Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 1 ORIGINAL RESEARCH Global health in foreign policy in South Africa – Evidence from state actors Moeketsi Modisenyane 1, Flavia Senkubuge1, Stephen JH Hendricks1 1 School of Health Policy and Systems, Faculty of Health Sciences, University of Pretoria, South Africa. Corresponding author: Moeketsi Modisenyane BSc, BEd, MSC, MPH; Address: School of Health Policy and Systems, Faculty of Health Sciences, University of Pretoria, South Africa; Telephone: +27123958833/4; E-mail: modisem44@gmail.com Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 2 Abstract Aim: There are currently debates about why South Africa integrates global health into its foreign policy agendas. This study aimed at exploring motivation and interests’ South African policy actors pursue to advance global health and the processes that lead to such integration. Methods: The study utilized a mixed-method design from a sample of state policy actors at the National Department of Health of South Africa. Participants were selected purposively and had experience of more than three years participating in various international health activities. All participants completed semi-structured questionnaires. Quantitative data was analysed to determine frequencies and transcribed text was analyzed using qualitative content analysis. Results: A total of 40 people were invited, of whom 35 agreed to participate. Of the respondents, 89.7% (n=32) strongly argued that health should facilitate ‘free movement of people, goods and services’. Majority (79.0%, n= 29) agreed that ‘development and equality’ are the main elements of foreign policy. Of the respondents, majority 77.1% (n=27) agreed that ‘moral and human rights’ are the main elements of foreign policy. Furthermore, 82.8% (n=29) agreed that the country should advance ‘Africa regionalism and south-south cooperation’ and 85.7% (n=30) strongly argued for a ‘whole-government approach’ in addressing global health challenges. ‘HIV/AIDS’ and ‘access to medicines agenda’ were the main policy issues advanced. The main domestic factors shaping South Africa’s involvement in global health were its ‘political leadership’ and ‘capacity of negotiators’. Conclusion: It is evident that within South Africa, state policy actors are largely concerned with promoting global health interest as a normative value and a goal of foreign policy, namely, human dignity and development cooperation. Furthermore, South Africa drives its global health through building coalition with other state and non-state actors such as civil society. HIV/AIDS, as a policy issue, presents a potential entry point for engagement in global health diplomacy. Keywords: diplomacy, foreign policy, global health, global health diplomacy, South Africa. Conflicts of interest: None. Acknowledgment: National Department of Health, South Africa. Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 3 Introduction Global health diplomacy (GHD) has dramatically increased in the recent years in global health and international relations (1,2). Amid this enthusiasm, it is apparent that the concept of GHD is an emerging concept, with new evidence and debates emerging but with clearly diverse and sometimes poorly clarified meanings ascribed to the terms (3,4). In addition, rapid increase in the number of state and non-state actors in global health is an important development. However, the main challenge for governments and non-state organizations is to develop a multisectoral and coherent approach to overcome fragmented policies (5). While the global health practitioners have welcomed this elevated political priority, there have been questions and debates about why and how South Africa has conceptualized and contributed to global health diplomacy. Furthermore, there has been less examination of why South Africa incorporates global health into its foreign policy agenda since 1994 elections. This then raises the question: why South Africa incorporates global health into its foreign policy? Therefore, these questions, and the broader issue of understanding the relationship between global health and foreign policy in South Africa are the focus of this study. Along this pathway, the study explored in-depth information on the views of senior state policy actors with the intention of generating new explanations or theory to account for pattern of such health influenced behaviour. As such, deductive process from existing knowledge and theory will be followed which would then be further tested and refined. Furthermore, the study explored the strategies, policy issues, domestic factors and diplomatic practices that would shape South Africa’s involvement in global health. Several authors have tried to introduce frameworks to analyse the relationship between global health and foreign policy. Whichever framework of GHD is used, most of the authors have agreed that no single policy framework offers a fully comprehensive description or understanding of the integration of global health into foreign policy as each answers somewhat different questions. Furthermore, some authors indicated that there are differing arguments between and within these policy frames, while others are overlapping, and can also be contradictory. In this study, Labonte and Gagnon framework was used to better explain why South Africa incorporates global health into its foreign policy agenda. Labonte and Gagnon (2010) use the deductive approach using six policy frames, namely: security; development; global public good; trade; human rights and ethical/moral reasoning (6). Therefore, this