participation in multilateralist institutions at global regional even sub regional levels and China's ratification of FCTC the framework the framework control anybody with convention framework convention on tobacco control sorry despite the strong this political strength of its domestic tobacco industry you know China actually ratified FCTC while I think partly it wants to demonstrate its desire to be seen as a responsible emerging power the third logic is a normative logic of appropriateness you know basically a country a BRICS country for example may adopt multilateralism because of this powerful norms that designated it as the most appropriate or legitimate means of pursuing that country's foreign policy in fact yesterday I was actually teaching in my teaching of the global health governance class I was introducing the students all those the multi polar in the global health governance this is basically like an unstructured polarity situation with the proliferation of all the state non-state actors but if you compare those multilateral organizations with non-multilateral organizations active in global health governance you would find this landscape is basically dominated by multilateral organizations and institutions when you have a global health landscape dominated by the multilateralism what countries may feel the normative pressure to engage in that multilateralist structure so well that is the case probably in China's negotiation of the international health regulations into in the in 2005 for example even though China objected to the IHR on grounds of sovereignty especially the issue of Taiwan and also the issue of the surveillance reporting these concerns did not impede the successful revision of the IHR in part I think China was receptive to that normative dominating normative of multilateralism and finally this pragmatic logic of opportunism well this is very easy to understand my friend Jack Chou wrote this piece in foreign policy a year ago on China's billion dollar appetite basically talking about how China reap the benefit of multilateral participation with little financial contribution again when the global health China's participation in global fund is actually a perfect example it rate in nearly 1 billion US dollars in years from the global fund but it only make a nominal yearly contribution of 2 million dollars annually so that China actually recouped its spending according to Jack 60 times that is a very good deal so and that logic also applies to the case of India actually if you compare China with India in terms of contribution to global fund India is adopted even more pragmatic approach just to be fair to China so and also if you look at these two countries India and China in terms of their attitude toward status as a donor state and a recipient of global health the funding India and China they both seems to be they provide fairly open spaces for multilateral actions but as donors they prefer to engage in bilaterally even though they are becoming increasingly active donors in multilateral settings so this is the four logics and the second question how many times do I have because I don't want to be okay so the second question what are the priority relationships, organizations associations within that multilateral arena I think here we want to basically address two major concerns here the first concern is sovereignty because even though you have increasing interest in multilateralism but still that interest encountered this traditional resistance to shared sovereignty and the constrained policy autonomy that accompanies this collective decision making in a multilateral setting so that leads BRICS countries and Beijing in particular to pursue the multilateralism on a selective basis so there is actually sort of like a twin dynamics of receptivity and resistance the very receptive to programs the multilateral participation that are going to offer advantages for program expansion of reputation enhancement but in the meantime the resistance to those the other participation that is going to clash with its normative domestic structures its own health system capacities so this is the first concern the second concern is the issue of power and influence if you look at China's participation in multilateralism we found that Beijing seems to pursue multilateral cooperation most enthusiastically either with global multilateral settings where the dominance of the U.S. or its allies is weak or participation in regional settings where it is the most powerful participants for the former we found China's active that explain why China is active at the global level in WHO, at United Nations UNESCO and at the regional level RCM plus three cooperation, organization and East Asia Summit and in WHO we know that China's participation in the group with 191 other members actually offers a more attractive alternative because its agenda is less likely or less easily dominated by the U.S. and its allies and that same logic also explains why China sort of avoids participating actively in G8 because 2008 for example Japan has played a leading role in this process and this is the the two main concerns and of course that also I want to point it out because since that involves delegating the policy control you have to make sure of the agent that you delegate those policy control sort of does not you want to make sure they do promote the preferences of the principle in this case the BRICS countries you want avoid situation with the agency Slack so that creates a dilemma for the so called principle in this case BRICS and agent in this case multilateral organizations institution so in order to minimize that agency Slack the principle in this case BRICS must either appoint the agents whose preferences identical to their own or find ways to write a contract that motivates the agent or make sure that agents follow your policy preference and that in this case of China's participation in WHO seems that the problem is solved with the Chinese national serving as a WHO DG and also given that China's concern about the issue of Taiwan and on China's sovereignty issue it has signed a memo of understanding with WHO about Taiwan's participation so that problem is solved with the paved way for China's active