Inada Hiroyuki Yamaya www.jogh.org 4 3 2 1 Haruka Sakamoto the G7 presidency leveraging by agenda political global health architecture atop ’s contribution to making NationalInstituteofInfectiousDisease,Japan,, Japan ofForeign Ministry Affairs ofJapan,Tokyo, Japan ofHealth, LabourandWelfare Ministry ofJapan, Tokyo, Japan DepartmentofGlobalHealthPolicy, UniversityofTokyo, Tokyo, Japan meetings canbeadriving force. health agendasatinternational ed meetingsandprioritizing el policy-makers at health-relat agenda. Attendance of high-lev awareness fortheglobalhealth is acrucialingredientforraising Having thehigh-levelchampions 2 • doi:10.7189/jogh.08.020313 , Takuma Kato outbreak in2014provided awake-upcallthatdrew theworld’s attentiontoGHA.TheWorld HealthOr [2 prospects economic and governance global in uncertainties and priorities, debates onGHAhavebeenfueledbythecomplexinteractions betweenhealthtransitions,global gaged in global health and the processes through which they work together” by Kickbusch et al. [2 en- actors different many the between relationship “the as defined is (GHA) architecture health Global further confoundedbynewlyemerging politicalandeconomicactorsinglobalhealtharena. [1 years recent in stagnated has health global for Assistance Development ficial the globaleconomy, terrorism, migration/refugees, andclimate change. Consequently, the amount of Of- ing numberofglobalissuescompetingforattentionamongpolicymakers,includingdownsiderisksto tainable DevelopmentGoalsgivelessattentiontohealthchallenges.Additionally, there isalsoanincreas- suffering from adoubleburden ofdiseases.Compared withtheMillenniumDevelopmentGoals,Sus- Global healthiscurrently atacrossroads. Themajorityoflow-andmiddle-incomecountriesare now FRAGILITY OFGLOBALHEALTHGOVERNANCE CHANGING DYNAMICSINGLOBALHEALTHANDFUNDAMENTAL 2 1 , NaokoYamamoto , SatoshiEzoe 2 , KenichiKomada - - 2 and theprovision ofotherpublicgoods[3 these core functions:containmentof viraltransmission,vaccineprovision, includingthatoftheWHO,whichcouldnot handle existing governance, tions in2007,theEbolaoutbreak revealed thefundamentalfragilityof ing theirefforts Health Regula- on GHA suchasrevision ofInternational externalities [4 todealwith international goods andtheimplementationofinterventions globalhealthorganizationsinternational bethepromotion ofglobalpublic [ efficiently, which has evoked a series of debates and controversies on GHA health, wascriticizedfornothandlingtheEbolaoutbreak effectively and ganization (WHO), as the only United Nations (UN) agency specializing in , KotonoHara 3 ]. In 1994, Jamison and colleagues proposed that the core functions of 2 , SarahKrullAbe 2 , MasamiMiyakawa 1 ]. Thoughglobalcommunity including WHOhasbeenmak- 3 , Yui Sekitani 1 , KenjiShibuya December 2018 •Vol. 8 No. 2•020313 4 , EijiHinoshita 2 , KeishiAbe ]. ]. Inparticular, theEbola ]. These challenges are 1 2 , Haruhiko , Haruhiko 3 , ]. The ]. The -

