the case for a global health strategy for canada · whether there is a resulting need for an...

TheCaseforaGlobalHealthStrategy

forCanadaJohnKirton,JamesOrbinskiandJenileeGuebert

GlobalHealthDiplomacyProgram,MunkCentreforInternationalStudies

UniversityofToronto

SubmittedonMarch31,2010

PreparedfortheStrategicPolicyBranchintheInternationalAffairsDirectorateof

HealthCanada

madelinekoch

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The views expressed in this report are those of the authors and do not represent those of Health Canada or the Government of Canada.

TheCaseforaGlobalHealthStrategy

forCanadaJohnKirton,JamesOrbinskiandJenileeGuebert1

GlobalHealthDiplomacyProgram,MunkCentreforInternationalStudies,

UniversityofTorontoMarch31,2010

PreparedfortheStrategicPolicyBranchintheInternationalAffairsDirectorateof

HealthCanada

AbstractHealthisincreasinglyrecognizedasaglobalaswellasadomesticissue.Thisstudythus examines the case for developing a Canadian global health strategy. IthighlightsthemajorstrandsofglobalhealthstrategiesalreadyinplaceinCanada,theprimaryCanadianplayers in the field and themotivation forpast actions. Itexamines the impact of global health trends onCanadians, and indicateswhereCanadahasledandwhereitwillbeimportantlyinvolvedinthefuture.ItassesseswhetherthereisaresultingneedforanoverallglobalhealthstrategyforCanada,and specifies the benefits, costs, risks and risk‐mitigation measures that couldarise in developing such a strategy. It suggests how a Canadian global healthstrategymightbedesignedandwhatitmightcontain.

Canadacouldderivemanybenefitsfromaglobalhealthstrategy.Therearealsocosts and risks that could arise. However, a properly prepared, designed andexecuted global health strategy would lead to better health both within andoutsideCanada.Aglobalhealthstrategywouldhelptoimprovetheeffectivenessand efficiency of the various actors and activities operating in global health. Itwouldprovideaclear focusforCanada’sglobalhealthgoals,wouldmobilizeandconcentratescarcehumanandmonetaryresources,andwouldprovideaplanforhowtoreachCanada’sglobalhealthobjectives.Withoutastrategy,Canadarisksfalling behind those consequential countries that already have or are likely todevelopastrategyanditwillbemoredifficultforCanadatocompeteandpartnereffectivelywithleadersinthefield.

1 The authors gratefully acknowledge the research assistance of Caroline Bracht, Robin Lennox,JuliaKulikandSophieLanglois.

Kirton,OrbinskiandGuebert:TheCaseforaGlobalHealthStrategyforCanada 3

AbouttheAuthors

JohnKirtonJohnKirtonisco‐directoroftheGlobalHealthDiplomacyProgram,directoroftheG8ResearchGroupandco‐directoroftheG20ResearchGroupbasedattheMunkCentre for International Studies at Trinity College, and a professor of politicalscience at the University of Toronto. He has advised the World HealthOrganizationandtheCanadianandRussiangovernments,andhaswrittenwidelyonglobalhealthgovernanceandG7/8andG20summitry.Hismostrecentbooksinclude Innovation in Global Health Governance: Critical Cases (co‐edited withAndrewF.Cooper,Ashgate,2009),GoverningGlobalHealth:Challenge,Response,Innovation (co‐edited with Andrew F. Cooper, Ashgate, 2007) and CanadianForeignPolicy inaChangingWorld(ThomsonNelson,2007).He isco‐authorof,amongotherarticles,“MakingG8LeadersDeliver:AnAnalysisofComplianceandHealth Commitments, 1996–2006,” Bulletin of the World Health Organization(March2007).Kirton is also co‐editorof threebook seriespublishedbyAshgatePublishing and the editor of Ashgate’s five‐volume Library of Essays in GlobalGovernance,includingavolumeonglobalhealthpublishedin2009.

JamesOrbinskiJames Orbinski is co‐director of the Global Health Diplomacy Program at theMunkCentreforInternationalStudiesatTrinityCollege,andaprofessorofbothmedicine and political science at the University of Toronto. He also practisesclinical medicine at St. Michael’s Hospital. As president of Médecins SansFrontières(MSF)from1998to2001,helauncheditsAccesstoEssentialMedicinesCampaign and accepted the Nobel Peace Prize awarded to MSF. He led MSFmissions inZaire andRwandaand servedasmedical coordinator inAfghanistanandSomalia.Heco‐chairedMSF’sNeglectedDiseasesWorkingGroup,whichledto the Drugs for Neglected Diseases Initiative. He is co‐founder of DignitasInternational and has served on the boards of the Global Alliance for TBDrugDevelopment,theStephenLewisFoundationandCanadianDoctorsforMedicare.HeisafoundingmemberoftheeditorialboardsofOpenMedicineandConflictandHealth.OrbinskiisamemberoftheClimateChangeandHealthCouncilandtheWorld Economic Forum’s Global Agenda Council on Health Care Systems andCooperation. He is the author of the award‐winning An Imperfect Offering:Humanitarianisminthe21stCentury(Doubleday,2008)andwasthesubjectofthe2007documentaryTriage:Dr.JamesOrbinski’sHumanitarianDilemma.


JenileeGuebertJenilee Guebert is the director of research for the Global Health DiplomacyProgramaswellasfortheG8ResearchGroupandtheG20ResearchGroup,basedattheMunkCentreforInternationalStudiesinTrinityCollegeattheUniversityofToronto.Herworkembracesglobalhealthgovernance,theclimatechange–healthconnection, environment’s lessons for global health governance, G8 healthdiplomacy and compliance, and Canadian and NAFTA responses to the H1N1outbreak. Recent works include “Looking to the Environment for Lessons forGlobalHealthDiplomacy,”“Canada’sG8LeadershiponGlobalHealth,”“BringingHealthintotheClimateChangeRegime,”and“MovingForwardonGlobalHealthDiplomacy: Implementing G8 and APEC Commitments.” She has had previousexperienceworkingfortheCalgaryHealthRegion,StatisticsCanadaandElectionsOntario. Shehasbeenamemberof the field teamsof theG8andG20ResearchGroupsonsiteatseveralG8andG20summitsandhasbeeninvolvedinanumberofworkshopsandconferences focusedonglobalhealthandCanada’syearasG8hostin2010.


TableofContentsExecutiveSummary 6 Introduction 8 CanadianPrinciplesforGlobalHealth 10 GlobalHealthStrategiesandCanada 11

CurrentHealthStrategiesinCanada 11 MajorPlayersinGlobalHealthinCanada 12 MotivationforCanadianActiononGlobalHealth 12 TheNeedforaStrategyNow 13 Benefits,CostsandRisksofaStrategy 15 PotentialAreasforActionandInitiative 18

ComponentsofaCanadianGlobalHealthStrategy 20 CanadianPriorities 20 GlobalDemands 20 Canada’sComparativeAdvantage 21 Canada’sPartners 22

References 26 AppendixA: Canada’sGlobalHealthContributions 34 AppendixB: GlobalHealthActorsinCanada 36 AppendixC: Canada’sRoleinRegionalandInternational

Health‐RelatedOrganizations 37 AppendixD: CanadiansAffectedbyDiseases 38 AppendixE: CanadianPublicOpiniononHealthIssues 39 AppendixF: Benefits,CostsandRisksofaGlobalHealthStrategy

forCanada 41 AppendixG: Canada’sFreeTradeAgreements 43 AppendixH: EffectsofClimateChangeonHumanHealthIdentifiedbythe

IntergovernmentalPanelonClimateChange 44 AppendixI: ComparisonofNationalGlobalHealthStrategies 45 AppendixJ: StepsforCreatingaCanadianGlobalHealthStrategy 48 AppendixK: ResearchMethodology 49


ExecutiveSummaryHealthis increasinglyaglobalissue.Nationalhealthchallengesoftenhaveglobalsourcesandtheirsolutionsthusrequireglobalresponses.Canadaanditscitizensarevulnerabletohealthchallengesfromabroad.AndCanadiansarecommittedtoachievingbetterhealthoutcomesathomeandabroadforall.

FordecadesCanadahasplayedanactiveroleinglobalhealth.Ithasdevelopedseveral health strategies to address a variety of health challenges. It hasworkedwithgovernments,non‐governmentalorganizations,businessesandacademicstoimprovehealthoutcomes.Canadahasparticipatedinnumerousglobalforumstocraft global health initiatives and commitments. And Canada has committedsignificant resources to improve thehealth and safetyofCanadians and citizensabroad.

In the current climate Canada needs a global health strategy. There is anincreasingnumberofhealth threats aswell asgreatermobilityof individuals andhealthworkers.Resourcesarelimitedandneedtobeusedinthemosteffectiveandefficient manner possible. Research on global health challenges, trends andapproaches has proliferated in recent decades and it is now understood thatcoordinated, global approaches are necessary for the effective governance ofhealth.Canadaishostingthreeinternationalsummitsin2010whereitwillhaveanopportunity to lead on global health. There has been a push for strongeraccountability in the international system to ensure that countries, includingCanada, are keeping their global health commitments. Other countries havealready developed global health strategies, which have proven useful formobilizingresources,settingclearprioritiesandimprovinginternalcollaboration,coordination,efficiencyandeffectiveness.Andwhilegovernmentshavecontinuedtofocusattentionandresourcesonglobalhealthchallenges,thenumberofpeopleinflictedwithdiseasehascontinuedtoincreaseandthusanadequateglobalhealthresponseisstillrequired.

ManybenefitswouldarisefromdevelopingaCanadianglobalhealthstrategy.It would lead to improved health in Canada and globally. It would provideCanadianglobalhealthactorswithabetterunderstandingof thehealthactivitiescurrently underway. It would provide greater transparency regarding Canada’sglobal health priorities and objectives. It would help Canada focus on whichactivities should be enhanced, eliminated or reformed in resource‐constrainedtimes. It would support collaboration, coordination and cooperation among themany departments, agencies and other actors that deal with health in Canada,fostering a more coherent and cost‐effective approach. It would strengthennationalsecurityand internationalpartnerships.ItwouldmobilizemoreresourcesbygivingCanadianandinternationalactorsclear,compellingprioritiestosupporton a broad scale. It would ensure that Canada could respond effectively to theunexpectedhealthcrisesthatwillinevitablyarise.ItwouldofferanopportunityforCanadians and others to cultivate a global heath regime that supportsCanada’s


interests and values. It would advance Canada’s foreign policy and internationaleconomicdevelopmentgoals.