participation and that participation if we compare to South Africa found that this domain is quite different South Africa especially the Zuma administration I'm not expert South Africa is just some of my premature observations seems to retreat from the leadership of continental issues and reach out to international partnerships such as BRICS IBSA that involves a tri-lateral development cooperation initiative involving countries such as South Africa, India and Brazil participating in WHO and UN AIDS and Gates Foundation also very actively like China but it has its priority of focuses but in addition to BRICS IBSA it also launched this FP with other countries such as Senegal, France, Indonesia and Thailand the FPGH initiatives by essential foreign policy and global health in September 2006 to promote the use of health as lanes for formulating foreign policy and so finally the question on what themes are topics is Brazil or this BRICS countries most engaged through multilateral channels again was the Catherine's no better than I this report on the key players seems to be the case that even though there's five emerging powers conceptually group together and even though they frequently do cooperate collaborate with each other on issues related to global health the each country seems to have approached global health governance issues differently Brazil we know so far is the most active but it has demonstrated leadership the global health rule rulemaking and a wide range of issues including negotiation of FCTC universal access to HIV AIDS medications pharmaceutical intellectual property rights and if you compare Brazil with China China is not as enthusiastic as Brazil in negotiating FCTC or issue of IHI was also not very enthusiastic but we know that they lobbied very hard to have a Hong Kong Chinese national seated as the director general of the WHO then this year they actually again supported McRae Chang to be the the only candidate for the election of the WHO DG but its relationship with WHO focuses more on cooperation of infectious disease prevention and and in contrast to Brazil and China's strong interest in using the WHO as a critical venue in global health governance Russians, India and maybe to a less extent South Africa appear to focus on the overseas health outreach more at the original level Russia's we know Judith is the expert that Russia's current engagement in global health revolves around health capacity building to fight against spread of infectious diseases such as HIV AIDS and polio in Central Asia and work closely with multilateral institutions such as World Bank and the UNDP and India despite its efforts to build health capacity in South Asia and Africa its participation in multilateral institutions does not appear to be a very high diplomatic priority it could be wrong but I want to point out it was very active in challenging some of the existing international health norms and rules for example the TRIPS agreement the FCTC it was a very played leading role in negotiating the FCTC it was more recently was also active in the agenda setting for the NCDs and noncommunicable diseases it succeeded actually to include for example the issue of mental health in the Moscow declaration and for South Africa the it was as Peter just presented it seems to have to be more interesting issue area of HIV AIDS diplomacy promoting innovative and wide access to affordable medical products, vaccines and health technologies through the channels multilateral channels such as UNAIDS, GAIDS and WHO so to quickly summarize despite there's some common grounds, partnerships, agreements the BRICS still approach global health in an individualistic more state centric manner so as such we can expect those emergent powers to lead through a more further fragmentation of global health institutions thank you now we turn to Julia Kulik for a discussion of Russia Julia is a senior researcher for the Global Health Diplomacy Program based at the Monk School of Global Affairs in Trinity College and at the Dalilana School of Public Health at the University of Toronto she has researched and written on G8 Health Governance for Africa G8 Global Health Governance and Canada's Global Health Strategy she's been involved in advisory projects for the WHO, PAHO and the Canadian Government Julia my name is Julia Kulik and I'm from the Global Health Diplomacy Program at the University of Toronto's Monk School of Global Affairs today I'm going to be speaking about Russia's leadership in governing global health particularly non-communicable diseases within the G8, G20 and the BRICS if there was ever a time that Russia needed to take leadership in governing global health it is now Russia has a great and growing health challenge that due to its constrained resources and increasing interconnectedness with the outside world it cannot solve alone its primary problem arises from the soaring burden of non-communicable diseases its crumbling post-Soviet health care system and its rapidly aging and declining population these national health problems match poorly the dominant emphasis of the major global health governance institutions which target infectious disease led by HIV AIDS malaria, tuberculosis and polio Russia is registering catastrophic levels of mortality subsequently creating major gaps between itself and the rest of the western world the main explanation for this gap is the surge of deaths due to NCDs particularly cardiovascular disease currently deaths from cardiovascular disease are three times higher in Russia than in western Europe although Russia may be rich in natural resources this wealth is not a substitute for human capital and its demographic decline will inevitably have a significant impact on its development and international security Russia does not stand alone as a net mortality society in fact three other G8 member countries Germany, Japan and Italy have also experienced rapid population decline the defining difference between Russia and these three countries is that the latter have sustained high quality systems of public health Russia on the other hand has yet to finance major public health campaigns that can mitigate the impact of these diseases this however is not the first time that Russia has