VIEWPOINTS VIEWPOINTS December 2018 •Vol. 8 No. 2•020313 agenda. ing forwardtheglobalhealth raising awareness and mov G7 itselfisnotenough for respect to global health, the G7 isaninfluentialbodywith holders isimportant.Though Connecting diversestake to includeGHAforfuture pandemicsintotheG7agenda;infact,itwasexpectedbymembers emergency reform plan was stillatanearlystage andtherefore, there wasvirtually no strong opposition light on at the 2015 G7 Elmau Summitin . In the aftermath of the Ebola outbreaks, the WHO’s As to the cohesion among G7 member states, GHA for future public health emergencies started to be shed derstanding ofkeyglobalhealthissues,includingthoserelevant totheG7. andrelevant topromote privateandcivilsocietyinstitutions,whichserve the government amutualun- a set of policy proposals from his working group [7 vious G8 summits hosted in Japan. In 2016, he led the track 2 process for the G7 Ise-Shima with asthemainadvocateforglobalhealthissuesthroughcesses whilealsoserving thetrack2process atpre- pro- preparatory G8 previous the influenced significantly that papers recognized internationally lished champion forglobalhealthwithasolidacademicandpolicy-makingbackground, Prof. Takemi haspub- a chairman on the Liberal Democratic Party’s Special Mission Committee for Global Health Strategy. As a Strong politicalsupportalsocamefrom Professor KeizoTakemi, memberoftheHouseCouncilorsand the G7Ise-ShimaSummit. basis fordiscussionsamongJapanesestakeholdersinreaching consensusontheglobalhealthagendaat which sought to make recommendations to the Japanese government [6 of twoworkinggroups: humanresources forglobalhealthpolicy-makingandgovernance, to institutionalizeamechanismdevelopglobalhealthpolicieswithintheMHLW. ThePanel consisted PanelonGlobalHealthinAugust2015so as HeestablishedtheAdvisory sion withinthegovernment. Under his leadership, the MHLW made a significant contribution to leading and promoting policy cohe- a leading figure who has expressed enthusiasm about Japan’s leadership and contribution to global health. Aside from PrimeMinisterAbe,Mr. Yasuhisa Shiozaki,thenMinisterforHealth,LabourandWelfare, is pan’s commitmentinaunifiedmanner. al levelparticipantsfrom eachministry, inorder toshare informationanddiscusshowtoconsolidateJa- [ the CabinetSecretariat andthesethree ministriessuccessfullyalignedaround thegoalofreinforcing GHA curity isstrongly related tonational,global,andhumansecurity, underPrimeMinisterAbe’s leadership, DevelopmentAssociations)torespond toandprepareInternational forhealthsecurity. Sincehealthse- the World Bank (WB) Group’s funding scheme initiatives (ie, Pandemic Emergency Facility (PEF) and promoting on policy. Japan’s focused foreign been core MOF has and fulfilment,” and freedom human man security, which is defined by UN as “protecting the vital core of all human lives in ways that enhance the MHLW expressed astrong interest inGHAatanearlystage.MOFA emphasizedtherelevance ofhu- and interests in GHA. Since health emergencies directly affect the health status of the Japanese citizenry, and Welfare (MHLW), of Finance (MOF). These ministries have slightly different and Ministry views on four majoractors:theCabinetSecretariat, ofForeign Ministry Affairs (MOFA), ofHealth,Labour Ministry ber states, non-G7 members and actors other than health sectors. First about actors in Japan, there are cohesion amongstakeholders.There were fourdifferent actors:Japanesedomesticstakeholders,G7mem- The keyfactorofJapantosuccessfullyraisepoliticalawareness onGHAwasthatthere wasstrong policy STAKEHOLDERS? HOW TOINCREASEPOLICYCOMMUNITYCOHESIONAMONG and successfullysetGHAasoneofitspriorities. In themidstofthistransformationinglobalhealth,JapanhostedG7Ise-ShimasummitMay2016 5 ]. Thethree ministriesandtheCabinetSecretariat constantly heldjointmeetings,withdirector-gener - -