paper, using the framework developed by Labonte and Gagnon’s health and foreign policy conceptualizations, contributes to this goal by reviewing health in foreign policy through an empirical research case study of South Africa. Methods Participants The study utilized a mixed-method design including both qualitative and quantitative methods (7). A cross-sectional study was conducted amongst state policy actors at the National Department of Health (NDoH), in Pretoria, the capital city of South Africa. Purposeful sampling (8) was used to identify and recruit interviewees based on relevant peer- reviewed or grey literature, as well as the lead author’s professional networks in global health and development. We then employed snowball sampling to enrol additional interviewees until we achieved theoretical saturation, that is, until successive interviews produced no new concepts. Participants eligible for in-depth interviews were key informants who had extensive experience in international negotiations for improved access to medicines in each of the three cases. Inclusion criteria consisted of key informants who had extensive experience and skills Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 4 (such as more than five years) in participating in international negotiations, which include bilateral, regional and multilateral activities and more than five years working in the health sector. Key informants not meeting the above inclusion criteria were excluded. The reason for using semi-structured interviews was to help to reduce bias, sequence, clarity and face validity (9). The need for ‘extra’ sampling arose during the process of interviewing and preliminary theorizing or analysis. The total of eligible participants was 40, and 35 individuals participated in the study giving a response rate of 87.5%. All participants completed a semi-structured questionnaire. Nevertheless, the study sample in general was limited by the number of state policy actors who normally participate in international health activities, especially in multilateral negotiations. Participants provided written informed consent. The items in the questionnaire were adapted from the previously published instrument used by Labonte (6,10). However, the questionnaire was adapted to fit South African context and discussed thoroughly until a consensus was reached, based on agreed criteria. In order to improve clarity, the questionnaire was pilot-tested amongst three state policy actors within the NDoH representing different areas. This pilot test provided the opportunity to refine the questions for clarity and local adaptation. Data collection Data for this study was gathered by using a self-administered semi-structured questionnaire. The closed questions provided an assessment of views and perspectives of state policy actors regarding what interests South Africa pursue when it engages in global health issues. The first five items provided socio-economic indicators of the respondents, namely: ranks; gender; health programme or service responsible for; experience working in health sector; and experience in participating in global health activities. The following 14 items were scored on a five-point Likert scale anchored at 5 as strongly agreed and 1 as strongly disagreed, with a mid-point for unsure. The structure of each question was in the following form: ‘The main motivation and/or interests used to justify why health should be a prominent element of foreign policy is that health is a global public good’. For these 14 items, participants were asked to provide a detailed narrative explanation or provide examples. By use of written individual narratives to explain their views, this process provided a validity check and complemented the findings. One item asked participants to identify the biggest challenges that South Africa face in fulfilling its commitment to global health. Procedures In the first stage of data collection, a semi-structured self-administered survey was given to 40 state policy actors within the NDoH who had participated in global health negotiations in various global health forums. All the potential participants were approached, and were asked if they were willing to participate in the study. In addition, the questionnaire was also given two present and previous health attachés who were willing to participate in the study. The questionnaires were delivered during lunch breaks and all potential participants were explained the purpose of the study and were asked about their willingness to participate. A register was made to record the number of questionnaires issued out. In case where participants were not in the office or were absent, appointments were made for a follow-up visit. The second stage of data collection included a review of published literature and reports on why South Africa incorporates global health into its foreign policy agenda. Searches were Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 5 conducted in numerous databases (PubMed, MEDLINE, Social Science Citation Index and Science Direct), selecting articles and reports that either directly addressed the relationship between global health and foreign policy, or were case studies of an interaction between global health and one or more of the six dimensions of foreign policy in South African context. Quantitative data was entered anonymously into the database. The data editing and data capturing on spreadsheet were initially done on site by the research team as soon as the completed questionnaires became available. Double data entry and validation was done by two operators