Several costs also could arise from a Canadian global health strategy. It willtake time and resources to develop a global heath strategy. It could generateconflicts over whether there should be a strategy, what it should contain, whoshould be involved and who should lead. It could divert attention away fromproblemsthatalsorequireattention.Itcouldrequireamodificationofmandatesoroperatingproceduresforcertainactors. Itcouldcomplicaterelationshipsbetweendifferentlevelsofgovernment,departmentsorotheractors.

Riskscouldalsoariseifthestrategyisnotdevelopedproperly.Ifthestrategyistoo inflexible,general,under‐ambitious orover‐ambitious, it could be ineffective.Satisficing,logrollingandaccountabilitydemandscouldallhavepotentialnegativeaffectsaswell.However,severalmeasurescouldmitigatethesecostsandrisks.

Canada’sglobalhealthstrategycould focusonthehealth‐relatedMillenniumDevelopment Goals (MDGs), the global health issues that have already had asignificant impactonCanadians athome, the international issuesor institutionswhereCanadaplaysasignificantrole,theglobalhealthcommitmentsthatCanadahas already made but not yet met, niche areas where Canada has medical andresearch expertise, neglected topics where Canada could carve out a leadershiprole,orhealthissuesthatarecriticalincountrieswhereCanadahasakeyforeignpolicy or development interest. Any one or combination of these factors couldformthecoreofaCanadianglobalhealthstrategy.

Available evidence suggests that Canada should develop a global healthstrategyandthatthestrategyshouldbecommencedassoonaspossible.


IntroductionThereisanincreasingrangeofhealthissuesthattranscendnationalboundariesandrequireactionon theglobal forces thatdetermine thehealthof people.Thebroadpolitical, social and economic implications of health issues have brought morediplomats into the health arena andmore public health experts into the world ofdiplomacy.Simpleclassificationsofpolicyandpolitics—domesticandforeign,hardandsoft,orhighandlow—nolongerapply.

—IlonaKickbusch,GaudenzSilberschmidtandPauloBuss

Since the 2000G8OkinawaSummit, therehasbeena significant shift in globalheath.Thenumberofactorsinthefieldhasgrownexponentially(Orbinski2007).International health commitments have expanded in number and ambition(Guebert 2009; Sridhar 2009). Financial pledges to global health have risensubstantially (see Appendix A; Fallon and Gayle 2010). Global health hasincreasinglybeenapriorityforinternationaldevelopmentandakeycomponentofforeignpolicy,security,tradeandtheenvironment.

At the same time, countries recognize that challenges to public health andsafety at home often have global sources and that their solutions thus requireglobal responses. The recent outbreaks of severe acute respiratory syndrome(SARS) and the H5N1 and H1N1 influenza viruses have dramatically shownCanadians and others how countries and societies are now integrallyinterdependent(Sridhar2009;Fidler2004).Canadaanditscitizensarevulnerableat home to diseases, pathogens, toxic contaminants and the effects of climatechange that cross borders via the atmosphere, humans, animals, wildlife andimported food. Food safety in Canada depends partially on the regulatorystructures of other countries (as in the case ofmelamine in Chinese baby foodexports, the emergence and spread of bovine spongiform encephalopathy [BSE],andtheuseornon‐useofbovinegrowthhormoneinbeef).Theeffectsofclimatechange in Canada are largely due to human activities outside Canada. The 2.5millionCanadianswho live abroad, the 50millionCanadianswho travel abroadand the 250,000 citizens who migrate to Canada every year are vulnerable toabundant health risks beyondCanada’s borders, some ofwhich they bringwiththem when they return (Cannon 2010; Canada, Department of Citizenship andImmigration2009).

Canada’s role in global health has grown. Pathogens and health “problemswithout passports” have diminished the ability of governments to protect theirpeoplebyerectingdefencesattheirborders.ThisisespeciallythecaseforCanada,whichhasoneofthelongestlandbordersandthelongestcoastlineintheworld.Health issues must thus be dealt with at their source, anywhere in the world,beforediseasecanerupt,spreadandintrudeintoCanadians’homes.Atthesametime, Canada remains committed to improving the health of all people,particularlythepoorestandmostvulnerable,intheworldoutside.


Various actors involved in global health within and outside Canada havecooperatedonpastprojects.ButCanadahasnooverarchingglobalhealthstrategyto guide a more comprehensive, collaborative and coordinated approach. Suchcoordinated responses for global and domestic action have become critical tosolving many “national” health problems (Switzerland, Federal Department ofHome Affairs and Federal Department of Foreign Affairs [FDHA/FDFA] 2006).Thusan inclusive,coherent globalhealthstrategy iscritical to governinghealth.Several consequential countries and communities close to Canada have alreadydeveloped their own global health strategies, among them theUnitedKingdom,the European Union and Switzerland. Other significant countries including theUnited States areworking toward one (Ali andNarayan 2009; Fallon andGayle2010).NowisthetimeforCanadatoidentifythebenefits,costsandrisksofsuchastrategytodeterminewhetherandwhyCanadashoulddeveloponeofitsown.


CanadianPrinciplesforGlobalHealthThe case for developing a Canadian global health strategy is supported by theconsistency and coherence of the basic health‐related principles that have beenhighlightedbyCanadiangovernments ledbybothmajorpoliticalparties in theirdefiningdoctrinesofnationalandinternationalpolicysince1945.2

• The first, fundamental principle, appearing since 1949, is a high‐qualitynational healthcare program, equally benefiting all Canadians regardless ofeconomicstatus.

• The second principle, first appearing in 1957, is the agricultural–healthpathway, which has been a development priority that includes food,agriculture, faminerelief (as inEthiopia in 1984)and,by2010,nutrition forchildren’sandmaternalhealthabroadaswellasadomesticpriorityinvolvingfoodsafety.

• Thethirdprinciple,arisingfirstin1967,isthelinkbetweentheenvironmentandhealth,andtheresultingneedforamulti‐stakeholderpartnershipamonggovernment, academics and the private sector; by 2002 climate changeappearedasthekeyenvironmentalelementaffectinghealth.

• Thefourthprinciple,emergingin1970inthewakeoftheNigeriancivilwar,isthe international–domestic link, affirming thatCanadians’health cannotbeprotectedifinfectionisrampantinotherpartsoftheworld.

• Thefifthprinciple,startingin1989,istheneedforafocusonawiderangeofhealth‐related issues: HIV/AIDS, drug abuse and aging‐associated illnesses,withbreastcancerandtobacco‐relatedillnessesaddedin1997,AIDS‐affectedchildren in 1999, SARS, avian influenza and AIDS in Africa in 2004, H1N1influenzain2009,andchildren’sandmaternalhealthin2010.

• Thesixthprinciple,foreshadowedin1957,isthehighpriorityaffordedtotheinstitutions of the United Nations and instruments of Canadian officialdevelopment assistance (ODA), with a recent focus on the MillenniumDevelopment Goals (MDGs), a possible G20 summit on health, access toaffordable medicines, the creation of the Public Health Agency of Canada(PHAC) in2004andtheprominentplaceof children’sandmaternalhealthontheagendaoftheCanadian‐hostedG8summitin2010.

Thereisthusacumulativelyclear,consistent,coherent,comprehensivesetofcoreprinciplesonwhichaCanadianglobalhealthstrategycannowbebuilt.

2 TheanalysisofCanadianprinciplesrelevanttoglobalhealthwasbasedonasystematicreviewofhealth‐related passages in the Speeches from the Throne andmajor foreign policy statementsissuedbytheGovernmentofCanadasince1947.


GlobalHealthStrategiesandCanada

CurrentHealthStrategiesinCanadaThe Canadian government has long led in advancing important global healthinitiatives. When the World Health Organization (WHO) was established, Dr.BrockChisholm—aformerCanadiandeputyministerofhealth—wasappointedas the first head. During the framing of the WHO constitution, a Canadiandelegate aptly argued for broad and inclusive membership in the organization,stating:

Wecannotaffordtohavegapsinthefenceagainstdisease;andanycountry,nomatterwhatitspoliticalattitudesoraffiliationsare,canbeaseriousdetrimenttotheeffectivenessoftheWorldHealthOrganizationif itis leftoutside.It isimportant that health should be regarded as a world‐wide question, quiteindependentofpoliticalattitudesinanycountryintheworld(Sharp1947).

Canada has subsequently developed specific strategies to address individualhealth challenges. They cover a wide range of demographic groups includingyouth, aboriginal people and women; diseases including diabetes and cancer;mental health; the determinants of health including food; and animal safety(Health Canada 1999; PHAC 2005, 2007, 2008a; Mental Health Commission ofCanada undated‐a, undated‐b; Government of Canada 2008b). These strategieshave largely been internally oriented, but have been influenced by or havecontained an inherent international dimension. Canadian stakeholders havesuggestedthatCanadashoulddevelopadditionalhealthstrategies.TheseincludeaglobalhealthstrategyforindigenouspeoplesandaCanadianglobalhealthstrategy(Smylie2004;Singer2009).

Canadacurrentlyinvestsapproximately$550millionannuallyonglobalhealthinitiatives (Singer 2009). Federal, provincial and territorial departments andagencies have devoted substantial resources to developing and implementingstrategies to tackle specific global health challenges. These include G8 healthactionplansandpandemicplans—particularlysincetheSARSoutbreakin2003,the H5N1 scare in the mid 2000s and the recent H1N1 pandemic (Canada,Department of Finance 2006; PHAC 2010a, 2010b; G8 2003). Several researchinstitutesinCanada,manystronglysupportedbyCanadiangovernmentresources,have developed collaborative national and international partnerships on healthinitiatives as well (Canadian Institutes of Health Research [CIHR] 2002; HealthResearch Council of New Zealand 2009; CIHR 2008; Ray, Daar, Singer andThorsteinsdóttir2009).

Canada has taken a leadership role in hosting meetings on global health. Ithosted the first meeting of the Global Health Security Initiative (GHSI) inNovember2001(GHSI2001).InOctober2005,Canadaconvenedan international


meeting to collaborate and coordinatepandemic influenzapreparedness (DFAIT2009).Canadaisalsooneoffiveindependentindustrializedcountriesoftencalledontochairormediatedelicateglobalhealthnegotiations(Silberschmidt2009).

ACanadianglobalhealth strategy could thus strengthen, improve and fostercomprehension, communication and coherence among this rich array ofcomponent sectoral strategies and partnerships. It could avoid unnecessaryduplicationandmobilizeactorstoworktogetherformaximumimpactinmeetingCanada’sglobalandnationalhealthgoals.

