POLICY AND PRACTICE
Health imperatives in foreign policy: the case of Malaysia
Impératifs sanitaires et politique étrangère : le cas de la Malaisie
Los imperativos sanitarios en la política exterior: el caso de Malasia
Simon BarracloughI; Kai-Lit PhuaII
ISchool of Public Health, La Trobe University, Bundoora, Victoria 3086, Australia.Correspondence to Simon Barraclough (email: s.barraclough@latrobe.edu.au).
IIMonash University Malaysia, Petaling Jaya, Malaysia
ABSTRACT
Malaysia's global, regional and bilateral international health relations are surveyed against the historical backdrop of the country's foreign policy. Malaysia has always participated in multilateral agencies, most notably the World Health Organization, as such agencies are part of the longstanding fabric of "good international citizenship". The threats of infectious diseases to human health and economic activity have caused an intensification and an organizational formalization of Malaysian health diplomacy, both regionally and bilaterally. Such diplomacy has also established a basis for developing a wider set of cooperative relationships that go beyond responding to the threat of pandemics. As Malaysia approaches "developed" status, its health sector is becoming increasingly integrated into the global economy through joint research and development ventures and transnational investment. At the same time, it will have the technological, financial and human resources to play an expanded altruistic role in global and regional health.
RÉSUMÉ
Les relations mondiales, régionales et bilatérales de la Malaisie en matière de santé internationale sont examinées dans le contexte historique de sa politique étrangère. La Malaisie a toujours participé aux organisations multilatérales, et en particulier à l'Organisation mondiale de la Santé (OMS), cette participation allant de soi dans un pays qui se considère comme membre à part entière de la communauté internationale. Les menaces que font peser les maladies infectieuses sur la santé et l'activité économique ont conduit la Malaisie à intensifier sa diplomatie sanitaire et à lui donner un caractère plus formel, au niveau régional comme au niveau bilatéral. Cette diplomatie a également jeté les bases d'un éventail plus large de liens de coopération qui dépassent le simple cadre de la réaction à la menace de pandémies. A mesure qu'elle se rapproche de la situation d'un pays développé, la Malaisie a progressivement intégré son secteur sanitaire à l'économie mondiale par le biais d'entreprises communes de recherche-développement et d'investissements transnationaux. Parallèlement, elle disposera des ressources technologiques, financières et humaines nécessaires pour jouer un rôle altruiste plus étendu dans la santé régionale et mondiale.
RESUMEN
Se analizan las relaciones de salud mundiales, regionales y bilaterales internacionales de Malasia con el telón de fondo histórico de la política exterior del país. Malasia siempre ha participado en organismos multilaterales, sobre todo en la Organización Mundial de la Salud (OMS), pues tales organismos forman parte de la urdimbre de larga data de la «buena ciudadanía internacional». Las amenazas que suponen las enfermedades infecciosas para la salud humana y la actividad económica han causado una intensificación y una formalización organizacional de la diplomacia de Malasia en el terreno de la salud, tanto a nivel regional como a nivel bilateral. Esa diplomacia ha sentado además las bases para el desarrollo de un conjunto más amplio de relaciones de cooperación que van más allá de la mera respuesta a las amenazas de pandemias. Conforme Malasia se aproxima al estatus de país «desarrollado», su sector de la salud se integra cada vez más en la economía mundial gracias a las iniciativas conjuntas de investigación y desarrollo y a las inversiones transnacionales. Al mismo tiempo, el país dispondrá de los recursos tecnológicos, financieros y humanos necesarios para desempeñar una función altruista ampliada en la salud mundial y regional.
Introduction
Health has increasingly become a significant element in foreign policy for both major and smaller countries, extending beyond their formal membership in global health agencies to feature more prominently in regional and bilateral relations. In this article, this phenomenon is explored through a case study of Malaysia that examines the motivations for health diplomacy, and illustrates the institutions and mechanisms for its conduct. It is argued that the narrow imperatives of national security imposed by fears of contagious diseases are giving way to a broader, more positive and collaborative diplomacy of health, with the potential for increased altruism. This study's conclusions are applicable to other middle-income countries of similar size.