faced devastating health challenges in fact Russia has endured problems with its health system since the collapse of the Soviet Union Russia has also had a long well documented battle with infectious disease particularly HIV AIDS but also measles tuberculosis and the avian influenza at the height of these challenges Russia was motivated by its domestic health problems to make contributions at the international level despite the growing burden of NCDs within Russia and within the countries it partners with in the G8, G20 and BRICS there has been almost no attention paid to the economic and social costs of these diseases in the global governance forums the G8 the primary forum in which Russia has displayed the clearest leadership in governing global health has failed to prioritize NCDs on its agenda or in its final summit documents although only minimal the G20 at its meeting in Seoul recognized the link between economic stability and addressing NCDs more recently at the BRICS health ministers meeting in China in 2011 the member countries paid particular attention to NCDs in a way that the other two forums have failed to do there has yet to be a significant response to NCDs within these respective global summits but there is hope that Russia following its role as host of the global ministerial meeting on NCDs in Moscow in April of 2011 will take the lead in collaboration with its BRICS partners the G8 and its member countries have been addressing global health since the late 1970s by first focusing on the challenges associated with hunger and malnutrition it made its first commitment in 1980 giving health and safety top priority when dealing with spent fuels and the disposal of nuclear waste the G8's focus from that time up until the 1996 Leon summit was minimal but the French hosted summit marked the turning point in the club's focus when it turned more globally oriented in the face of the introduction of diseases like Ebola and cholera in the developing world since 2000 the G8 took a major leap forward in governing global health across a number of dimensions there was an increase in deliberation the number of references to health in the club's official documents decision making the number of its health related collective commitments delivery the fulfillment of and compliance with those commitments and the development of global governance the creation of institutions dedicated to health at both the international and ministerial level of all G8 summits health was most prominent in St. Petersburg it was successful in producing a substantial report against the fight of infectious diseases which acknowledged the devastating effects that they have on individual well-being international economic development and progress on the UN millennium development goals also highlighted challenges associated with limited availability of vaccines and treatment lack of essential health care services and the migration and shortage of health care workers Russia displayed progressive leadership by extending an invitation to the members of the outreach five Brazil, China, India, Mexico and South Africa as well as the World Health Organization Russia was also successful in hosting a summit that produced the highest number of health related commitments in summit history and they themselves were implying with those commitments with a score of 80%. While the G8 has not proven to be the forum for Russia or any other member for that matter to address NCDs it has provided the clearest case of Russia's global health leadership Russia is set to host again in 2014 and it has the opportunity to continue its trend in producing successful and substantial achievements in health three very similar conditions have emerged that seem to replicate the environment in 2006 and Russia is instrumental in putting health on the agenda in St. Petersburg has announced that he will seek a presidential term come the election in March 2012 second Russia is faced with a health threat that will almost certainly cause severe demographic economic and security challenges this time from NCDs and third it has an opportunity to demonstrate international leadership by following up on its ministerial meeting on NCDs in Moscow in April of 2011 as part of the preparations for the UN high-level meeting the G20 unlike the G8 has in fact acknowledged the growing global burden of NCDs through the communique that was produced out of the Seoul summit in November 2010 this however was the only reference to NCDs and one of the only references to health in the summit's documents since its inception the G20 has yet to establish itself as a forum that fosters dialogue on issues like global health or as a forum that Russia has utilized for such issues the G20 comprised of the most powerful developed and emerging economies was first created at the finance minister's level in 1999 it emerged as the premier summit forum to respond to the onset of the global financial crisis in 2008 when the G8 failed to fully recognize the increasing capability of the emerging economies the G20's agenda quickly expanded after its first meeting in Washington to include issues like global market access sustainability and approaches to development beyond additional development assistance in its first four meetings the G20 made little or no reference to health in its official documents on a number of occasions the leaders reaffirmed the importance of and their commitment to meeting the UN millennium development goals half of which are dedicated to improving the lives of people around the world the Washington communique also acknowledged the importance of addressing issues like disease and the importance of promoting economic development attention to health was again minimal at the summit in Toronto in June 2010 however the G20 did briefly mention the importance of strengthening social safety nets like public health care at Seoul later that year in addition to recognizing the barriers that NCDs present in improving productivity and skills development the leaders acknowledged a disproportionate impact of the financial crisis on low income countries and its role in selling progress to the United States at the most recent summit in Cannes in November 2011 there was hope that health