MajorPlayersinGlobalHealthinCanadaWithinCanada,manyactorsplayakeyroleinglobalhealth(seeAppendixB).Attheinternationalandregionallevels,Canadahasaroleinmanyintergovernmentalinstitutions involved in global health (see Appendix C). Given the number anddiversityoftheseinstitutions,therearebenefitsinhavingCanadianparticipationineachflowfromasingleglobalhealthstrategyathome.

Withincivilsocietyandtheprivatesector,therearemanyacademic,research,business and non‐governmental organizations (NGOs) — nationally oriented,transnational in nature or linked internationally— that are dedicated to globalhealth. For example, Canadian civil society organizations such as the CanadianPublicHealthAssociation(CPHA)workedwiththeWHOandmanyinternationalgovernmental and non‐governmental partners to establish the 1986 OttawaCharter for Heath Promotion. This seminal international charter focused onenabling people to increase control over their health and on building healthypublicpolicyacrossalldomainsofgovernmentbeyondthehealthsector.LedbyCanadiancivilsocietythroughthe1990sandnowintothe21stcentury,thischarterhas resulted in the globally successful Healthy Cities project that looks atenvironmental aspects of sustainable urban development as a determinant ofhealth (Kickbusch 1989). In 2005, an offshoot of this process produced thedomestically successful BC Healthy Communities Project, an initiative to buildcapacityforhealthythrivingandresilientcommunitiesinOntario,NewBrunswickandQuebec(see<www.bchealthycommunities.ca>).

MotivationforCanadianActiononGlobalHealthCanadians have beenmotivated to act on global health as a result of the directimpact of global health challenges, such as pandemic disease, food safety andsecurity, and climate change on health at home and abroad as well as by theinternational and domestic application of the core values that Canadians share.ManyCanadianssufferfrominfectiousandchronicdiseases,manyofwhichhavespread fromother countries (seeAppendixD).Canadianswant tomaintain andimprovetheirhealthand,atthesametime,thehealthofothersaroundtheworld(see Appendix E; International Development Research Centre [IDRC] 2008).


Beyond self‐interest and altruism, Canadians increasingly recognize theinterdependenceofthehealthofpeopleathomeandthehealthofpeopleabroad.

Protecting the health and safety of Canadians has been a deep and durablepriorityoftheCanadiangovernmentfordecades.Canadaspends10.1%ofitsgrossdomestic product (GDP) on health — one of the highest in the world(OrganisationforEconomicCo‐operationandDevelopment[OECD]2009b).Thegovernment has long pursued a foreign policy that reflects Canadians’ values ofdemocracy,peaceandequityanditsdistinctivenationalvaluesofantimilitarism,environmentalism, openness, multiculturalism, globalism and internationalinstitutionalism (Singer 2010; Kirton 2007). This pursuit has led to supportingactions and initiatives on global health, such as the Global Polio EradicationInitiative(GPEI)since1985,theMDGssince2000,theGlobalFundtoFightAIDS,Tuberculosis and Malaria since 2002, the Framework Convention on TobaccoControl(FCTC)since2003andtheInternationalHealthRegulations(IHR),whichCanada was involved in negotiating and revising since 2004 and which enteredinto force in 2007. Numerous bilateral initiatives have been taken as well (seeAppendixA).

Increasingly, the government has recognized that Canada’s interests areconnectedwiththerestoftheworld(GovernmentofCanada2010).Thusactionson global health not only promote Canadians’ values and a broad range ofCanadian interests, but are also necessary to directly protect Canadians’ ownhealth.

TheNeedforaStrategyNowNow is the time forCanada todevelop its ownglobalhealth strategy.Countriescannotgovernhealthadequatelyontheirown(UnitedKingdom,HMGovernment2008; Cooper, Kirton and Schrecker 2007). Infectious diseases do not respectborders and therefore collaboration to deal with health threats at their distantsource isnecessaryforasuccessfulresponse.Developmentstrategiesareintegralto advancing democracy and human rights, to creating a more prosperous,democraticandequitableworld,tostoppingandpreventingterrorism,tobuildingastableglobaleconomy, tostoppingandpreventingconflicts,andtopreventingandcontainingglobalpandemics(Clinton2010).

All states, including Canada, have become increasing vulnerable to globalhealth threats (Fischer 2009). This vulnerability became clear after the anthraxattacks in the United States immediately following the attacks of September 11,2001, and the casesof SARS,H5N1 andH1N1 (Bennett 2009;Chan2009a, 2009b;GlobalHealthSecurity Initiative2009).Canada isalsovulnerable to the loominghealth impacts of climate change, such as increasing incidence of malaria(Berrang‐Fordetal.2009).

Demand forattentiontoglobalhealthandinternationalhealthstandardshasbeen increasing due to the increasedmobility of individuals and healthworkers


(throughmigration and travel), rising costs, increasing scientific knowledge andthegrowingtechnicalcomplexityofhealthchallengesandcapacitytorespondtothosechallenges(FDHA/FDFA2006).Byplacingmoreemphasisonhealthabroad,Canada can help to limit diseases from spreading to its territory. Morecollaboration and regulation on food and product safety challenges such as BSEand avian influenza will help limit the negative health, trade and economicimpacts that can result. For example, it is estimated that $1.5 billionwas lost ineconomicrevenueinOntarioaloneasaresultofSARS(Price‐Smith2009).Bettercollaborationandcooperationcouldpreventoratleastlimitsimilarimpactsinthefuture.Boththeawarenessofglobalhealthchallengesandglobalhealthresearchhave increased and much more is known about the interconnectedness andinterdependenceofhealthchallenges (Kirton2009).Thereisthusmoreevidencetosupportthedevelopmentofaglobalhealthstrategynow.

In 2010,Canadahas auniqueopportunity toplay a leadership roleonglobalhealthasitwillhosttheG8summitinMuskokaandtheG20summitinTorontoinJuneandtheNorthAmericanLeaders’SummitinSeptember.ThePrimeMinisterhasalreadydeclaredthatchildren’sandmaternalhealthisatoppriorityfortheG8MuskokaSummit.AstrategycouldsupporttheinitiativesthathavealreadybeenputforwardatMuskokaandotherinternationalmeetings.

A strategy could also helpkeepCanada andothers accountable to their pastand future health commitments, including the MDGs, which remain far frombeing reached. As the Prime Minister said at the World Economic Forum inJanuary2010,“Accountability…istheprerequisiteforprogress”(Harper2010b).AglobalhealthstrategycouldhelpCanadareachtheMDGsby their2015deadline(HMGovernment2008).ItcouldalsoassistinensuringaccountabilityonCanada’scommitmentsmadeinabroadarrayofinternationalforumsinrecentyears.

Other countries have recently recognized the benefits of developing a globalhealth strategy. The growing number includes some of Canada’s closestinternationalpartners.Switzerland,nowoneofCanada’s free tradepartners,wasthefirsttoadoptaglobalhealthstrategy,doingsoinOctober2006(Sridhar2009;FDHA/FDFA2006).TheUnitedKingdomandEuropeanUnionadoptedstrategiesin 2007 and 2008 respectively (Commissionof theEuropeanCommunities 2007;HM Government 2008). The United States, China and Brazil are currentlyconsidering similar policies (Kickbusch and Erk 2009; Ali and Narayan 2009;FallonandGayle2010).Norway,whichallocatesthehighestpercentageofGDPtoODA and has taken the lead in pushing countries to reach MDGs 4 and 5, isconsideredoneofthemostactivecountriesinglobalhealth(Silberschmidt2009).To be competitive with its peers and to partner effectively with them, Canadaneedsitsownglobalhealthstrategy.

Moreover,Canada shoulddevelopa globalhealth strategybecause theworldsimplywillnotwait.Populationgrowth,climate–healthimpactsandthespreadofinfectiousdiseasewillnot improveunless drasticmeasures are taken toprevent


andstopthem.Thehealth,economy,securityandstabilityofmanyathomeandabroadwillsuffergreatlywithoutaction.

WhyNow?1. Vulnerabilitytoglobalhealththreatshasincreased.2. Individualsandhealthworkersaremoremobile.3. Better, more effective use of scarce resources is needed in today’s time of

restraint.4. Moreisknownabouttheinterdependencies,intersectionsandimpactsofhealth.5. Canadawill host threemajor summits in 2010 atwhichglobalhealth couldbea

focalpoint.6. Increasedaccountabilityforcomplianceonhealthcommitmentsisneeded.7. Morecountriesaredevelopingglobalhealthstrategies.8. Theworldwillnotwait.

AglobalhealthstrategywouldhelpensurethehealthandsafetyofCanadians.Itwould strengthen progress and plans for future actions. Itwould help outlineCanada’s short‐,medium‐and long‐termglobalhealthgoalsandensure that theindividualhealth‐relatedcommitmentsCanadamakesininternationalforumsandathomeare consistent and coherentpartsof anoverall approach. Itwouldhelprender consistent and synergistic provincial, national and international plans. Itwould provide a mechanism for better coordination. It would clearly set outCanada’s global health priorities so that all the actors involved have a clearunderstanding of Canada’s objectives. It would enable Canada to take a moreproactiveroleonglobalhealth(asopposedtoareactionaryanddefensiveone).Itwouldprovidemoreeffectiveandefficientresponsesthatareincreasinglyneededtosaveandenhancehuman livesandtoreduce thesoaringsocialandeconomiccostsbothinCanadaandabroad(Kates,FischerandLief2009).

Benefits,CostsandRisksofaStrategyThere arebenefits, costs and risks that could come fromdeveloping aCanadianglobalhealthstrategy(seealsoAppendixF).

BenefitsCanada could derive many benefits from the process of developing a Canadianglobalhealthstrategyaswellas fromthestrategy itself.Aglobalhealthstrategywould lead to better health in Canada and abroad (World Vision International2009; HM Government 2008). It would provide the various Canadian actorsinvolved in global health with a clearer understanding of what their relevantcolleaguesarecurrentlydoing. Itwouldprovidegreater transparencyandaclearframeworkofwhatCanada’sglobalhealthprioritiesare,howCanadaplanstomeetthem andwhat each actor’s role should be. This framework would also help tofocusresearchefforts.Itwouldprovideguidelinesforcollaboration,coordination


andcooperationparticularlyamongactorsfromnon‐healthareasandthosewithtraditionalhealthbackgrounds.Itwouldimproveinternalcooperationandprovideshared objectives and better clarity for all Canadian actors in the field of globalhealth and theCanadianpublic as awhole (FDHA/FDFA2005). It couldhelp tobuild stronger partnerships with key international actors. It would help ensurethatCanada isusing its scarce resources tobest effect. Itwould catalyzeothers,includingphilanthropists,tocontributemoreresourcestodefined,identifiedandcompelling priorities. It would help improve preparation and response forunexpected health crises that will inevitably arise. It would promote Canadianinterests andvalues (seeAppendixE).And itwouldhelp to ensure thatCanadameetsitforeignpolicyandinternationaldevelopmentgoals.