In exploring connections between health and foreign policy, Fidler has suggested a useful hierarchy of functions.1 The principal goal of foreign policy is to ensure national security; this is followed by a concern with serving economic interests through promoting trade, commerce and investment. These goals are, in turn, furthered by the fostering of order and stability. Finally, human rights may be served through the provision of humanitarian assistance.
Elements of this hierarchy are reflected in Malaysia's international health relations. Its professed foreign policy priorities include socioeconomic and political linkages within its immediate geographical region, and in particular with the Association of Southeast Asian Nations (ASEAN); self-identifying as an Islamic country; and undertaking a broad commitment to global citizenship through membership in the United Nations and other international bodies, including the Commonwealth of Nations. While seeking an engagement with, and openness to, the global economy, Malaysia also reserves the right to criticize what it sees as the unjust consequences of economic globalization, many of which have ramifications for human health.2
Malaysia and WHO
Malaysia is actively involved in WHO and is affiliated to the Western Pacific Region. The country office for Brunei Darussalam, Malaysia and Singapore is located in Kuala Lumpur. There are seven WHO collaborating centres in Malaysia, most of which are government agencies. They are concerned with research into health systems, pharmaceuticals and tropical contagious diseases. Such collaborations provide valuable international linkages and recognition for Malaysian technical leadership in these specialized areas.
Malaysia's regional role in assisting the development of WHO's Framework Convention on Tobacco Control illustrates the importance of international health diplomacy in furthering public health and the influence that such international agreements can have upon public policy in individual countries. A meeting in Penang in 2001, hosted by the Malaysian Government, WHO and the National Poison Centre of Universiti Sains Malaysia, not only galvanized regional support for the framework but also helped strengthen domestic efforts to engage the Malaysian Government with this global initiative. The meeting decided that regional meetings would be based upon membership of ASEAN groupings, rather than those of WHO. This decision to bypass WHO regional arrangements highlights a longstanding logistical problem for Malaysia and other ASEAN countries in their participation in WHO. Indonesia, Myanmar and Thailand are grouped within the South-East Asia Region, while the other members of ASEAN are in the Western Pacific Region.
The 2001 meeting resulted in the Penang Declaration, which called for the establishment of "mechanisms for regional cooperation to facilitate a consolidated global response to the tobacco menace".3 The Declaration, forwarded to the 2002 meeting of ASEAN health ministers in Vientiane, also urged ASEAN countries to seek assistance from WHO and other UN and international bodies to implement the framework convention.3
The Association of Southeast Asian Nations
Malaysia was a founding member of ASEAN, the regional body central to Malaysian foreign policy. Although established in 1967 as a regional security organization seeking to keep south-east Asia free of conflict between the major powers, its role was expanded to encompass economic and sociocultural functions, including health. ASEAN health ministers hold regular formal meetings. In 2000, the Yogyakarta Declaration on the Healthy ASEAN 2020 strategy was posited as the basis for cooperation between member countries, as well as with international health agencies.
The seventh ASEAN meeting of health ministers, hosted by Malaysia in 2004 with the theme "health without frontiers", was particularly relevant for foreign affairs and health. This meeting endorsed continuing cooperation between members not only to counter infectious diseases but also to deal with the health ramifications of international trade agreements, to encourage joint food standards policies and to harmonize health services standards and regulation. It was also agreed that ASEAN countries would work with WHO and other UN agencies to examine the recommendations of the Commission on Macroeconomics and Health to monitor health-related Millennium Development Goals.4
Despite the positive pronouncements of ASEAN health ministers about regional cooperation, it must be recognized that there have also been some significant health-related tensions between Malaysia and some of its neighbours. The burning of Indonesian forests to clear land has caused regular and serious pollution over the Malay peninsula. Malaysia's treatment of foreign workers, which has included imposing higher fees for non-citizens using public hospitals, also has been a source of diplomatic tension with Indonesia.