and NCDs in particular would find its way onto the agenda first as a reiteration of the club's commitment at Seoul but also building on the Russian hosted ministerial meeting in April and the UN high level meeting in September the Cannes summit did neither although the G20 has yet to address health in a major way it has many elements that may lend itself well to becoming the next major forum to do so its reach extends beyond those networks accessible to the G8 and it's not limited by bureaucracy in the same way that formal institutions are which may allow it to act much faster especially in times of crisis it represents 85% of the world's economy and 2 thirds of the world's population which gives it the representative legitimacy that the G8 is often criticized for lacking although the the G20 can be a key forum to respond to non-communicable diseases as it has emphasized the interconnectedness of economic development and health issues from very early on NCDs represent a major economic burden to every G20 member within the club and Russia is no exception although Cannes did not advance a response to the prevention and control of NCDs there is hope that Russia will provide leadership as host for the very first time in 2013 Russia was the first country to host the BRIC summit at the leaders level in 2009 however it did not seem to be the forum in which Russia would choose to govern global health the forum arose as a vehicle for the major emerging market economies like BRIC's members to become more equal players in global affairs with a goal to improve the global economy the first two summits in Russia and Brazil made no direct mention to health there were however references made to the health related issues of agriculture, development and poverty at the third leaders meeting in China of April in April of 2011 the BRIC's leaders now with South Africa made their first ever health commitment it was a specific commitment to strengthen dialogue and cooperation in social protection which included public health and the fight against HIV AIDS here they also committed to hosting the meeting of their health ministers who would gather a few months later this meeting seemed to be an appropriate forum in which BRIC's country could discuss non-communicable diseases they acknowledged the challenges faced by all BRIC's nations due to the increasing rates of NCDs and the need to strengthen health systems and remove impediments to access to medicines treatment and technology at their meeting BRIC's health minister has agreed to meet again in conjunction with the UN high level meeting on NCDs in New York and to establish a technical working group despite a slow start the BRIC summit has arisen as a key forum to address global health and to address non-communicable diseases in a way no official documents were released out of the most recent summit in Cannes halting momentum on the commitments made in Seoul the BRICS in Beijing and the UN in New York it is unclear how Russia will lead within BRICS as it has not yet used it as a forum to govern global health but it is set to host again in 2014 and there is hope that Russia will use its role as host of all three summits within the next few years to continue the momentum gained from its role as host of the ministerial meeting in April in Moscow in April of 2011 Russia used the UN high level meeting process to assume leadership in addressing NCDs when it hosted the global ministerial meeting in the lead up to the high level meeting in New York Russia collaborated with 90 ministers and 155 delegates to acknowledge the socioeconomic impact of these diseases discuss international strategies on prevention and control and advocate for a framework for strengthening health systems the Moscow declaration the meeting's official concluding document and 48 commitments which focus mainly on integrating health into all sectors strengthening health systems and engaging in partnerships with private and civil society actors Russia's role as host of the ministerial meeting signaled that it might continue to dedicate itself for better NCD governance through global symmetry however come the UN high level meeting in September there was no head of government or state representative from Russia in attendance there were also a number of issues that were left inadequately addressed absent from the agenda where any specific targets and timelines which proved to be an important catalyst in promoting global action and compliance in other forums like the G8 and the G20 the declaration at the high level meeting also failed to include any references to trips flexibilities which would allow greater access to low cost medicines for developing countries also absent was the commitment by leaders to invest any new money into combating NCDs either through prevention or treatment or solid mechanisms for accounting and follow-up thus gaps in leadership and governance were still evident as the UN high level meeting came to a close Russia and its BRICS allies now have an opportunity to take the lead particularly since the disease burden only continues to get worse by now the global health community is familiar with the statistics affirming that NCDs account for 65% of deaths worldwide 80% of which occur in low and middle countries Russia is clearly not alone in its struggle with these diseases in fact some of the most staggering figures come from its partners within BRICS who risk digressing from emerging economy status if they are not addressed in China NCDs account for 85% of deaths well above the average for the rest of the world China now has the largest population of people suffering from diabetes and its rates are increasing faster than those in the United States and Europe by 2014 it is suggested that China will have more people suffering from Alzheimer's than anywhere else part of this trend can be explained by the country's rapidly aging population but China has also failed to address risk factors like smoking, environmental degradation, use of illegal substances and physical inactivity China like Russia has long overlooked its public health care system in pursuit of economic growth which has subsequently caused rapid declines in the health of its population in India the story is