Benefits1. ImprovedhealthinCanadaandglobally.2. Clearerunderstandingofcurrentandrelevantglobalhealthactivities.3. Greatertransparency.4. ClearframeworkofCanada’sglobalhealthpriorities.5. Guidelinesforcollaboration,coordinationandcooperation.6. Strengthenedinternationalpartnerships.7. Moreeffectiveandinnovativeapplicationofresources.8. Betterresponsetounexpectedhealthcrises.9. PromotionofCanadianinterestsandvalues.10.SupportforCanadianforeignpolicyandinternationaldevelopmentgoals.

CostsA global health strategy will bring some costs to Canada. It will take time andresources to develop. There will be potentially conflict‐generating conversationsaboutwhether such a strategy is necessary, how it should be done,who shouldlead,whattheroleofeachactorisandwhatthecommonprioritygoalsshouldbe.3Theprocessofdevelopingthestrategycoulddivertattentionfromotherindividualand immediate problems. It may require some actors to change their missions,expertise and even authorizing legislation to play their full intended part as anintegral componentof the largerwhole. Itmight also require that an analysis ofcurrent commitments and component strategies be conducted, which would betimeconsumingandwoulddelayprogress.Canada’scomplex federalsystemalsoaddscomplications.

3 Because there is a diverse array of actors involved in global health in Canada, conflicting orcompeting objectives may arise. For example, actors in trade may have different views andobjectives from those in development, complicating the treatment of issues such as access toaffordable medicines (Silberschmidt 2009). Similarly, environmental actors and health actorsmayhavedifferentviewsontheuseofdichlorodiphenyltrichloroethane (DDT) tofightmalaria.Thesevaryingviewswillbechallengingtoovercome.


Costs1. Timeandresources.2. Conflict‐generatingconversations.3. Divertedattentionfromindividualandimmediateproblems.4. Possiblechangesforactors’missions,expertiseandauthorizinglegislation.5. Time‐consuminganalysisofcurrentcommitmentsandcomponentstrategies.6. Complicationsfromfederal‐provincialrelations.

RisksAs with any new development, there are potential risks to developing a globalhealth strategy. Inflexibility inpolicy and resource investment could result fromdeveloping a fixed comprehensive approach. This in turn would make it moredifficult for Canada to shift its priorities after putting a public global healthstrategy inplace.Anemergingcrisis that requires immediateattentionmightbeignoredordealtwithinappropriatelyorinadequatelyasaresult.Attheotherendofthescale,thereisthedangerofsettingobjectivesthataretoogeneralinscopeorprovideinsufficientguidance.Suchgeneralitymaycontributetoconfusiondueto multiple interpretations. Under‐ambition could result from a consensus thatrests at the lowest commondenominator or defines global health too narrowly.Over‐ambition may result from defining global health too broadly. A poorlydesignedglobalhealthstrategycouldalienatekeyactorsthatshouldbeinvolvedintheprocess,causing furtherdivisionand inconsistency.There isalsoachanceofovercrowding,withtoomanyactorsdilutingtheusefulnessofsuchanexerciseormaking it unmanageable. Satisficing could result as actorsmaymeetmerely theminimum requirements to comply with their obligations, preventing moreambitiouscommitmentsfrombeingachieved.Logrolling—exchangingfavourstomutualbenefit—couldcauseincoherenceandsynthetic,forcedsynergies.Thereisalsotheriskthatexistingcommitmentscouldbedisregarded.Thespecificationof goals in a global health strategy could imply that they trump older, but stillimportant,commitments.

Risks1. Inflexibility.2. Generality.3. Under‐ambition.4. Over‐ambition.5. Alienation.6. Overcrowding7. Satisficing.8. Logrolling.9. Divertedorneglectedattentiontoexistingcommitments.


CostandRiskMitigationMeasuresMeasurescanbetakentomitigatethecostsandrisksinvolvedinaglobalhealthstrategy.

First, a list of all the possible costs and risks should be identified. This willensurethatmeasuresaretakentopreventorreducethem.

Second, the global health strategy should be properly thought through. Anexerciseundertakeninhasteismorelikelytoproduceunintendedrisksandcosts.

Third,alltherelevantactorsshouldbeincludedindevelopingaglobalhealthstrategy.Acomprehensiveandconsultativeapproachwillhelpguaranteeasenseof inclusiveness and a coherent, synergistic and successful strategy. Anycompeting,inconsistentonirrelevantproposalscanbetackledatanearlystage.

Fourth, goals and limitations should be clearly identified at the outset. Thearticulationofwhyaglobalhealthstrategyisdesirableandwhatitaimstoachieveiscriticaltocreatingacoherentandusefulstrategy.

Fifth, it is important to identify who will supply the resources necessary todevelopingtheglobalhealthstrategy.

Sixth,theglobalhealthstrategyneedstobeproperlybalanced.Itneedstobesufficientlyflexibletoadapttoemergingcrises,yetbeboundinsuchawaythatitisclear,conciseandconstraininginwhatithopestoachieve.

Seventh, it must respect existing commitments and support theirimplementation. Doing so will uphold the integrity of the actors involved indeveloping the global health strategy and keep them accountable for their pastpromises.

PotentialAreasforActionandInitiativeCanada’s globalhealth strategy could focuson several subjects, inparticular thefollowing:

• The health‐related MDGs that deal with children’s and maternal health,whichthePrimeMinisterhasalreadysetasoneofCanada’sprioritiesfortheG8MuskokaSummit(Harper2009,2010a;GovernmentofCanada2010).

• Global health issues that have already significantly affected Canadians athome,suchasWestNilevirus,SARS,BSEandH1N1(seeAppendixD;Maioni2008; Bennett 2009; Price‐Smith 2009; Chan 2009a, 2009b; PHAC 2009d,2010b).

• Those international issues or institutions where Canada has played asignificantroleinthepast,suchastheGlobalFund,polio,theInternationalAIDS Vaccine Initiative (IAVI), tuberculosis, the GAVI Alliance, theInternationalPartnershipforMicrobicides,infantandchildhealth,maternalhealth,micronutrient deficiencies and the strengthening of health systems(seeAppendixA;Government of Canada 2008a; Kirton andGuebert 2010a;Singer2009;Cannon2010).


• Otherhealthcommitmentsalreadymadeontheglobalstagebutnotyetmet,suchaspledgesmadeattheG8summit(Guebert2009).

• AnynichewhereCanadahasmedicalandresearchexpertise,suchasdiabetesorglobalhealthresearch(Phillips2001;CNWGroup2009a;Singer2009).

• The identification of a neglected topic where Canada could carve out aleadershiprole,suchasglobalhealthdiplomacy,neglectedtropicaldiseases,foodsecurity,genderequality,thedefinitionofglobalpublichealthgoodsorinnovation(Singer2009).

• Health issues that are critical in countrieswhereCanada has a key foreignpolicyanddevelopment interest,notablyAfghanistan,Haiti, theDominicanRepublic, India, El Salvador, Guatemala, Honduras and Nicaragua (seeAppendicesAandG).


ComponentsofaCanadianGlobalHealthStrategy

CanadianPrioritiesA Canadian global health strategy will reduce pandemic risk and improve thehealth and safety of Canadians at home and abroad. It will help ensure thatCanadiansareprotected fromsecurity threatssuchasbioterrorism. Itwill fosterinnovation in global health. It will help Canada plan and protect its citizensagainst the negative health‐related effects of climate change, unsafe food andproducts,andmigration(Berrang‐Fordetal.2009;KirtonandGuebert2010b).

A global health strategy will also express Canadians’ interests and valuesabroad.Canadiansbelievethathealthcareisoneofthemostimportantdomainsthat politicians should address. In repeated public opinion surveys, Canadianshaveidentifiedhealthcareasthemostimportant(oroneofthemostimportant)issuesforpoliticianstodeliberateon.Canadiansapproveofthemdoingsoabroadaswellasathome(seeAppendixE;Bildook2008;PublicWorksandGovernmentServices Canada 2008; Robbins SCE Research 2010; Association of Faculties ofMedicineofCanadaetal.2010).

As an integral part of protecting Canadians’ health and promoting theirinterests and values, a global health strategy will help meet Canadians’international responsibilities in the many communities that they share withothers. These responsibilities start geographically with the North American andArctic communities and extend to the Americas, the Atlantic and Asia Pacificregions, Africa through the Commonwealth and Francophonie, and the globalcommunityasawhole.

Canadahasalsocommittedtosolvingglobalhealthchallenges inavarietyofinternationalforumsoverthepastdecades.Manyofthesecommitmentsstillneedtobe fulfilled. Inadditionto theMDGsandcommitmentsmadeatG8summits,promises made at Asia Pacific Economic Cooperation (APEC) summits and atCommonwealthandlaFrancophonieheadsofgovernmentmeetings,Canadahasbilateral commitments with countries including Afghanistan, Haiti and Sudan(CIDA 2009a). Canada could use a global health strategy to help meet theseobjectivesinareasonableandresponsibleway.

GlobalDemandsMany actors have devoted time and resources to developing and using globalhealth strategies because many health challenges are increasing, are ofteninherently global and therefore require global coordination in response(FDHA/FDFA 2006; HM Government 2008; Commission of the EuropeanCommunities2007;Sridhar2009).

Therehasalsobeenanincreasingrecognitionthatnon‐healthinfluencesactorsfromabroad—especiallythosethatareinherentlyandfullyglobal—canseverely


affect human health (Sridhar 2009; HM Government 2008; Kirton and Guebert2010b). Non‐health influence begin with climate change, food and agriculture,tradeandmigration.TheIntergovernmentalPanelonClimateChange(IPCC)hasidentified numerous connections between climate change and health (seeAppendixH; IPCC 2007a, 2007b). A 2007 survey showed that 82% ofCanadianswereconcernedwith“climatechangeanditsimpactonhealth”(CanadianMedicalAssociation2007).

The food and agriculture–health connection was highlighted by recentexperienceswithBSE,H5N1andH1N1(GovernmentofCanada2008b).

TheAgreement onTrade‐RelatedAspects of Intellectual Property (TRIPS) attheWorldTradeOrganization (WTO) forgedanecessary collaborationbetweentradeandhealth,whileCanada’sgrowingarrayofbilateral freetradeagreementsintensifythetrade‐healthconnectionaswell(DFAIT2010a;seeAppendixG).