The Commonwealth of Nations
The Commonwealth of Nations has a significant commitment to international health. Within the Commonwealth Secretariat in London, the Health Section has merged with the Gender and Education Sections to form the Social Transformations Programmes Division; this new division coordinates health initiatives. The organization is committed to the Millennium Development Goals, which include action on maternal and child health as well as disease control and eradication.5
Although Malaysia has been a member of the Commonwealth since its independence from Britain, its participation has waxed and waned. With Britain's military disengagement from the region in the early 1970s, the Commonwealth had little functional use for a regionally focused Malaysian foreign policy. In Malaysia's immediate region, Brunei Darussalam and Singapore are the only two other members of both the Commonwealth and ASEAN.
In the late 1980s, Prime Minister Mahathir bin Mohamed revived Malaysia's engagement with the Commonwealth, especially as a forum for championing the interests of developing countries. In 1989 Malaysia hosted the Commonwealth Heads of Government Meeting. An important health-related outcome of the meeting was the Langkawi Declaration on the Environment.
However, the Commonwealth's health initiatives have limited consequences for Malaysia. Commonwealth health ministers meet annually on the eve of WHO's World Health Assembly in Geneva. Occasionally Malaysia is involved in Commonwealth-initiated projects. In 2002 Malaysia became the principal sponsor of the Commonwealth's Global Information Hub for Integrated Medicine, which provides an electronic database of traditional and complementary medicine.
Islamic diplomacy and health
Malaysia helped establish the Organization of the Islamic Conference in 1969. This body, composed of 57 countries with headquarters in Jeddah, was formed to promote cooperation between countries with an Islamic identity. Malaysia conducts elements of its diplomacy with the Muslim world through this vehicle. The organization's mandate has been extended to embrace cooperation in socioeconomic matters, including health, and the organization's health ministers meet regularly. However, its health activities have been limited and Malaysia's participation has been modest. In 2005, a scheme funded through the Islamic Development Bank was established to combat diseases in member states.6 Malaysia has been praised by the organization's secretary-general for its support for the eradication of polio in Muslim countries where it is still endemic.6
Although its involvement in the organization's health activities provides an opportunity for altruism, it also offers the potential for contributing to the Malaysian Government's policy of encouraging the export of health-related goods and services, and promoting joint ventures in health. Members of the organization provide a ready market for halal (lawful for Muslims) therapeutic products, including vaccines. In 2001, the health minister of Malaysia conducted a diplomatic mission to Jordan; part of this mission included promoting the Malaysian health industry. The visit resulted in a memorandum of understanding on bilateral health cooperation.7
Bilateral health relations
Malaysia has developed a range of bilateral health relationships with bordering countries, as well as with others both within and beyond the region. Of particular concern to Malaysia in developing these bilateral ties has been the threat posed by infectious diseases, especially since several hundred thousand foreign workers have entered Malaysia and play a vital role in the country's economy. The smuggling of illicit and counterfeit drugs and contraband cigarettes has also been of serious concern.