at the University of Pretoria using the statistical package Epi-info, version 13. In the case of qualitative data from both the primary (questionnaire) and the secondary sources, the data were transcribed into Microsoft Word, and initial notes were written which were used during the coding cycle. The process, settings, events, as well as discussions with respondents were all meticulously recorded. The study received ethical approval from the Research and Ethics Committee of the University of Pretoria and the NDoH of South Africa. In addition, participants provided informed consent to participate in the study. Analysis Quantitative data was exported using Start Transfer and analysis was done using the statistical package Stata (Version 12). Following cleaning of the data, variables were recorded. The main outcome measure was successful participation in global health diplomacy. Descriptive statistical analysis was used to compute frequency distributions and sample characteristics in order to summarize and describe data in a concise form. In the case of qualitative variables emanating from survey questionnaire, published literature and government reports on global health and foreign policy, data was analyzed for content (9). All the texts were read several times and were labelled with codes to conceptualize and categorize the respondents’ experiences. Codes sharing communalities were grouped into sub-categories, which later supported the construction of categories. Analysis was done concurrently with data collection, making interpretations and preliminary reports on ongoing basis. The explanations given by participants in the survey questionnaire illuminated the experiences, perspectives and views of state policy actors. A ‘thick description’ of both participants and document quotes were presented throughout the results section to contribute to the trustworthiness of the research (9). The study used a combination of emerging codes and those that fitted already predetermined codes. Secondary sources were also used to support and give context to the findings. The analysis was characterized by constant comparison of the sub-categories and categories with the original text to ensure that the interpretations were grounded in the data (9). Limitations A limitation is that it was not possible to examine all papers across a broad range of public health, political science and international relations literature dealing with the understanding of international networks’ GHD processes. Thus, this study is not a comprehensive review of every published article related to this subject; rather, this study sought key literature that illuminates the relationship between global health and foreign policy. Furthermore, this study did not interview all possible key informants. In addition, there was a potential for selection bias resulting from the purposive sampling and initial selection of documents to be analyzed. In an attempt to mitigate or overcome this problem, we expanded the analysis to examine documents from other sources. Furthermore, there was a high rate of responsiveness of many Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 6 potential respondents who had knowledge and experiences in participating in negotiations for integration of health into foreign policy in South Africa. The responses from the questionnaire served as a useful purpose of validating the data from the published literature and reports, and acted as a control mechanism to test the validity of the findings. Results A total of 35 state policy actors completed the questionnaire, providing their views about why South Africa incorporates global health into its foreign policy agendas. The response rate was 87.5%. Table 1 presents the socio-demographic characteristics of the study participants. Of the 35 respondents, 54.3% (n=19) were female; 45.7% (n=16) were at post level 13 (Directors); 48.6% (n=17) had more than 15 years experience working in health sector; and 34.3% (n= 12) had between 5 to 10 years experience participating in global health activities. Table 1. Socio-demographic characteristics of study participants Variable Number Percentage Gender: Male Female Total 16 19 35 45.7 54.3 100.0 Rank: Post level 15 Post level 14 Post level 13 Post level 12 or below 2 6 16 11 5.7 17.1 45.7 31.4 Experience in the health sector: >15 years 10-15 years 5-9 years <5 years 17 8 8 2 48.6 22.9 22.9 5.7 Experience in the health sector: >15 years 10-15 years 5-9 years 3-4 years 6 7 12 10 17.1 20.0 34.3 28.6 Analysis of the quantitative and qualitative data from the questionnaire and published literature resulted in 16 categories that correspond to four content areas, namely: motivations and interests used to advance global health agenda; strategies and approaches used to advance global health; domestic factors affecting South Africa’s participation in global health discourse and policy issue(s) to be advanced in global health. Motivations and interests used to advance global health agenda The responses are shown in Table 2. Of the respondents, the majority 89.7% (n=32) agreed that health is a global public good. Conversely, only 42.8% (n=15) agreed that health is part of global security concerns. However, a significant number of respondents, 34.3% (n=12) disagreed that security concerns is the main motivation why health is an element of foreign policy. Of the respondents, 45.9% (n=16) agreed that trade and economic interest are the Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 7 main elements of foreign policy. Of the respondents, majority agreed 79.0% (n=29) that development assistance for health is the main element of foreign policy. Furthermore, the majority 77.1% (n=27) agreed that human rights and ethical/moral reasoning are main elements of foreign policy. Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 8 Table 2. Motivation and interest used to advance global health Variable Number Percentage Global public good: Strongly disagree Disagree Not sure Agree Strongly agree 0 0 3 8 24 - - 8.6 22.9 68.6 Security argument: Strongly disagree Disagree Not sure Agree Strongly agree 0 12 8 6 9 - 34.3 22.9 17.1 25.7 Trade and economic interest: Strongly disagree Disagree Not sure Agree Strongly agree 4 8 7 9 7 11.4 22.9 20.0 25.7 20.0 Development agenda: Strongly disagree Disagree Not sure Agree Strongly agree 1 1 5 11 17 2.9 2.9 14.3 31.4 48.6 Human rights and moral reasoning: Strongly disagree Disagree Not sure Agree Strongly agree 0 2 6 11 16 - 5.7 17.1 31.4 45.7 In order to complement the quantitative results presented above, the qualitative analysis of the narratives from the semi-structured questionnaires, published literature and government reports regarding why health is a prominent element of foreign policy in South Africa, post 1994, resulted in the following categories: Free movement of people, goods and services Most of the respondents believe that due to globalization, health is becoming a global public good, as indicated below: ‘Globalization and movement of people into the country and out of the country due to country to country interactions, asylum seeking activities, wars that cause people to be displaced, health tourism, sports. People movement and goods may result in transfer of disease pathogens from country to country’ [respondent no 25]. Human security and better health for all Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 9 Most respondents have argued strongly on focusing on human security, safety and protection of the individuals more than the state security, as indicated below: ‘Public health issues goes beyond bioterrorism and outbreaks of influenza. Public health is about addressing inequalities and social determinants of health and therefore must be an important element of all foreign policy. Health has no geographic border, it affect all people, everywhere’ [respondent no 8]. However, some respondents are of the view that acute outbreak of infectious diseases such as SARS and H1N1, threaten the citizens and security of the country. As a result, there is a need to establish effective cross border disease control and management, as indicated below: ‘The world we live in has become highly permeable and an attack on one nation has got a ripple effect in term of other nations. This was evident during the H1N1 influenza outbreak’ [respondent no 26]. Socio-economic development and equality Most of the respondents have argued strongly that trade and commerce should not lead to reduction of the fundamental rights to health and dignity, as indicated below: ‘The issue of trade and socio-economic interest should not be at the centre stage undermining people’s rights to health and dignity’ [respondent no 26]. Some of the responses from state policy actors clearly indicate tensions in the trade-and- health relationships due to conflict between economic interests and global health goals, as indicated below: ‘Again, although this is a realistic and driving force for many countries’ foreign policy, it would be better if this was discounted, but that would be regarded as naïve’ [respondent 20]. Development, equality and solidarity Most respondents have argued that South Africa’s engagements in global health should lead to the advancement of developmental health agenda and equality, located within African solidarity, as indicated below: ‘SA in line with its foreign policy has always prioritized development and equality, such as making spaces available for training of students from SADC, assist other countries such as DRC, Rwanda during humanitarian situation’ [respondent no 28]. Furthermore, most respondents are of the view that South Africa should strengthen its international cooperation and developmental assistance, and also address issues of poverty and underdevelopment, as indicated below: ‘Consolidation of the African agenda is key to the RSA’ foreign policy. To this end, the goal of this priority is for the Continent to be able to resolve conflicts and building of an environment in which socio-economic development can flourish’ [respondent no 3]. Rights-based structural cooperation Most respondents argued that South Africa’s engagements in global health should be framed within human rights, morality and democratic principles, as indicated below: ‘(SA) Constitution, align with it. Regional perspective in terms of our moral and human right standing in the Africa Continent’ [respondent no 23]. The review of the available published literature highlighted the need for South Africa to use its role of peace making and institutions building in Africa, as part of its continent’s renewal and advancement of interest of the developing countries (11). The literature also revealed that South Africa should use its moral power, its own struggle for democracy, commitment to promoting human rights, and multilateral focus, to leverage its own sovereignty and that of weaker states, especially in the areas of access to medicines and migration of health Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 10 professionals (12). Many authors argue that South Africa needs a stronger and focused foreign and global health policies (12,13). This focused global health policy can include the