Themigration of healthworkers remains a challenge for countries of origin,many of which are already suffering from major deficiencies in health workers(WHO2007). Canada is home tomore than 15,000 scientific and health‐relatedprofessionalsfromdevelopingcountries(Singer2010).ThereisalsothepossibilitythatcurrentandprospectiveCanadiansandothercitizenswhoenterorimmigrateto Canada can bring illness contracted abroad that may spread (Kirton andGuebert2010b).

ThelevelsandtrendsinsomemajorcommunicablediseasessuchasHIV/AIDS,and non‐communicable diseases such as diabetes, obesity, cancer and tobacco‐relatedillnesseshaverisenandarepredictedtocontinuetorise(seeAppendixD;WHO2006,2009).

Thepublichasincreasinglydemandedthatgovernmentsjustifytheirspending,particularly in recent timeswhen resourceshavebecome limited (Clinton 2010).Globalhealthstrategiesprovideatoolforgovernmentstocommunicatewhyitisimportant to spend money on global health initiatives and to clearly indicatewherefundingisallocated.

Canada’sComparativeAdvantageCanada can contribute to globalhealth and improve its impacton thehealthofCanadians and others through international leadership, accepting globalresponsibilitiesandexpandingitsinternationalinfluence.Canadahasastrongandcapable community of health professionals, facilities, research, development,innovationandtrainingtomobilizeinacoordinatedway(Singer2009).Canada’sacademic institutions, private sector innovators, civil society actors andorganizations,andresearchbodies,ledbytheCIHRandIDRC,canallcontributeto a strong Canadian global health strategy (Singer 2010; Canadians for HealthResearch2008).

Canada can contribute financially to global health through public sector,privatesector,civilsocietyandothernon‐governmentaldisbursements,including


tothoseglobalinitiativeswhereCanadahasalreadymadealeadingcontribution(seeAppendixA;CIDA2009a).

Canada can lead on global health issues in key international institutions,startingwiththehostingoftheG8,G20andNorthAmericanLeaders’Summitin2010. Canada has alreadymade health a priority of the G8Muskoka Summit inJune.The stated topicof children’s andmaternalhealth could alsobe discussedwith the G20,which deals with the health‐related issues of finance, trade, foodsecurityanddevelopment(Silberschmidt2009;KirtonandGuebert2010a).AttheNorth American Leaders’ Summit in September, a continued discussion ofpandemicpreparednessandplanningandbestpracticeswouldbeuseful (KirtonandGuebert2010c,2010d).

Canada could build on its global health leadership by seeking to appointrespected officials to the executive boards and senior staffs of health‐relatedinternational organizations of consequence, including theWHO, Pan AmericanHealth Organization (PAHO) and the OECD. It could encourage any newinternationalhealthorganizationsthatarisetolocatetheirsecretariatsinCanada.It could make sure that Canadian representatives at health‐related meetings ofconsequenceincludeshigh‐levelofficials.ItcandrawontheCanadianexperienceofthosewhoarealreadyinpositionsofpower,andthosesuchasWHOdirectorMargaretChan,whoobtainedhermedicaldegreefromtheUniversityofWesternOntario.

Canada could also lead in creating a platform to explore and supportinnovation as it applies to global health. This would mean recognizing thatinnovationincludesseekingsuccessthroughexperimentationwhileacceptingthatrisk is a necessary component of innovation, because tolerance for failure is alearningstage indevelopinggenuinelyeffectivenewglobalhealth initiativesandstrategies.Suchaprocesswoulddrawfromdomesticandinternationalcivilsocietyactors,theprivatesector,academia,philanthropicentities,andgovernmentalandintergovernmentalbodies toexploreandexperimentwith the factors,actorsandenablers that can lead to resilient and healthy individuals and communitiesdomesticallyandglobally.

Canada could also consider identifying specific responsibilities and assumingleadership inneighbouringandstrategic regions, includingtheArctic, theNorthAmericancommunity,HaitiandAfghanistan.Withintheseareas, itshould focusonthemostvulnerablefirst.

Canada’sPartnersWith regard to a partnership strategy, several lessons can be learned from theevidenceandcasesofwhatothershavedone(seeAppendixI).

First,itisimportanttoestablishwhyastrategywouldbeusefulandbeneficialin Canada. This report and the companion one written by Ronald Labonté andMichelle Gagnon (2010), as well as others exploring a Canadian global health


strategy, shouldbe sharedwith the variousCanadianglobalhealth actors.Theircommentsandquestionsshouldbetakenintoconsiderationandexploredfurtherwherenecessary.

Second,Canadashoulddeterminethefactorsdriving ittoconsideranationalglobalhealthstrategy.Twomainaimsdrove theUKtodevelop itsglobalhealthstrategy:“tousehealthasanagentforgoodinforeignpolicy”andtoensuremoretransparencyandclarityontheimpactofforeignanddomesticpoliciesonglobalhealth(Sridhar2009).Switzerland,whichhosts theWHOinGeneva,recognizedthat internationally coordinated responses were required in health; these twofactors drove it to develop a global health strategy (Sridhar 2009). Others havesuggested that the search for effective ways to use scarce resources was a keydriver.Newresearchandevidencethathighlightedtheeffectivenessandbenefitsofmore integrated and focused global health approaches also had an impact. AclearunderstandingofthereasonsbehindCanada’sdesireforastrategywillhelptoframethecontextandnarrativeoftheoverallpolicy.

Third,themainaimsoftheglobalhealthstrategymustbeidentified.TheUK’s“stability first” strategy targeted five actions: enhance global health security toimproveeconomicandpoliticalstability;createstronger,fairerandsafersystemsto deliver health;make international organizations including theWHO and theEUmoreeffective;engageinstronger,freerandfairertradeforbetterhealth;andstrengthen the way the UK develops and uses evidence to improve policy andpractice (HM Government 2008). The EU identified three main objectives:fosteringgoodhealth inanagingEurope,protectingcitizens fromhealth threatsandsupportingdynamichealthsystemsandnewtechnologies(CommissionoftheEuropeanCommunities2007).The fivemainprioritiesoftheSwissgovernment’sglobalhealth strategy are toprotectnationalhealth interests fromglobalhealththreats, including influenza pandemics, consumer health threats and non‐communicable disease; harmonize national and international health policies;improve the effectiveness of international collaboration in the area of health;improve the global health situation; and safeguard Switzerland’s role as hostcountry to international organizations and major companies working in health(FDHA/FDFA2006).Canadacanlooktoalltheseareasandobjectivestoseewhichshould be adopted in a Canadian global health strategy. Certain ones, such astrengthening health systems, protecting citizens from global health threats andharmonizing national and international health policies, stand out as worthycandidates. Canada’s global health strategy should consider aims that are bestsuitedtoCanadianvaluesandinterests.

Fourth,theresourcesnecessaryfordevelopingandexecutingtheglobalhealthstrategymustbedetermined.AswiththeEUandSwitzerland,Canadaneednotnecessarily findnewresourcesattheoutset.Fundscouldbedrawnfromexistingindividualglobalhealthinitiatives.Theglobalhealthstrategywouldthereforebereinforce the goals already targeted (Sridhar 2009). However, allocating newresources,astheUKdid,wouldsignalthatCanadaisseriousaboutimplementing


its strategy and committed to seeing it through. It could also help catalyze ormobilizefundingfromothersources.

Fifth,aglobalhealthstrategyshouldidentifyone‐year,five‐yearand10‐to15‐year initiatives. The strategy should be reviewed after each period with reportspublished publicly, including recommendations for future actions and changes.Thereshouldbeabalanceof specifiedand flexible initiatives, so thatcleargoalscan be set. At the same time there should be room to adjust to any crises thatmightarise,suchasthe2010earthquakesinHaitiandChileorafutureinfluenzapandemic. A five‐year approach as an initial basewould be a suitable timeline,following the example of theUK, the EU and Switzerland. Starting in 2010/11, itwouldalsofitwithintheMDGtimeframe.Itcouldalsoincludeshorterplansandlongerplans,asintheU.S.strategy(FallonandGayle2010).

Sixth, the strategy should build on Canada’s strengths in the academic, civilsociety, business and government sectors. It should also identify areas whereCanada can improve and close critical gaps. It should specifywhat departmentsand agencies should be responsible for each initiative. It should also focus onmerging non‐health actors, such as those in trade, agriculture and theenvironment, and match them with those with relevant technical capacity,understandingandexpertiseinhealth.

Seventh,Canadashouldconsidercollaboratingwithotherkeyactors,includingthosecountriesthathavedevelopedoraredevelopinghealthstrategies.Itshouldcontinuetocollaboratewithlong‐standingpartnersstartingwiththeWHOastheleadintergovernmentalorganization,andalsowiththeUK,theU.S.andtheEU.Canadashouldalsoencourageothercountriestodeveloptheirownglobalhealthstrategies,aspartofabroad,globallycoordinatedapproach.

Eighth,followingtheUK,Canadashouldconsiderappointinganindependent,third‐party body or office to review the success and effectiveness of a Canadianglobalhealthstrategy.Thissameindependentbodyshouldproduce theprogressreportsandprovideconstructiveadviceonthenextstepstoensurethestrategyisimplementedeffectively.

Ninth, Canada should ensure that it remains open and transparent aboutconflicting interests that exist between departments and agencies, such as tradeand development or environment and health. It should make it clear that it isreadytoresolvediscrepancies,oratleastreducedifferences,byclarifyingrolesandhighlighting synergies. With the Canadian government already focused onaccountability,thisapproachwouldstrengthenitscommitmenttotransparency.

Tenth,aswithSwitzerland’sstrategyanditsfederalsensibilities,theCanadiangovernment shoulduse its globalhealth strategy to improve the integrationandsynergies among provincial, national and international health policies. It shouldclearly specify which actor or actors should lead and which should play asupportingroleoneachinitiativeforbetterclarity,cooperation,coordinationandcosteffectiveness.


SpecificstepsfordeliveringastrategyfollowingtheseguidelinesareidentifiedinAppendixJ.

Amoresystematicsurveyshouldbeundertakentoexplorethepotentialimpactof a Canadian global health strategy. Cross‐Canada consultations should beundertakenwith academics,NGOs, politicians, bureaucrats andmembers of thebusiness and industry communities. New public opinion polls should beconducted. Interdepartmental workshops should be convened. Internationalstakeholders, particularly those from consequential countries that have alreadydevelopedglobalhealthstrategies,shouldbeincludedintheseprocesses.


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Kirton,John(2007).CanadianForeignPolicyinAChangingWorld.Toronto:Thomson‐Nelson.