ment (OECD) also joined discussions. Together with three official preparatory CHA), theWBandOrganisation forEconomicCo-operationandDevelop - Affairs (UNO- Humanitarian Coordination of the Office for UN WHO, the as isters’ MeetingwasheldinSeptember, 2016,where fourAsianMinistersaswell described attheG7Ise-Shima Leaders’Declaration,theG7KobeHealthMin- Ise-Shima SummitinMay2016 andpropose concrete actions toattainthegoals In order toelaborateandmoveforward thehealth-related agendaattheG7 importance ofhealthsecurityattheBerlinHealthMinister’s Meeting in2015. ing theGlobalHealthSecurityAgenda(GHSA)andGermany highlightedthe health securitytobeincludedasaG7agendaitem.TheUS hasbeenpromot- heads ofstate.ParticularlytheUnitedStatesAmerica and Germanyurged 2 ]. Prof. Takemi alsochairsround tablemeetingswith ]. Thisprocess contributedtothe www.jogh.org • doi:10.7189/jogh.08.020313 - www.jogh.org Ministry ofHealth,LabourandWelfare; usedwithpermission) Photo: atthe42ndG7summit,Ise-Shima(from theMinistryofForeign Affairsand • doi:10.7189/jogh.08.020313 cases and 11 the Ebola outbreak is no exception. Because it caused tremendous damage, amounting to a total of 28 [8 forums or discoveries, disasters, as such events major after open to likely is erally,window policy a structure areThe policywindowandgoodglobalgovernance keyforattainingpoliticalattentionandgen- POLITICAL SURROUNDINGSANDFINANCIALSITUATIONONGHA ing in2016),whichclearlymentionedtheimportanceofcollectiveefforts toward GHA. G7 Foreign Ministers’ MeetingJointCommunique(adopted attheG7Hiroshima Foreign Ministers’Meet- the in time first the for ministers foreign for issues security as highlighted also wereemergencies health Public ministers. from foreign came influence noteworthy sectors, health than other actors about Lastly Declaration anditsimplementationmeasures. sensus onwhatshouldbedonetoprepare forandrespond tofuture healthcrises,deepenedthe Nairobi al organizations, andcivilsocietyorganizations. Throughout thisconsultationprocess, theyreached con- matic session,regarding howtoraiseawareness forreinforcing- GHAamongAfricanleaders,internation During thepreparatoryprocess, theMHLW hadanextensivedebatewiththeWB,co-chairof- bate withtheAfrican heads ofstateand ministers, as wellleadersfrom organizations. international As thechairofmeeting’s thematicsessionforhealth,thenHealthMinisterShiozakiledanintensede- the WHO. At the G7 Finance Ministers and Central Bank Governors’ Meetingin Japanin2016where the WHO.At the G7FinanceMinistersand CentralBankGovernors’ Minister Abepledgedatotal ofUS$1.1billiontoglobalhealthinstitutes,including US$ 50millionto experts andbeginoperations immediately. OntheoccasionofG7Ise-Shima Summit,JapanesePrime deploy to emergency, WHO an enables of which onset the from gap critical a fills CFE launched. were The WHO’s ContingencyFundforEmergencies (CFE)andtheWB’s PandemicFinancingFacility (PEF) progress has been the driving force has been made, and the Japanese government of theseimprovements. [3 resources financial disbursing effectively of mechanisms nor outbreaks for funding adequate neither had community global the outbreak, Ebola the of time the at situation, financial to As dination betweentheworkdonebytaskforce andthepreparatoryprocess oftheG7Summit. ed in this task force with financial contributions from the Japanese aiming government, to enhance coor launched. Dr Shigeru Omi, the former WHO Regional Director for the Western Pacific Region participat- Crises. Followingtherecommendations madebythePanel,GlobalHealthCrises Task Force was for opening the policy window by publishing an influential report, (UNSG), theUNHigh-LevelPanelonGlobalResponseto HealthCrisesworkedatthestrongest power creation oftheUNMissionforEbolaEmergency Response(UNMEER).UndertheUNSecretary-General as at the UNHigh-LevelMeetingonResponsetoEbola Virus DiseaseOutbreak in2014orthe 301 deaths with global pandemic potential [9 3 ], it naturally attracted political attention, such ], itnaturallyattractedpoliticalattention,such discuss GHA specifically with African leaders. (TICAD) inAugust2016wasaplatformto tional Conference onAfricanDevelopment around theworld,whereas theTokyo- Interna out to health ministers and policy makers seminate G7efforts towards GHAandreach The WHAwasanopportunityforJapantodis- GHA. global communityshouldrebuild andrevamp enhanced mutualunderstandingofhowthe Health Assembly(WHA), whichresulting in ing severalsideeventsatthe69thWorld throughout itsG7presidency in2016includ- al dialogueopportunitieswiththesecountries with non-G7countries.Japanprepared sever sively and effectively as possible, especially important tohavecommunicationasexten- In order tosecure anddeepencohesion,itwas both atheadofstateandhealthministerlevel. creasing policycohesionamongG7members meetings, themeetingalsocontributedtoin- Protecting HumanityFrom Future Health December 2018 •Vol. 8 No. 2•020313 ]. However, some 616 616 ]; ]; - -