identification of strategic global health priorities, greater institutional co-operation with agencies dealing with health and foreign policy; and the need for South Africa to develop a stronger leadership role in the African continent on global health. Strategies and approaches used to advance global health The responses are shown in Table 3. Of the respondents, majority 82.8% (n=29) agreed that South Africa build coalition with other countries. Table 3. Strategies, approaches and domestic factors used to advance global health Variable Number Percentage Coalitions with other countries: Strongly disagree Disagree Not sure Agree Strongly agree 0 3 3 13 16 - 8.6 8.6 37.1 45.7 Capacity building for actors or negotiators: Strongly disagree Disagree Not sure Agree Strongly agree 11 12 11 1 0 31.4 34.3 31.4 2.8 - Role of other ministries: Strongly disagree Disagree Not sure Agree Strongly agree 0 0 5 13 17 - - 14.3 37.1 48.6 Role of academia and private sector: Strongly disagree Disagree Not sure Agree Strongly agree 0 0 2 15 18 - - 5.7 42.9 51.4 Role of civil society: Strongly disagree Disagree Not sure Agree Strongly agree 1 2 1 14 17 2.9 5.7 2.8 40.0 48.6 Domestic factors: Strongly disagree Disagree Not sure Agree 1 1 9 10 2.9 2.9 25.7 28.6 Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 11 Strongly agree 14 40.0 However, 65.7% (n=23) said that there is no national programme for capacity building for South African actors or negotiators on global health issues. Of the respondents, 85.7% (n=30) agreed that other ministries have a role to play in addressing global health challenges. Of the respondents, 94.3% (n=33) agreed that academia and private sector have a role to play in addressing global health challenges. Of the respondents, 88.6% (n=31) agreed that civil society have a role to play in addressing global health challenges. To complement the quantitative results shown above, the qualitative analysis of narratives from the semi-structured questionnaires and available literature regarding strategies and approaches used to advance South Africa’s involvement in global health, post 1994, resulted in the following categories: Whole-government approach Most respondents argued that South Africa’s engagement in global health should include consistency of purpose across all government sectors, as indicated below: ‘Health needs a “whole government approach”. This is very well illustrated with regards to NCDs, where we need changes in eating, behavior, physical activity, etc. We cannot achieve this without changing pricing of health, foods, involvement of schools, sport, transport, etc.’ [respondent no 14]. Role of non-state actors Most respondents argued that South Africa’s engagements in global health should use the soft power of non-state actors such as civil society, academia and private sector as a global health policy instrument, as indicated below: ‘… For example the NCD Alliance played a prominent role in advocating for the UNEA political declaration on NCDs and gave perspectives of users and experts, which was critical to the final declaration’ [respondent no 14]. African regionalism Most respondents argued that South Africa’s engagements in global health should be framed within Africa’s socio-economic development agenda, as indicated below: ‘Consolidation of the African agenda is key to the RSA’ foreign policy. To this end, the goal of this priority is for the Continent to be able to resolve conflicts and building of an environment in which socio-economic development can flourish’ [respondent 3]. South-south cooperation Most respondents argued that South Africa’s engagements in global health should aim at advancing development socio-economic development within the developing world, as indicated below: ‘ … IBSA promotes South-South cooperation and build consensus on issues of increasingly trade opportunities amongst the three countries as well as exchange of information, technology and skills to complement each other’s strengths’ [respondent 3]. The review of the available literature highlighted that non-state actors, including civil society, universities and other academic institutions, as well as private cooperation, have contributed to the advancement of global health goals (11,12). For example, South African health activists community like Treatment Action campaign (TAC) and COSATU, in consultation with transnational activism networks in the global south, have advocated for a broader access to affordable medicines, especially ARVs. Furthermore, the country was successful in Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 12 building strategic alliances with countries such as Brazil, during negotiations of 2001 Doha declaration on the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS). Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 13 Domestic factors affecting South Africa’s involvement in global health The responses are shown in Table 3. Of the respondents, majority 68.6% (n=24) agreed that South Africa’s newly assertive foreign policy and global health remains constrained by its domestic challenges. Furthermore, 65.7% (n=23) indicated that South Africa has no capacity building programme for its actors or negotiators. The qualitative analysis of narratives from the semi-structured questionnaires and the available literature regarding domestic factors affecting South Africa’s involvement in global health, post 1994, resulted in the following categories:  High disease burden: Most respondents argued that South Africa’s engagements in global health should be framed within South Africa disease burden or challenges, as indicated below: ‘RSA is faced with quadruple diseases that impact immensely on the economy and this is compounded by the HR scarce to meet the health needs of the people’ [respondent no 6].  