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Kirton,JohnandJenileeGuebert(2010cforthcoming).“NorthAmericanHealthGovernance:Shocks,SummitryandSocietySupport.”Norteamerica.Inpress.

Kirton,JohnandJenileeGuebert(2010d).“SoftLawRegulationCoordinationandConvergenceinNorthAmerica.”InMonicaGattingerandGeoffreyHale,eds.,BordersandBridges:Canada’sPolicyRelationsinNorthAmerica.Toronto:OxfordUniversityPress.

Maioni,Antonia(2008).“TheMediaandPublicOpinionaboutHealthCare.”HealthInnovationForum.<www.healthinnovationforum.org/2008/may/01/media‐public‐opinion>(March2010).

MentalHealthCommissionofCanada(undated‐a).“Evergreen:ChildandYouthMentalHealth.”<www.mentalhealthcommission.ca/English/Pages/evergreen.aspx>(March2010).

MentalHealthCommissionofCanada(undated‐b).“MentalHealthStrategyforCanada.”<www.mentalhealthcommission.ca/English/Pages/Strategy.aspx>(March2010).

Labonté,Ronald,andMichelleGagnon(2010).“WhatIstheCaseforaCanadianGlobalHealthStrategy?”PapercommissionedbytheStrategicPolicyBranchoftheInternationalAffairsDirectorateofHealthCanada.DraftofMarch15.

Orbinski,James(2007).“GlobalHealth,SocialMovements,andGovernance.”InAndrewF.Cooper,JohnKirtonandTedSchrecker,eds.,GoverningGlobalHealth:Challenge,Response,Innovation.Aldershot:Ashgate.

OrganisationforEconomicCo‐operationandDevelopment(2009a).“MeasuringAidtoHealth.”November.<www.oecd.org/dataoecd/44/35/44070071.pdf>(March2010).


OrganisationforEconomicCo‐operationandDevelopment(2009b).“OECDHealthataGlance2009:KeyfindingsforCanada.”<www.oecd.org/documentprint/0,3455,en_2649_33929_44220787_1_1_1_1,00.html>(March2010).

Phillips,Anne(2001).“CanadaLeadstheWayinDiabetesResearch.”GSKNews(November)<www.gsk.ca/english/docs‐pdf/PPNov01ENG.pdf>(March2010).

Price‐Smith(2009).ContagionandChaos:Disease,Ecology,andNationalSecurityintheEraofGlobalization.Cambridge:MITPress.

PublicHealthAgencyofCanada(2005).“TheIntegratedPan‐CanadianHealthyLivingStrategy.”<www.phac‐aspc.gc.ca/hl‐vs‐strat/pdf/hls_e.pdf>(March2010).

PublicHealthAgencyofCanada(2006a).“Canada’sNewGovernmenttoDevelopaNewHeartHealthyStrategy.”Pressrelease,October23.<www.phac‐aspc.gc.ca/media/nr‐rp/2006/2006_09‐eng.php>(March2010).

PublicHealthAgencyofCanada(2006b).“DiabetesFactsandFigures.”<www.phac‐aspc.gc.ca/ccdpc‐cpcmc/ndss‐snsd/english/facts_figures‐eng.php>(March2010).

PublicHealthAgencyofCanada(2007).“CentreforChronicDiseasePreventionandControl.”<www.phac‐aspc.gc.ca/ccdpc‐cpcmc/cancer/cpac‐accc_e.html>(March2010).

PublicHealthAgencyofCanada(2008a).“CanadianDiabetesStrategy.”<www.phac‐aspc.gc.ca/cd‐mc/diabetes‐diabete/diabetes_strategy‐diabete_strategie‐eng.php>(March2010).

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AppendixA:Canada’sGlobalHealthContributions

SelectedProjectsGlobalPolioEradicationInitiative CA$267million(1985–2010)

GlobalFundtoFightAIDS,TuberculosisandMalaria US$100million(2002–10)

GlobalAllianceVaccineInitiative(corefunding) US149million(2002–06)

GlobalAllianceVaccineInitiative(AMC) US$200million(2007–10)

CatalyticInitiativetoSaveaMillionLives CA$105million(2007–12)

Avianand/orpandemicinfluenza CA$1billion(2006–11)

BilateralaidtoIndiaforthehealthsector US$1million(2006–07)

BilateralaidtoNigeriaforthehealthsector US$9million(2006–07)

BilateralaidtoKenyaforthehealthsector US$3million(2006–07)

BilateralaidtoSouthAfricaforthehealthsector US$6million(2006–07)

BilateralaidtoMozambiqueforthehealthsector US$8million(2006–07)

BilateralaidtoEthiopiaforthehealthsector US$37million(2006–07)

BilateralaidtoZambiaforthehealthsector US$15million(2006–07)

BilateralaidtoTanzaniaforthehealthsector US$11million(2006–07)

BilateralaidtoUgandaforthehealthsector US$1million(2006–07)

BilateralaidtoPakistanforthehealthsector US$7million(2006–07)

Bilateralaidtounspecifiedrecipientsforthehealthsector US$358million(2006–07)

FundingRecipients•Afghanistan•Bangladesh•Bolivia•Ethiopia•Haiti

•Honduras•Indonesia•Mali•Mozambique•Pakistan

•Peru•Sudan•Tanzania•Ukraine•WestBankandGaza

Additionalrecentandcurrentinitiativesincludesupportfor:•RespondingtocholeraoutbreaksinAngola•Community‐basedtreatmentofmalariaandpneumoniainallAfricancountries•UNICEF’sRecoveryofVitalSocialSectorprograminIraq•SupportfortheGlobalFundtoFightAIDS,TuberculosisandMalaria,whichincludesfundingtotheMiddleEastandEasternEurope

•SupportforthePanAmericanHealthOrganization,whichincludestheAmericas•TheCARECanadaprogram,whichfocusesonHIV/AIDSandassistsCambodiaandNepal,andothers•Asia‐PacificStrategyforEmergingDiseases,acomponentoftheCanada‐AsiaRegionalEmergingInfectiousDiseaseProject(CAREID)inSouthEastAsiaandChina

•StrengtheningHealthSystems,aWorldHealthOrganizationprojectinBoznia‐Herzegovina•HIV/AIDSHarmReduction,anOpenSocietyInstituteprojectinRussia,UkraineandGeorgia•TheWorldBank’sMontenegroHealthSystemImprovementProject•CanadianSocietyforInternationalHealth’sPrimaryHealthCarePolicyReformintheBalkans

Note:Canadaannouncedin2009thatitwouldfocus80%ofbilateralresourcesin20countriesoffocuschosenaccordingtorealneeds,capacitytobenefitfromaidandalignmentwithCanadianforeignpolicypriorities.


Sources:GlobalPolioEradicationInitiative(2010);GlobalFundtoFightAIDS,TuberculosisandMalaria(2010);GAVIAlliance(2010);CanadaInternationalDevelopmentAgency(2009b,2009c,2010);OrganisationforEconomicCo‐operationandDevelopment(2009a);Canada,DepartmentofFinance(2006).


AppendixB:GlobalHealthActorsinCanada

•CanadianFoodInspectionAgency(CFIA) •CanadianInstitutesforHealthResearch(CIHR)•CanadianInternationalDevelopmentAgency(CIDA)•DepartmentofAgricultureandAgri‐FoodCanada•DepartmentofForeignAffairsandInternationalTrade(DFAIT)(formerlyDepartmentofExternalAffairs)

•DepartmentofNationalDefence(DND)•EnvironmentCanada•HealthCanada•HealthCouncilofCanada•IndianandNorthernAffairs(INAC)•IndustryCanada•InternationalDevelopmentResearchCouncil(IDRC)•PrimeMinister’sOffice(PMO)•PrivyCouncilOffice(PCO)•PublicHealthAgencyofCanada(PHAC)•PublicSafetyCanada


AppendixC:Canada’sRoleinRegionalandInternational

Health‐RelatedOrganizations

International–Multilateral•FoodandAgricultureOrganization(FAO)•JointUnitedNationsProgrammeonHIV/AIDS(UNAIDS)•UnitedNationsGeneralAssembly(UNGA)•UnitedNationsHighCommissionforRefugees(UNHCR)•WorldHealthOrganization(WHO)andtheWorldHealthAssembly(WHA)•WorldIntellectualPropertyOrganization(WIPO)•WorldTradeOrganization(WTO)

International–Plurilateral•AsiaPacificEconomicCooperation(APEC)•Commonwealth•GlobalHealthSecurityInitiative(GHSI)•GlobalPublicHealthIntelligenceNetwork(GPHIN)•GroupofEight(G8)•LaFrancophonie•OrganisationforEconomicCo‐operationandDevelopment(OECD)

Regional•ArcticCouncil•CommissionforEnvironmentalCooperationofNorthAmerica(CEC)•NorthAmericanLeaders’Summit•PanAmericanHealthOrganization(PAHO)


AppendixD:CanadiansAffectedbyDiseases

WestNileVirus Tuberculosisa HIVb AIDSc SARS H1N1

SeasonalInfluenza Measles Diabetes Obesitye

Year Cases Deaths Cases Deaths Cases Cases Deaths Cases Deaths Cases Deaths Cases Cases Cases%of

Population1979 1 1980 3 2 1981 8 5 1982 26 13 1983 64 28 1984 162 80 1985 402 175 1986 688 341 1987 1,012 528 1988 1,180 622 1989 1,408 820 1990 1,997 1,466 912 1991 2,018 1,515 1,105 1992 2,109 1,755 1,292 1993 2,012 1,829 1,412 1994 2,074 32,878f 1,789 1,470 1995 1,931 2,948 1,651 1,501 1996 1,849 117 2,737 1,189 1,063 1997 1,975 120 2,471 725 473 1998 1,810 122 2,293 647 282 1999 1,821 129 2,191 558 272 7,027 1,200,000 2000 1,724 111 2,105 500 265 4,154 ~200 14.92001 1,773 126 2,217 426 202 6,771 ~10 2002 414 14 1,666 115 2,469 410 144 3,517 ~10 2003 1481 14 1,613 112 2,482 382 153 251 44 11,435 ~10 15.42004 25 0 1,613 105 2,530 324 83 12,879 ~10 1,800,000 23.42005 225 10 1,641 98 2,496 354 66 7,422 ~10 1,900,000 242006 151 2 1,654 111 2,550 311 56 8,133 ~10 2,000,000 2007 2215 12 1,577 143 2,452 260 48 12,256 101 252008 36 0 1,600 NA 2,623 255 45 12,262 77 23,376 2009 8 0 33,477 348 39,044

Notes:

SARS=severeacuterespiratorysyndrome.

a.Incidencerateisper100,000.Numbersfor2008areprovisional.

b.ThenumberofpositiveHIVtestreportsbyyearuptoFebruary13,2009.AnnualdataareunavailableforpositiveHIVtestreportspriorto1995.PositiveHIVtestreportsvaryforcasesundertwoyearsofage.

c.ThenumberofreportedAIDScasesbyyearofdiagnosisgoestoFebruary12,2009,exceptforQuebec,forwhichnodataareavailableafterJune30,2003.

d.In2008–10therehasbeenanincreaseincasesduetopandemic(H1N1)2009influenzavirus.The2009–10influenzaseasonbeganonAugust30,2009.CasesincludeinfluenzaAandBuptoFebruary6,2010.

e.Datafor2000–04includeadultsages20–64.Datafor2005and2007includeadultsoverage18.

f.Numberofcasesreportedbetween1985and1994.