similar it has high rates of diabetes and increasing rates of cardiovascular disease which are striking people in the most productive years of their life high rates of tobacco use and obesity as well as occupational hazards and poor living conditions have contributed to the rising burden of these diseases India's health care system has made improvements in dealing with infectious disease as well as maternal and child health but health promotion and chronic disease prevention have yet to be properly addressed in Brazil 72% of deaths are due to NCDs with neuropsychiatric disorders being the largest contributor unhealthy diet and physical inactivity are contributing to high rates of diabetes and hypertension however the Brazil example is slightly more optimistic the successful implementation of anti-smoking and NCD prevention policies has meant that NCD mortality has been decreasing by a rate of 1-8% per year Brazil has also invested in the expansion of primary health care which integrates health into all sectors and includes individuals and communities in health promotion the growing global burden of non-communicable diseases threatens the strong economic growth experienced by BRICS countries in recent years the ongoing costs associated with loss of productivity, disease surveillance and the production and distribution of medicines will inevitably lead to higher levels of inequality and poverty however the emerging economies of Brazil, Russia, India, China and Africa have offered innovative solutions for their domestic health problems that they can use to provide leadership in governing global health in the 21st century BRICS countries have become increasingly involved and influential at the center of global health governance through their contribution to the G8 as the outreach 5, the G20 and the BRICS summits these countries have moved beyond second tier status within the G8 to full and equal members of the G20 and founding members of BRICS the emerging economies now have valuable lessons for the global community for governing NCDs Brazil has a well known successful HIV AIDS prevention care and treatment program which provides a leading example of an approach to epidemics by a middle income country fraught by social inequality its program for universal access to treatment has caused a dramatic decrease in morbidity and mortality from AIDS India is known to have a strong pharmaceutical industry that has produced and provided low cost treatments to prevent epidemics in countries in Africa the serum institute of India agreed to reduce the price of a vaccine that protects against five fatal diseases and distributed to some of the poorest countries in the world through the global alliance for vaccines and immunization South Africa has become the center of research and development, epidemiology and pharmaceutical production within Africa it has successfully battled the pharmaceutical industry to circumvent patent protections and allow for access to low cost medicines China is likely to expand its domestic production of antiretrovirals and is considered a promising leader in addressing health challenges within Africa since the shocking outbreak of the severe acute respiratory syndrome the Chinese government has invested significant resources in improving its ability to control infectious disease China has created monitoring and reporting mechanisms at the district level to ensure that mistakes made during SARS aren't repeated the Chinese government has also committed to giving large rural populations priority and access to low cost care which is supported by its scientific capacity to produce innovative solutions Russia has already demonstrated its willingness to lead in global health governance particularly through its role as host of the 2006 St. Petersburg summit and the 2011 ministerial meeting on NCDs in the coming years as Russia prepares to host a series of summits the APEC in 2012 the G20 in 2013 and the G8 in bricks in 2014 it can use its partnerships with the emerging economies to take action against the NCDs that burden their countries and the rest of the world the limited participation of leaders at the UN high level meeting and the absence of ambitious results mean Russia must look elsewhere to mobilize global health governance on behalf of its core domestic concerns it can do so by constructing a strategy to bring NCDs onto the agenda of the plurilateral summit to host over the next few years in this strategy its bricks partners could serve as core allies as China, Brazil and India and soon South Africa will face the same challenges of NCDs as Russia does although there are many differences among the big four NCDs of cancer, diabetes, cardiovascular disease and chronic respiratory disease they share a similar property with HIV AIDS in that they are both chronic the bricks countries have all struggled with the onset and spread of HIV AIDS in recent years which has meant a scale up of their health systems to treat this disease Brazil has led the bricks countries in its battle with pharmaceutical companies to obtain low cost access to antiretrovirals to fight against HIV AIDS which will be important moving forward on NCDs as access to medicines and treatment is an essential component of disease control and prevention another key element that went into the scaling up of health care systems in response to HIV AIDS is the continuity of care both HIV AIDS and NCDs require the coordination of services from the primary care to the tertiary level in a number of years sustaining a continuous relationship with health care professionals over time can lead to fewer hospitalizations by focusing on education and prevention and identifying problems early on the strengthening of health care systems to respond to the spread of HIV AIDS also focused on community and family based care this approach to health care emphasizes greater coordination between pediatric and adult care family medical records and family member outreach community and family based care approaches can be effective in managing risk factors within families and recognizing the disproportionate impact of NCDs on certain communities together with the lessons learned from the recent struggle with infectious disease and their desire