VIEWPOINTS VIEWPOINTS December 2018 •Vol. 8 No. 2•020313 REFERENCES 3 2 1 before thenext pandemic.thereport oftheHarvard-LSHTM IndependentPanelontheGlobalResponsetoEbola. Lan Moon S,SridharD,PateMA,Jha AK,ClintonC,DelaunayS,etal.Will Ebolachangethegame?Ten essentialreforms New York: Springer;2012. Kickbusch I,ListerG,Told M,DragerN.Global healthdiplomacy:Concepts,issues,actors,instruments,fora and cases. FGH_2014_1.pdf. Accessed:26 March 2017. Available:http://www.healthdata.org/sites/default/files/files/policy_report/2015/FGH2014/IHME_PolicyReport_2015. Institute forHealthMetricsandEvaluation.FinancingGlobal Health 2014:ShiftsinfundingastheMDGeracloses. cet. 2015;386:2204-21. Medline:26615326 hinder sustainability. financial resources is needed as scarce financial resources and tendency of waning political attention may particular,In evaluated. of and monitoredefficienteffective use closely and be should mechanisms new these and launched was CEPI and PEF CFE, after, for and schemes 2016 financing in new ThroughG7 G7 KobeHealthMinisters’Meeting. organizations and international atTICADVI,andwithG7healthministers,WHO,UNOCHAthe ers atG7Ise-ShimaSummit,withhealthministersthe69thWHA,leadersfrom Africancountries Japan was also leading the political process and contributed to opening the political window: the G7 lead- agenda, health global the of advancement meetings leaders G7/G8 Additionally,previous da. in seen as boostedGHAtothetopofglobalhealthagen- discussed attheUNhigh-levelmeeting,whichinturn [11][12]. GHAwas agenda health the promoted largely meetings high-level UN NCDs, and HIV/AIDS ease Outbreak and in several influential reports from WHO and academic institutions. As also seen with creased politicalattention,suchasattheUNHigh-LevelMeetingonResponsetoEbolaVirus Dis- With regard oftheEbolaoutbreak itselfcausedin- tothepoliticalcontext,severityandexternality litical leadershiphelpedgenerateahighlevelofpoliticalattention. children’sto attention drewglobal successfully who (UNICEF) [10], the emergencehealth of strong - po health policymaking.AsseenwiththecaseofJamesGrant,formerdirector oftheUNChildren’s Fund of WHOandtheWorld BankGroup, remains anexceptionalachievementinJapan’s ofglobal history that powerfulpoliticalleadersfullyendorsedthisagenda,echoedbytheG7leadershipaswellheads Prof. KeizoTakemi, allcontributedtostrengthening collective efforts toward reinforcing GHA.Thefact Three leaders,PrimeMinisterAbe,whichwere echoedbythenHealthMinisterYasuhisa Shiozakiand munity cohesionwithinandoutsideofG7members. public health crises through the involvement of notable Japanese politicalleaders and byenhancingcom- Taking advantageoftheG7presidency in2016,Japanhascontributedtostrengthening GHAforfuture FUTURE DIRECTIONSONGHA million peryearinorder tofunditsprograms. demics. Japanisafoundingmemberofthisnewinitiative,andhascommittedtocontributingUS$25 2017 World collectiveeffort EconomicForum,aninternational tocreate vaccinestocombatfuture pan- Moreover, the Coalition for Epidemic Preparedness Innovations (CEPI) was also officially launched at the million tothisnewfacility. PEF was officially launched, the announced their financial commitment of US$50 Competing interests: The authors completed the Unified Competing Interest form at www.icmje.org/coi_disclo KK, NN,EH,HYandSArevised thearticle,made usefulcomments,andprovided importantintellectualcontent. Authorship declaration:HS, SE and KH wrote of NY and KS. YS, KA,HI, TK, the article under thesupervision Funding: None. respective organizations. Institute ofInfectiousDiseasesJapan.Theirviewsexpressed here donotnecessarilyrepresent theviewoftheir Japan. KHandEHareofForeign employeesoftheMinistry Affairs ofJapan.MMisanemployeetheNational Disclaimer: SE,YS,KA,HI,TK,KK,HYandNYareofHealth,LabourWelfare employeesoftheMinistry of Acknowledgements: TheauthorsthankMr. CyrusGhaznaviforeditingthemanuscript. sure.pdf (availableonrequest from thecorresponding author)anddeclare noconflict ofinterest.