Sources:CommunityandHospitalInfectionControlAssociation–Canada(2009,2010a,2010b);PublicHealthAgencyofCanada(2006b,2008b,2008c,2008d,2009a,2009b,2009c,2009e,2010c);Starky(2005);WorldHealthOrganization2004.


AppendixE:CanadianPublicOpiniononHealthIssues

Date % Rank Statement Poll

Dec2004

35 1aCanadiansbelievetheirmemberofParliamentshouldbespendingtimeondiscussionsoftheCanadaHealthActanditspracticalevolutioninmaintaininghighstandardsofhealthcareforallCanadians

RSR

2006 67 Canadiansapprovetheoverallqualityofhealthcareservicesavailable IRSep2006

54 HarperwaswrongnottoattendtheInternationalAIDSconference IR

Apr2006

63 CanadiansarenotconfidentthatCanadawillhaveenoughhealthcareprofessionalsin10years

IR

Apr2006

60 Canadiansbelievethathealthservicesarebestimprovedwithincreasednumbersofhealthprofessionals

IR

Aug2007

27 Canadianshavebeenaffectedbyanenvironmentalhealthconcern IR

Aug2007

65 Canadianshavetakenactiontoprotecttheirhealthfromtheenvironment

IR

Aug2007

36 Canadiansthinkthefederalgovernmentisdoingenoughtoaddressenvironmentalandhealthconcerns

IR

Aug2007

87 Canadiansareconcernedaboutenvironmentalstandardsinothercountriesandimpactonimportedfood

IR

Aug2007

82 Canadiansareconcernedaboutclimatechangeanditsimpactonhealth

IR

Aug2007

82 Canadiansareconcernedaboutthepotentialforclimatechangetoencouragespreadofdisease

IR

Aug2007

79 Canadiansareconcernedaboutairpollution IR

Aug2007

76 Canadiansareconcernedaboutheatandsunexposure IR

Aug2007

75 Canadiansareconcernedwiththeuseofherbicidesandpesticides IR

Aug2007

74 Canadiansareconcernedwiththeeffectsofsoilcontaminationonlocalfruitsandvegetables

IR

Aug2007

70 Canadiansareconcernedwithwaterquality IR

Aug2007

62 Canadianapprovedoftheoverallqualityofhealthcareservicesavailable

IR

Aug2007

91 CanadiansbelieveitisimportantforgovernmenttohelpincreaseaccesstotreatmentforpeoplewithHIV/AIDSindevelopingcountries

IR

Aug2007

48 Canadiansbelievegovernment’sforeignspendingonHIV/AIDSisnotenough

IR

Nov2007

77 CanadiansareconcernedaboutHIV/AIDSwhentheythinkaboutglobalissues

IR

Nov2007

90 CanadiansbelieveiftheycanpreventpeoplefromgettinginfectedwithHIVtheyhaveamoralobligationtotry

IR

Nov2007

80 CanadiansthinkgovernmentshoulddomoretoensurepeoplegetHIV/AIDStreatment

IR

May2008

86 Canadiansthinkthereisashortageofdoctors IR


Date % Rank Statement PollMay2008

96 Canadiansthinkthegovernmentshouldaddresstheshortageofdoctors

IR

Aug2009

86 Canadiansstrengtheningpublichealthcareratherthanexpandingfor‐profitservices

NR

Aug2009

85 Canadiansaged15andoverreportedbeing“verysatisfied”or“somewhatsatisfied”withthewayoverallhealthcareserviceswereprovided

NR

Nov2009

88 CanadiansbelieveCanadashoulduseitsinfluenceinhostingtheG8andG20toreduceglobalchildmortality

IR

Jan2010

89 CanadiansbelievethatCanadashouldbeagloballeaderinglobalhealthandmedicalresearch

RC

Jan2010

84 Canadiansthinkhealthandmedicalresearchmakesanimportantcontributiontotheeconomy

RC

Jan2010

90 Canadiansbelievebasicresearchshouldbesupportedbythegovernmentevenifitbringsnoimmediatebenefit

RC

Jan2010

12 3bCanadiansthinkhealthcareisthemostimportantissuefacingCanadatoday

RC

Mar2010

23 2cCanadiansthinkhealthcareshouldbethetoppriorityforCanadianleaders

IR

Notes:

IR=IpsosReid;NR=NanosResearch;RC=ResearchCanada;RSR=RobbinsSCEResearch.

Italicsindicatespollsrelatedtointernationalissues.

a.CanadianwereaskedtochoosebetweendiscussionsoftheCanadaHealthActanditspracticalevolutioninmaintaininghighstandardsofhealthcareforallCanadians(35%),theroleofCanada’sArmedForcesinnegotiationsrelatedtoCanadiansovereigntyandstrategicmissiledefencewithU.S.presidentGeorgeW.Bush(32%),theissueofCharterrightsandspecificallytherightsofgaymenandwomentomarry(3%),andtheuseoftheemploymentinsurancesurplusof$50billiontoreducenegativeimpactofhighemploymentinsuranceratesonemployeesandemployers(34%).

b.Of14issueareas,healthcarewasrankedthirdmostimportantaftertheeconomy(32%)andtheenvironment(13%).

c.Theeconomywasrankedfirst(36%),followedbyhealthcare(23%),theenvironment(17%),andjobsandunemployment(16%).

Sources:CNWGroup(2009b);IpsosReid(2006,2007,2008,2009);AssociationofFacultiesofMedicineofCanadaetal.(2010);RobbinsSCEResearch(2004).


AppendixF:Benefits,CostsandRisksofa

GlobalHealthStrategyforCanada

BenefitsAglobalhealthstrategyforCanadawould:•leadtobetterhealthinCanadaandglobally•provideaddedvalueforeachministryinvolved•improvetheunderstandingofwhatisbeingdoneamongCanadianactorsandstakeholders•improveeffectivenessandefficiency,intermsofbothfinancialandhumanresources•provideaclearframework,aimandfocus•supportCanadainmeetingitsdomesticandinternationalheathobjectives•beanexampleofcooperationthatcouldbefollowedinotherareas,suchasagriculture•providearticulatedandidentifiablegoals•providegreatertransparencyonCanada’sglobalhealthgoalsandonactionstakentoachievethem•determinetopics,subjectsandresearchthatmightbeexplored•addressanycompetingobjectivesthatexistwithindifferentdepartmentsoragencies•coordinateandstreamlinethehealth‐relateddepartmentsandagencies•ensurethatCanadacanrespondtounexpectedhealth‐relatedcrises•ensurethatCanada’sinterestsandvaluesarereflectedinitsglobalhealthinitiatives•supportCanada’sforeignpolicyandinternationaleconomicanddevelopmentgoals•strengthennationalsecuritythroughbetterpartnershipsathomeandabroad•respondtothedesiresofCanadiansandstakeholderswhowantCanadatoplayalargerroleinglobalhealth

•mobilizemoreresourcesbyprovidingacentralizedforumwhereallactorscanidentifyopportunitiesforcooperation

•identifyactivitiestobeenhanced,eliminatedorreformedduringresource‐constrainedtimes•helpCanadacoordinatebestpractices•supportCanada’scollaborationwithpartnercountriesthatalreadyhaveaglobalhealthstrategy

CostsCostsinvolvedinaglobalhealthstrategyinclude:•financialandhumanresourcestodevelopingastrategy(staffing,consultations,etc.)•diversionofresourcesandattentionfromotherchallenges•possibleadjustmentormodificationofmissionsamongactors•possibledifficultyinagreeingonacomprehensiveapproach•possiblefactionsordivisionsamongactorsinvolved•delaysindevelopingthestrategy•time‐consuminganalysisofexistingcommitmentsandcomponentstrategies•potentialrequirementormodificationoflegislationtoauthorizetheinvolvementofsomeactorsorresources

•possiblecomplicationsthatarisefromCanada’scomplexfederalsystem


RisksRiskstoCanadainhavingaglobalhealthstrategyinclude:•dissatisfactionamongactorsduetoconflictingpriorities•alienationamongactors•overcrowdingofactors•possibleunintendedconsequences,suchasresourcesdivertedfromissuesthatneedmoreattention•negativeconsequencesforothercountries(suchasseekinghealthprovidersfromothercountries)•unwanteddebates•astrategythatistoorigidtobeabletoadapttochangingsituationsandneeds•astrategythatisunder‐orover‐ambitious•astrategythatdoesnotincludealltherelevantactors•astrategythatistoogeneralorinsufficientlyfocused•limitstocoherenceininvestments•satisficing•logrolling•failuretoachievedeclaredgoals•failuretofulfilexpectationsandsatisfydemandsforaccountability•disregardforexistingcommitmentsinfavourofnewprioritiesorpledges•reducedcompetitionamonghealthactors

Note:Thisisacompilationofpointsidentifiedthroughresearchofpublishedmaterials,keyinterviewsandbrainstormingexercises.


AppendixG:Canada’sFreeTradeAgreements

Canadahasfreetradeagreementswiththefollowing:•Chile•Colombia•CostaRica•Iceland(Canada‐EuropeanFreeTradeAssociation)•Israel•Jordan•Liechtenstein(Canada‐EuropeanFreeTradeAssociation)•Mexico(NorthAmericanFreeTradeAgreement)•Norway(Canada‐EuropeanFreeTradeAssociation)•Panama•Peru•Switzerland(Canada‐EuropeanFreeTradeAssociation)•UnitedStates(NorthAmericanFreeTradeAgreementandpreviouslytheCanada‐U.S.FreeTradeAgreement)

Canadaisnegotiatingfreetradeagreementswiththefollowing:•Americas•AndeanCommunity•CaribbeanCommunity•CentreAmericanFour—ElSalvador,Guatemala,HondurasandNicaragua•DominicanRepublic•EuropeanUnion•India•Korea•Morocco•Singapore•Ukraine

Source:Canada,DepartmentofForeignAffairsandInternationalTrade(2010b).