to demonstrate leadership within global cemetery Russia in partnership with its bricks allies can take the lead in producing innovative solutions and strategies combating for combating NCDs with the upcoming summit hosted by Russia there is an opportunity for Russia to prove itself capable of this role as social and economic costs continue to rise due to these diseases thank you thanks very much Julia we have a little over 15 minutes in this session remaining for questions and discussions so I would like to open the floor and as you make a question or comment could you please identify yourself in your affiliation there's a microphone coming your way hi good morning thank you very much very interesting presentations my name is David Greeley I'm with a international development health organization called FHI 360 based here in Washington North Carolina a lot of you and I'm sure the panelists for on indium Brazil will also say the same thing in terms of the success that the countries have had in terms of increasing access to low cost medicines through trips and various work with the WTO and Intellectual Property as these countries are emerging and want to demonstrate that they're part of the first world if you will where is the investments in R&D for new medicines vaccines and diagnostics again sometimes for the infectious diseases but elsewhere as well that would show a leadership role that these countries can provide going forward July July 2011 and this is the issue of the access to medicine through the Beijing Declaration Health Ministers from brief countries plagued to transfer the technologies to make sure the vaccines the medical technologies the cooperation in the R&D research and development medical products in fact I noticed that Russia recently announced the plans to make Russia a significant player in this field as well obviously that implies more significant funding in that area and that has been very active in that field as well although we have to point out that China in this case is not they always they have problems producing their own innovative patented drugs in the GEO they have hundreds of thousands of so-called new drug applications to the SFDA but probably more than 99% just the changing ingredients is not real innovative new drugs and for South Africa they also they have built a the beefed up this research and development capacity with the establishment of that program called I forgot the name of the for the research and development also I think there's some strong interest there although I'm not sure that whether this is going to be done on an individual basis or on a partnership based on their partnerships what I have seen so far is still this is more state-centric individualistic approach I found that in recent years private foundations in particular have focused on dedicating resources to resource and development just a quick comment because I think it's not necessarily that the resources aren't there but that there needs to be some sort of accountability mechanism to ensure that the resources are dedicated to the appropriate initiatives and diseases to ensure that diseases aren't excluded so that's all I would add South Africa's gross expenditure on research and development is way below 1% of GDP so we're not doing well and but comparatively speaking we're the champion in Africa of that I think it would a pooling of resources not only money amongst the BRICS countries would be the way to go South Africa has a stand of experience in legal battles around both domestically as well as multilaterally access to medications and looking at the structural dynamics there India is spectacular in manufacturing Brazil in terms of also manufacturing and distributing and policymaking so I think a pooling of resources not only money might be an interesting area for BRICS multilaterally as a body to explore the pool will be towards infectious diseases at the moment I think for the foreseeable future so I think within BRICS there should probably also be some priority placed on the NCDs given the change in demographic certainly I think something very few people in South Africa about is the lower mortality levels that we're experiencing I think we're also going to see a significantly aging population really soon older people on ARVs so there's another storm coming I forgot to actually talk about India actually this is the important actor I also said that this is still pretty much stay centric probably India's perception because in the case of India it has a very robust private sector in fact the Indian Health Minister in the Beijing meeting pointed out the difficulties of transferring technologies for making vaccines and medical products is that it cannot make decisions all by itself this is not just like state behavior because it has the decisions being made by the private sector actually pointed out that's an obstacle for further cooperation in this area so one last thing I think it would also be worthwhile if BRICS can be used as a forum to look at technology transfer protocols around pharmaceuticals in particular some kind of patent bank I don't know there was something else but I can't remember now thank you very much my name is Hernan Rosenberg and I'm formerly retired from Pan American Health but I'm also one of the founding fathers of the Global Fund but I can't talk now without food notes because I'm independent so I think there's some important topics that were issued but I think we should develop a little more on those the issue of governance the important part of the Global Fund is the first hybrid in other words has a governmental structure that both includes governments and the civil society and sometimes the difference between honeymoon and rape is discussable and in this case it has evolved both ways and I think that this is very important because how do you what has not been resolved is the issue where the government is the government who is the civil society and I think it's particularly important what your main business Peter the difference between the participation of the civil society involved with the AIDS business to those with malaria and TB is phenomenal I mean there's no such thing as representation of the civil society of the other two which