Malaysia has signed several bilateral agreements that deal with cross-border issues, including health. In 1997 a memorandum of understanding concerning health cooperation between Thailand and Malaysia was signed in Kuala Lumpur. Regular meetings of health officials have included the nineteenth meeting of the Thailand-Malaysia Border Health Goodwill Committee, which in 2006 discussed issues including the smuggling of illegal and counterfeit drugs, infectious diseases, maternal and child health, and the human resources development through exchange visits.8
In December 2003, in the wake of the severe acute respiratory syndrome (SARS) epidemic, Brunei Darussalam and Malaysia initiated bilateral health meetings. They agreed to establish working groups for future joint projects and for a memorandum of understanding to strengthen and formalize future cooperation on health.9 A year later, the health ministers instigated joint cooperation not only on communicable diseases but also laboratory facilities, health surveillance, food safety, tobacco control and the cross-border movement of patients.10
Health relations with Singapore (as with relations on some other issues) have been marked by tensions. In 2003, Malaysian health officials criticized Singapore for allowing four people with symptoms of SARS to enter Malaysia; the officials also rejected Singapore's suggestion that officers be placed at each other's border crossing points to monitor screening activities.11 Despite such disagreements, regular high-level bilateral meetings were held to deal with SARS, and bilateral commitments to mutual cooperation and collaboration were reaffirmed.12 In January 2004, during a ministerial delegation to Singapore led by Prime Minister Abdullah Badawi, officials pledged cooperation to deal with the threat of avian influenza.13
In May 2004, China and Malaysia used Prime Minister Badawi's visit to commemorate the thirtieth anniversary of the establishment of diplomatic relations between the countries and to reaffirm their memorandum of understanding on public-health cooperation; they also announced a mutual mechanism for reporting epidemics.14
Contagious disease and health cooperation
Much Malaysian health diplomacy can be categorized as safeguarding national security regarding contagious diseases. The Ministry of Health instituted the International Health Unit to implement the provisions of WHO's International Health Regulations as well as Malaysia's Prevention and Control of Infectious Diseases Act of 1988. Malaysia has also been actively involved in negotiations to revise the International Health Regulations.
Between 1998 and 1999, Malaysia experienced one of its most serious outbreaks of contagious disease when a previously unknown viral illness among pig farmers in Perak and Negri Sembilan led to 101 deaths in Malaysia and the death of an abattoir worker in Singapore. In an effort to control the spread of the disease, hundreds of thousands of pigs were slaughtered and the export of pig meat was suspended, causing serious damage to a major Malaysian export industry.
This incident highlighted Malaysia's dependence upon international cooperation in dealing with a major health crisis as well as the benefits of links with WHO. The WHO Collaborating Centre for Arbovirus Reference and Research at the University of Malaya mobilized the WHO network for assistance. A team from the United States' Centers for Disease Control and Prevention provided on-site assistance. Australia also organized a range of experts from human and animal health agencies to support Malaysian diagnostic and control efforts.15 The close collaboration between Malaysian and Australian health authorities occurred despite diplomatic tensions between the governments of the two countries during Prime Minister Mahathir's incumbency.
In April 2003, Malaysia played a prominent regional role in responding to the outbreak of SARS. It hosted the first special meeting on SARS of the ASEAN+3 ministers of health in Kuala Lumpur. (ASEAN+3 is an expanded grouping comprising the members of ASEAN as well as China, Japan and Korea.) At this meeting, participants agreed to take comprehensive transborder action to contain the disease and to facilitate the exchange of information. They also affirmed their intention to follow WHO's travel guidelines and initiated the establishment of an ASEAN research centre on controlling communicable diseases.16 Two months later, Kuala Lumpur was the venue for WHO's international conference on SARS.