AppendixH:EffectsofClimateChangeonHumanHealthIdentifiedby

theIntergovernmentalPanelonClimateChange

VeryHighConfidence HighConfidence MediumConfidence LowConfidenceClimatechangecontributestoglobalburdenofdiseaseandprematuredeaths

Emergingevidenceshowsthatclimatechangehasalteredseasonaldistributionofsomeallergenicpollenspecies

Emergingevidenceshowsclimatechangehasaltereddistributionofsomeinfectiousdiseasevectors

Projectedtrendswillincreasenumberofpeopleatriskofdengue

Projectedtrendswillaffectmalaria:contractinsomeareasandexpandinothers;transmissionseasonmaychange

Projectedtrendswillincreasemalnutritionandconsequentdisorders,includingthoserelatingtochildgrowthanddevelopment

Emergingevidenceshowsthatclimatechangehasincreaseddeathsrelatedtoheatwaves

Economicdevelopmentiscomponentofadaptationbutcannotinsulatepopulationfromdiseaseandinjuryduetoclimatechange

Projectedtrendswillincreasethenumberofpeoplesufferingfromdeath,diseaseandinjuryfromheatwaves,floods,storms,firesanddroughts

Projectedtrendswillincreaseburdenofdiarrhealdiseases

Projectedtrendswillchangerangeofsomeinfectiousdiseasevectors

Projectedtrendswillincreasecardiorespiratorymorbidityandmortalityassociatedwithground‐levelozone

Projectedtrendswillbringsomebenefitstohealth,fewerdeathsfromcold,butlikelyoutweighedbynegativeeffectsofrisingtemperatures,especiallyindevelopingcountries

Adaptivecapacityneedstobeimproved;impactsofrecenthurricanesandheatwavesshowthatevenhigh‐incomecountriesnotwellpreparedforextremeweatherevents

Adversehealthimpactswillbegreatestinlow‐incomecountriesand,inallcountries,onurbanpoor,elderly,children,traditionalsocieties,subsistencefarmersandcoastalpopulations

Source:IntergovernmentalPanelonClimateChange(2007b).


AppendixI:ComparisonofNationalGlobalHealthStrategies

Britain Switzerland EuropeanUnion UnitedStatesPrinciples

•Donoharm;evaluateimpactofdomesticandforeignpoliciesonglobalhealthtoensureintentionsarefulfilled

•Baseglobalhealthpoliciesandpracticeonevidence;developevidencewhereitdoesnotexist

•Usehealthasagentforgood,recognizingitcanpromotealow‐carbon,high‐growthglobaleconomy

•PromoteglobalhealthoutcomesthatsupporttheMDGs

•Promotehealthequitythroughforeignanddomesticpolicies

•Ensureeffectsofforeignanddomesticpoliciesonglobalhealthareexplicit;ensuretransparencyonconflictsbetweenthepolicyobjectives

•Workforleadershipthroughreformed,strengthenedinstitutions

•Learnfromothercountries’policiesandexperiencetoimprovepopulationhealthandhealthcaredelivery

•Protecthealthbytacklinghealthchallengesthatbeginabroad

•Workwithothergovernments,multilateralagencies,civilsocietyandbusiness

•Basedonsharedhealthvalues

•Considerhealththegreatestwealth

•ConsiderHealthinAllPolicies(HIAP)

•StrengthentheEU’svoiceinglobalhealth

•Matchambitionswithlong‐termcommitmentsatthehighestlevelsofUSleadership

•“Trustbutverify”•Buildonexistingsuccesses

•Prioritizeprevention•Betargeted•Embedglobalhealthinvestmentswithinlargerdevelopmententerprise


Britain Switzerland EuropeanUnion UnitedStatesGoals

•Betterglobalhealthsecurity

•Stronger,fairerandsafersystemstodeliverhealth

•Moreeffectiveinternationalhealthorganizations

•Stronger,freerandfairertradeforbetterhealth

•Strengtheningofthewayevidenceisdevelopedandusedtoimprovepolicyandpractice

•ProtecthealthinterestsoftheSwisspopulation

•Harmonizenationalandinternationalhealthpolicies

•Improveeffectivenessofinternationalcollaborationinhealth

•Improveglobalhealthsituation

•Safeguardroleashosttointernationalorganizationsandbaseforcompaniesinhealthsector

•FosteringgoodhealthinanagingEurope

•Protectingcitizensfromhealththreats

•Supportingdynamichealthsystemsandnewtechnologies

•MaintaincommitmenttofightagainstHIV/AIDS,malariaandtuberculosis

•PrioritizewomenandchildreninUSglobalhealthefforts

•Strengthenpreventionandcapabilitiestomanagehealthemergencies

•EnsuretheUnitedStateshascapacitytomatchglobalhealthambitions

•Investinmultilateralinstitutions

Measures •Establishcoordinating

officeforhealthforeignpolicy

•Createinformationplatformforhealthforeignpolicy

•Producepolicypapersonhealthforeignpolicyandstrengthenacademiccompetence

•Harmonizewithgeneralforeignpolicyandotherpolicies

•CreateInterdepartmentalConferenceonHealthForeignPolicy

Resources•07%ofGNIoninternationaldevelopmentby2013

•£6billiononhealthsystemsandservices(2008–15)

•£1billionfortheGlobalFund

•£400millionforglobalhealthresearch(2008–13)

•Noadditionalresourcesplannedforimplementation

•Actionssupportedbyexistingfinancialinstrumentsuntilendof2010financialframework(2013),withoutadditionalbudgetaryconsequences

•$63billionforGlobalHealthInitiative(2009–14)

•$25billionannually(adjustedforinflation)(2010–15)

•increasemultilateralfundingfrom15%to20%


Notes:BoldindicatesactionswhereCanadianprioritiesandinterestsoverlap.

GlobalFund=GlobalFundtoFightAIDS,TuberculosisandMalaria;GNI=grossnationalincome;MDGs=MillenniumDevelopmentGoals.

Sources:Switzerland,FederalDepartmentofHomeAffairsandFederalDepartmentofForeignAffairs(2006);UnitedKingdom,HMGovernment(2008);CommissionoftheEuropeanCommunities(2007);Sridhar(2009);FallonandGayle(2010).


AppendixJ:StepsforCreatingaCanadianGlobalHealthStrategy

ThenextstepstoconsiderwhendevelopingaCanadianglobalhealthstrategyshouldincludethefollowing:

1. Chooseataskteamthatwillberesponsibleforoverseeingandreviewingtheprocess,reportingonimplementationandsuggestingnextsteps.Anindependent,third‐partycouldmakeupthisteamoritcouldcomprisekeyofficialsfromHealthCanada,PublicHealthAgencyofCanada(PHAC),theCanadianInternationalDevelopmentAgency(CIDA)andtheDepartmentofForeignAffairsandInternationalTrade(DFAIT).TheteamwouldberesponsibleforoverseeingtheCanadianglobalhealthstrategyandcoordinatingtheadditionaldepartmentsandactorsinvolved.

2. Engageintwophasesofconsultationswithallkeyactors,bothwithinHealthCanadaandPHACaswellasinterdepartmentallyatthefederallevel,toincludethePrimeMinister’sOffice,DFAIT,AgricultureandAgri‐FoodCanada,EnvironmentCanada,IndianandNorthernAffairs,PublicSafetyCanada,DepartmentofNationalDefence,IndustryCanada,CIDAandtheCanadianFoodInspectionAgency.ConsultationsshouldalsoincludetheHealthCouncilofCanada,theCanadianInstitutesofHealthResearch,theInternationalDevelopmentResearchCentre,andprovincialandterritorialgovernments.Theyshouldalsodrawonexpertisethatexistsintheprivatesectorandincivilsociety,includingphilanthropicentities,non‐governmentalorganizationsandacademia.

•PhaseOne:IdentifytheobjectivesoftheCanadianglobalhealthstrategyandtheirunderlyingprinciplesofthoseobjectives.Thetaskteamshouldcompilealistofalltheobjectivesandprinciples.Anycontradictionsthatcannotberesolvedinternallyshouldbeaddressedwiththeinvolvementofrelevantoutsideactors.Provincial,internationalandpublicobjectivesandprinciplesshouldbenextconsideredandcomparedwiththoseidentifiedforanationalglobalhealthstrategy.

•PhaseTwo:DeterminetheprioritiesoftheCanadianglobalhealthstrategy.Thespecifictargetsshouldbeweightedaccordingtothosewiththemostsupportamongstakeholdersandthenplacedwithinabroaderframework.Theleadandsupportingactorsforeachactionshouldthenbeidentified.

5. Thetaskteamshouldchooseanappropriatetimelinethatfitswiththeestablishedpriorities.Afive‐yeartermisconsistentwiththeothercountries’globalhealthstrategiesandfitswellwithintheMillenniumDevelopmentGoals.However,theprioritieschosenshoulddictatethetimeframe.Thescheduleforconductingreviewsshouldalsobedecidedsothatthestrategycanremainrelevantandeffective.

6. ThetaskteamshouldidentifypartnerswithinCanadafromoutsidegovernment,includingacademia,theprivatesectorandcivilsociety,aswellasothernationalgovernmentsandinternationalorganizations.

7. Thetaskteamshouldidentifynecessaryresourcestodeveloptheglobalhealthstrategy,includingfinancialcommitments,humanresourcesandprogrammingcoststoimplementtheglobalhealthstrategy.


AppendixK:ResearchMethodology

AteamofresearchersfromtheUniversityofToronto’sGlobalHealthDiplomacyProgramandG8ResearchGroupcompiletheappendicesfrompublishedandpublicmaterial.TheanalysisusedtoidentifytheCanadianprinciplesrelevanttoglobalhealthwasbasedonasystematicanalysisofallhealth‐relatedpassagesintheSpeechesfromtheThroneandmajorforeignpolicystatementssince1947,includingstatementsbyCanadianprimeministersattheUnitedNationsGeneralAssemblyandstatementsmadebyCabinetministers.Materialsareavailableuponrequest.

InterviewswereconductedwithkeystakeholdersandexpertsinthefieldsrelatedtoCanadaandglobalhealth.

DeliberationsheldattheGlobalHealthDiplomacyProgram’sconferenceon“Accountability,InnovationandCoherenceinG8HealthGovernance:SeizingCanada’sG8Opportunity”inJanuary2010attheMunkCentreforInternationalStudiesinTrinityCollegeattheUniversityofTorontowereconsidered.

Theauthors’fieldexperiencesandpastresearchweredrawnon.

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