represent probably most of the poor people of the world I mean not that it's very democratic but I think that this is a key issue that has not been dealt with properly that's point number one point number two I wanted to make is that the way we have tended to solve these issues is with the snowball effect in other words we're not satisfied with something working we add a new institution but we don't disengage the previous one so then this institution is spending a lot of time fighting for territory rather than doing whatever they're supposed to be doing so I think that's another point that I wanted to raise and the third point that I think is important to keep in mind here is that the current problems faced by say the global fund stem precisely from this issue of mandates that sometimes are not thought over to the end so for example the fact that some people are probably abusing the leeway that is giving to some civil society institutions this is true but this was foreseen by some of us but not necessarily taken care of and I think that at the level of the global and at the global governance of public health this becomes a very big issue I happen to agree with most of what the the foundations are pushing and as some foundations have a bigger budget than WTO but what if I didn't agree with them what can I do I mean I think foundations whoever donates the money is entitled to do whatever they want but is that the way to run global business so I think that those are points that I wanted to highlight in this one thank you we might be more efficient if we collect a couple of other questions before we go back to the speakers thank you very good presentations thank you very much is there any consideration of what Cuba is doing in cooperation with Cuba I know last week I think it was they signed an agreement with China for the production of medicines using biotech research from both countries and looking towards marketing elsewhere as well as within their own countries and a lot of the things that Julia raised at the end about things that need to be done to improve the health systems dealing with the NCDs are things that Cuba has done of course their system has deteriorated considerably and there is a lack of money but there are a lot of lessons that can be learned from that experience so I'm just wondering if there is any consideration I think it's on, thanks my name is Brad Taito with Global Health Strategies we're an advocacy consultancy and we're spending a lot of time these days focused on engaging the BRICS more in global health issues and as everyone referred to in their session the BRICS are continuing to wrestle with a huge number of domestic health challenges and at the same time we're looking to them more and more and asking them to take on a greater leadership role in global health both in terms of the dialogue but also to invest increased resources in global health and assist poorer countries because the traditional donors are starting to cut back with the global financial crisis and I was just interested in hearing everyone's thoughts on how do you strike the balance there because coming from an advocacy perspective in South Africa there's a lot of work going on to get the government to help its own people that's the advocacy that you want to do to get South Africa to take a better leadership role globally and same thing with China and Russia and with India and Brazil how will the governments be able to strike that balance and can they? Hi my name is Mike Hage Dudley I'm a student at Washington University in St. Louis and I just got back from some time with the American Chamber of Commerce in China and my question is that over the past few years we've seen that at times China's reluctance and lack of transparency has global health such as SARS and more recently avian influenza how can we use the BRIC as a form to leverage China not just to participate in a multilateral setting but to look inwardly and understand that its internal health problems have ramifications particularly in Asia and the rest of the world We have a pretty rich menu of questions here ranging from institutional governance to the role of Cuba to the relationship between these countries domestic health challenges and their global behavior and then questions about the use of the BRIC's format as a tool to influence China's behavior so why don't we just take responses in the order that the panelists first spoke Peter? In terms of representation of bugs malaria, tuberculosis, HIV and AIDS global fund we know global fund is supposed to look after all three all the pressure is on HIV and AIDS certainly in South Africa there's no conversation about malaria although it's a larger killer on the African continent than the other epidemics that said the link between tuberculosis and HIV and AIDS has now been written quite explicitly into the latest national strategic plan that was announced last week on the 1st of December in South Africa and it will now probably be as hard to divorce TB from HIV and AIDS as it was during the Mbeki era to divorce HIV from AIDS so certainly in the South African case TB and HIV seems at the policy document level at least now have coalesced it's viewed as a single not as a single epidemic but it comes very close to that so the terrible twins have managed malaria complete silence on that it's a tacit epidemic I would agree that global fund should be making when it makes a commitment it must be a multi-generational commitment there's a lot of anger I think in the developing world around 11 and the reduction in funds that are made available from the global north developed countries again instead of the global south moping about this maybe we can use that to create a movement for social justice rather than only HIV and AIDS specific screaming people are sick of AIDS they don't want to talk about it there's no good news it's not a win situation so maybe maybe some of that energy can be harnessed and channeled somewhere constructively but you're absolutely right it does raise the issue of accountability in governing the global fund who's responsible for the global fund it's very easy in the global south to just put your fist in the air and scream about it and that's what the global south is