doi:10.1016/S0140-6736(15)00946-0 4 www.jogh.org • doi:10.7189/jogh.08.020313 - - www.jogh.org REFERENCES • doi:10.7189/jogh.08.020313 11  10  9 8 5 12  6 7 4       mortality. en/. Accessed:26March 2017. World HealthOrganization. WHOEbolaoutbreak 2014-2015.2016.Available:http://www.who.int/csr/disease/ebola/ Shiffman 10.1080/13439006.2016.1195956 1998; Abe Japan GlobalHealthWorking Group. S0140-6736(15)01172-1 Takemi cet. Jamison factor surveillance inKenya. factor surveillance Mamka Anyona books/2016/2016_jim_grant.pdf. Accessed:26Marc 2017. European CenterforPeaceandDevelopment.RememberingJimGrant.2016Available:http://www.ecpd.org.rs/pdf/2015/ Alfvén sons formonitoringthesustainabledevelopmentgoals. doi:10.1007/s10461-016-1662-9 2016; S 351: . T Japan’s visionforapeacefulandhealthierworld. K , DT J Erkkola . 387: Lancet. , 514- Japan’s GlobalHealthStrategy:Connectingdevelopmentandsecurity. Smith , Frenk 2155- 7 . R Medline:9482466 2007; T , S , . De Courten J Ghys Generation of political priority for global health initiatives: a framework and case study of maternal Generation ofpoliticalpriorityforglobalhealthinitiatives:aframeworkandcasestudymaternal 62. , Knaul 370: Medline:27301827 PD, 1370- AIMS PublicHealth. F . Padayachy International collectiveactioninhealth:Objectives,functions,andrationale. International M . 9 An analysisofthepolicyenvironment surrounding noncommunicablediseasesrisk . Medline:17933652 doi:10.1016/S0140-6736(97)11451-9 Protecting humansecurity:Proposals fortheG7Ise-ShimaSummitinJapan. J , Warner-Smith doi:10.1016/S0140-6736(16)30177-5 2014; 5 1 doi:10.1016/S0140-6736(07)61579-7 : 256- Lancet. M AIDS Behav , Rugg 74. Medline:29546090 2015; D , et al. 386: . 2017; Global AIDSReporting-2001to2015:Les 2367- December 2018 •Vol. 8 No. 2•020313 University ofTokyo Department ofGlobalHealthPolicy Haruka Sakamoto,MD,MPH Correspondence to: [email protected] Tokyo, Japan 7-3-1, Hongo,Bunkyo-ku Hongo Campus Medical BuildingNo.3 21 Asia-Pacific Rev Asia-Pacific 9 Suppl 1: . Medline:26700515

5 - 14.

. Medline:28124296 2016;

23:

doi:10.1016/ 21-

31. Lancet. Lan doi:

- -

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