Political leadership: Most respondents argued that South Africa’s engagements in global health are shaped by the leadership that was provided recently, especially in the area of HIV and AIDS and recently in non-communicable diseases, as indicated below: ‘HCT (HIV/AIDS Counseling and Treatment) campaign initiated by the Minister of Health has drawn interest globally and regionally and has had a positive influence in the global agenda’ [respondent no 8]. ‘In the past decade SA has taken a particular leadership role in HIV and AIDS, MDGs and now recently in NCDs. Also in Tobacco Framework and now alcohol related harm’ [respondent 14].  Moderate resources: Most respondents argued that South Africa’s engagements in global health have been shaped by its moderate resources, especially its scientific skills, R&D and private sector, as indicated below: ‘Our technical and expert knowledge will be our entry into new market in Africa, South Americas and Asia. With expansion in develop countries to assist with global financial crises’ [respondent 30].  Capacity of negotiators: Most respondents indicated that there is no health diplomacy training programme for actors or negotiators, as indicated below: ‘Available programmes are not specific for health, but assist in orientating health actors, like the orientation programme for Ambassadors by DIRCO’ [respondent no 11]. The review of the literature clearly indicated that despite South Africa’s increasing participation in global health discourse, it is facing several constraints in implementing its global health initiatives. These constraints are found in South Africa’s socio-economic challenges and institutional capacity (13). The country faces challenges of high unemployment, poverty and inequality. On health, the country face quadruple burden of diseases, due to HIV and AIDS and TB, an increasing burden of chronic diseases, high rates of interpersonal violence and injuries (14). This has limited South Africa’s scope and influence of its global health assistance programme. That said, literature has also highlighted that South Africa has had broad influence and has provided leadership on global health, especially in terms of clinical research, advocacy and policy (15). The literature also indicated that South Africa’s weak institutional capacity of its negotiators is another major challenge to its ability to deliver a robust global health policy befitting its Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 14 newly enhanced global standing. Nonetheless, South African actors or key negotiators have played significant role in major negotiations, such as during negotiations of TRIPS agreement, WHO FCTC tobacco control and WHO Code for Ethical Recruitment of Health Professionals. During these negotiations, South Africa has demonstrated its ability to play a leadership role in the South, as a facilitator and a bridge-builder between North and South. Policy issue(s) to be advanced in global health  Access to medicine agenda: Most respondents argued that South Africa’s success in global health diplomacy has been achieved within access to medicines control, especially in ensuring availability ARVs to all, as indicated below: ‘SA realizes that it will not be able to provide medical care to all unless it assists in bringing prices of medicine down. It therefore collaborate(s) with other countries and strategizes how best this can be done’ [respondent no 14].  HIV/AIDS: Most respondents argued that South Africa’s success in global health diplomacy has been achieved within area of HIV and AIDS, as indicated below: ‘Without SA’s interventions on issues such as HIV, the world would not have moved to where it currently is’ [respondent 14].  Tobacco control: Most respondents argued that South Africa’s success in global health diplomacy has also been achieved within the WHO’s FCTC, as indicated below: ‘FCTC is a(n) excellent example where we were proactive & prepared & followed through with active … actions & perseverance & purpose!’ [respondent no 20]. ‘SA was one of the first few countries to ratify the WHO FCTC’ [respondent no 8]. The literature review highlighted that, given that nearly six million South African are HIV- positive, the country can take up the global leadership on HIV and AIDS (11). The notion of niche or focused diplomacy brings the identification of ‘transnational issue networks’ that can be used to advocate for improved health outcomes (12). In addition, South Africa need to use its bridge-builder and facilitation ability, to explore closer multilateral ties with Brazil (via IBSA) to seek to advancement of a shared health goals (11,12,16). Discussion Findings from the current study reveal that South Africa’s participation in global health discourse is limited by its domestic health challenges. The findings confirm other studies in that South Africa is faced with challenges of epidemics such as HIV/AIDS and TB, an increasing burden of chronic diseases including obesity, and high rates of interpersonal violence and injuries (11). Behind these epidemics, there is the continuing mortality of mothers, babies and children, which still primarily affects the poorest families. Hence, the findings of the study are in line with results of other studies which have demonstrated that South Africa has understandably chosen to prioritize domestic health over global health (11). The findings of this study are also in line with other studies in that South Africa should use a human rights framework to position its approach to health diplomacy (11,12). South African government has used its human rights emphasis to champion for increase access to antiretroviral drugs in order to provide universal treatment to all HIV-positive people. However, studies have also revealed that South Africa has experienced a palpable tension between the politics of solidarity and sovereignty on the one hand and human rights on the other, as evidenced in its voting patterns on Zimbabwe to Libya in the UN Security Council and AIDS denialism (17). Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 15 This study, consistent with other studies, confirms that overemphasis on health security overshadow the opportunity to use health as a constructive and novel perspective to shape international, transnational and global action (17,18). The findings support other studies in that the governance of health threats should be about the search for equity, justice and well being, other than the current perspective of protection of international commerce from a free- riding epidemics (11,19). The findings of this study are also consistent with other studies in that some state policy actors still tend to focus on “high politics” of health issues, rather than on “low politics” in which health issues are seen as a reflection of human dignity (11,19). The findings of this study are consistent with many other studies that have argued that South Africa should explicitly pursue issues of poverty and equality within its global health agendas and debates (11,19). Furthermore, studies have highlighted that South Africa’s attention on global health diplomacy should focus on global trade, as ‘trade and health linkage highlights the new prominence of health within foreign policy’ (20). The findings of this study are consistent with other studies and reports that have reported that South Africa does allocate limited resources to health assistance through multilateral agencies, bilateral channels and other South-South partnerships (15,21). The findings suggest that South Africa can play a more transformative role, through providing focused technical assistance for health projects, supplying medical goods and services to very poor countries in its immediate geographic neighborhood. For example, South Africa has provided funding to Seychelles for infrastructure rehabilitation and Republic of Guinea to boost rice production (21). The findings of this study are consistent with other studies in that the contribution of non- state actors, including civil society, universities and other academic institutions, as well as private cooperation, is an important development in the advancement of global health goals (11,15). For example, South African health activists community like Treatment Action Campaign (TAC), in consultation with transnational activism networks in the global south, have advocated for broader access to affordable ARVs and health care services in South Africa and developing countries.15 This study is consistent with other studies, in that South Africa as an emerging middle income country, should prioritize its global health efforts (17). South Africa should avoid using rhetoric or ineffectual diplomacy, and try to be all and do all for everyone. For example, Brazil used focused diplomacy in areas of antiretroviral drugs, using health rights framework, while Cuba and China used medical diplomacy to achieve their foreign policy goals (22,23). Therefore, given the current burden of diseases, South Africa can use its HIV and AIDS diplomacy as a project of emancipating and transformation, rather than an affirmation of the world as it is (15). Lastly, this study found that there is no formal training programme for actors and diplomats on global health diplomacy in South Africa. Other studies have also indicated the need for the development of a training programme on global health diplomacy (24,25). All these studies have clearly indicated that for health to be a sustainable lens for foreign policy thinking and agenda setting, it must be mainstreamed into the training of diplomats and health officials. This finding therefore highlights the need for South Africa to take a lead in training of diplomats and health officials within the country and in the Africa region. Conclusion This study has showed that South Africa has a limited engagement in global health diplomacy. South Africa is still inward focused, and that its domestic challenges (such as especially the burden of HIV/AIDS and TB) will drive its engagement internationally. Modisenyane M, Senkubuge F, Hendricks SJH. Global health in foreign policy in South Africa – Evidence from state actors (Original research). SEEJPH 2016, posted:20 September 2016. DOI 10.4119/UNIBI/SEEJPH- 2016-129 16 Furthermore, due to its domestic challenges, South Africa has not taken a regional leadership role in global health diplomacy. South Africa’s economic diplomacy can presents a potential entry point for engagements in global health diplomacy. Non-state actors might also push the government to be more actively engage in global health diplomacy. 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Bull World Health Organ 2007;85:971-3. __________________________________________________________ © 2016 Modisenyane et al; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=Silberschmidt%20G%5BAuthor%5D&cauthor=true&cauthor_uid=18278266 http://www.ncbi.nlm.nih.gov/pubmed/?term=Alcazar%20S%5BAuthor%5D&cauthor=true&cauthor_uid=18278266