doing in terms of Cuba as an example South Africa loves Cuba for many reasons and Cuba is used as an example in terms of health personnel and capacity and training in particular during the previous health minister's disastrous tenure she shifted the tertiary education there were talks anything ever came of it of reducing the amount of years that you need to study to become a medical doctor basing it on a Cuban model and in South Africa since 1994 has been importing Cuban medical personnel with Cuban health diplomacy initiative that's worked extremely well I think for both countries so it's been going well on that front but not in terms of health system strengthening in terms of any sustainable initiative and then Brad the question around domestic and global tension there will only be I think the irony in South Africa is that the governance push will be towards being seen to do the right thing at the global level rather than any great imperative to provide these services at the domestic level for the simple reason that health is number 18 or number 16 it's in the double digits in terms of what the South African electorate wants to talk about and what's important to them when they vote jobs comes first other issues are first HIV and AIDS and health issues really tumble down so health is useful multilaterally globally but not so much domestically I'm just going to address some of the questions given we have here the first is about the issue of civil society participation the first question is the participation of civil society international organizations multilateral institutions well actually my presenting a focus on the state actors especially as far as the BRICS is concerned is the reason because in my opinion or in my opinion I would say the participation of civil society of the BRICS country still not very prominent you know that you know I'm not expert on Brazil and obviously it has lots of NGOs civil society seems to be very robust but in China one of the reasons lack of participation of civil society international health cooperation is the lack of civil society participation itself in the health arena you know we saw that this absence of civil society fighting the H1N1 SARS totally absent there might be some health promoting NGOs in HIV AIDS prevention control but still they're very weak, they're very small in size and in number so how could you expect them to participate internationally so compared to the developed countries they have a very robust society participation in the AIDS foundation this is itself like a game changer but we don't see the counter parts in the BRICS the second question is on the BRICS the question on the how to balance the domestic health challenges and international health participation well that is of course a concern here but so far my impression that this has not prevented Russia making more contributions significant contributions increasingly significant contributions to global health Russia is already determined to be a donor country and South Africa recently established is owing sort of like USAID USAID is owing version of developing the agency for international cooperation obviously they want to expand this role in international health cooperation and China is still very hesitating in chipping more international health cooperation but that is not because of the international not because of internal health challenges it's basically all those internal political logic and foreign policy logic for example the conspiracy theory sort of prevents China from showing more responsibilities in international health but over time I see this factor will increase in fact I saw very recently there's the criticism the netizens of the China donating these school buses to Macedonia there's a very strong criticism based on we haven't even addressed our own problems our own case even don't have access to the school bus why did you donate the school bus to Macedonia that's ridiculous this factor is going to become more prominent concerns in the decision making on international health cooperation finally this issue of lack of transparency reluctance of China to participate I think recently I published a piece in Foreign Affairs China's health crisis I pointed out this issue indeed exists but largely that is because of China's the own governance problems we could attribute to its political systems the civil state societal relationships bureaucratic fragmentation all those internal problems but that said international factors could play an important role we saw that in SARS WHO could indeed play actually a significant role simply by naming and shaming but I probably shouldn't say that I wish that the WHO could use that same instrument during the 2009 H1A1 crisis thank you just to address the first question I don't want to repeat myself too much about the issue of accountability but within the global summits we've seen an increasing role of civil society particularly at the Muskoka summit when there was the introduction of the maternal and child health initiative which was heavily influenced by religious based civil society organizations and then also the role of private foundations and I think there is a concern that private entities have too much control over the global public good of health and because civil society and private institutions aren't as transparent as governments are then there needs to be some sort of way to ensure that their interests are kept in check and then just to follow up on the balance between domestic health challenges and their role globally it's something that we've looked at a lot within the GA research group because we find that national health problems actually promote countries involvement in governing global health and leading in particular and I think although they may be constrained by resources they have the ability to influence agenda setting for example and their role as hosts I think plays a big part in contributing to that. Thanks very much. We'll now take a short break and reconvene at 11 o'clock for the next panel on regional interactions and regional cooperation. Let me thank you for your attention and for your excellent and insightful questions and most of all thank our panelists for a fascinating discussion this morning.