It is indicative of national perceptions of the threat posed to the region by SARS and the need for decisive health diplomacy that all ASEAN heads of government attended a subsequent summit meeting in Bangkok in 2003. Malaysia was represented by Abdullah Badawi, then acting prime minister. He used the occasion to explain Malaysian policy on medical screening for immigrant workers, a matter of sensitivity among the ASEAN countries from which these workers came. He also noted the diplomatic significance of the attendance of Wen Jiabao, China's new premier.17
Coordinated international dialogue, planning and action helped to defuse some of the precipitate "fear response" by national governments in the early stages of the SARS outbreak; these responses had included the blanket refusal of entry to some south-east Asian countries of the nationals of countries affected by the disease. In addition, stronger health linkages were forged both within ASEAN and between this regional grouping and China, Japan and the Republic of Korea. The SARS outbreak led the Government of the Russian Federation, a country geographically extending to Asia, to seek formal links with ASEAN in the interests of preventing the spread of future infectious disease outbreaks.18
In the case of Malaysia, cooperating with China to counter SARS contributed to stronger bilateral health links as well as restoring Malaysian health authorities' confidence in China, as the latter country had been suspected of not fully disclosing the prevalence of the disease. In April 2004, Chinese Vice Minister for Health Zhu Qinsheng attended the first bilateral meeting on health in Kuala Lumpur. There the Malaysian health minister expressed the hope that:
"... both our countries will be able to help each other in many areas, including training and capacity-building, information exchange and electronic database development, cross-border control of infectious diseases, research, pharmaceuticals and traditional and complementary medicine".19
Malaysia is a member of the Asia-Pacific Economic Cooperation (APEC) group, a 21-member body formed in 1989 to promote regional economic development by fostering trade liberalization and technical cooperation. Even before SARS, APEC had issued a report on threats posed by infectious diseases to trade and travel, concluding that both human health and competitiveness of APEC's economies were at risk if appropriate actions were not taken.20
Faced with the serious economic ramifications of SARS, APEC initiated a security action plan. In addition, the health ministers of APEC met in June 2003 and established a Health Task Force.21 Confronted with further threats from contagious diseases, an APEC ministerial meeting on avian influenza pandemics was convened in Viet Nam in May 2006 to consolidate planning and communication protocols.22
In terms of Malaysia's international health relations, APEC has provided a further forum for health diplomacy as well as a network extending beyond the immediate region. APEC's involvement in health matters also reinforced the economic imperatives of international cooperation for health protection and advancement.
Concluding observations
This brief survey has explored the health imperatives evident in Malaysian foreign policy and also some of the changes in Malaysian health diplomacy, which has both expanded and intensified during the past two decades. The salience of health in Malaysia's foreign policy has been demonstrated by Prime Minister Abdullah Badawi's participation in several regional summits and bilateral meetings, by the increasing acknowledgement of the need for health cooperation in official diplomatic communiqués, by the hosting of health conferences and meetings in Malaysia, by the health minister's involvement in diplomatic missions and by the negotiation of health-related documents with neighbouring countries.
Despite these developments, Malaysian health diplomacy is not coordinated by the Ministry of Foreign Affairs. Although the ministry has a substantive division concerned with the Organization of the Islamic Conference and a centre to deal with the threat of terrorism, it has yet to establish a health division. Rather, health diplomacy is coordinated principally by means of interministerial working parties and liaison between the health and foreign affairs ministries.
The historical origins of global health agencies can be traced back to common action taken in the face of contagious diseases; this led to the realization that cooperation can be extended to research and preventative activities as well as the sharing of knowledge.23 This pattern is evident in Malaysia's international engagements in health. The threat of infectious diseases, and in particular SARS, human immunodeficiency virus (HIV) and avian influenza, has been the major imperative for Malaysia's participation in regional forums.
For the most part, Malaysia's health diplomacy, unlike some other areas of foreign policy, has been relatively free of serious international conflict. Malaysia has projected an image as a trusted and active partner in the control of infectious diseases and a supporter of institutional arrangements to further both regional and global health. Yet many of the international health initiatives undertaken by Malaysia look beyond a focus on national security. Malaysia is expanding its international engagement in health-related research, development, education and training. Foreign investment is attracted to its health industries, and health tourism is being promoted to attract foreign patients and generate export earnings. Malaysia has embraced globalization and is a member of the World Trade Organization, yet it has demonstrated independence when acting in the interests of its citizens' health. In 2003 it became the first country to issue a compulsory import licence for generic antiretroviral drugs under the World Trade Organization's Trade-related Aspects of Intellectual Property Rights agreement.
Malaysia's continuing economic prosperity, its substantial experience with successfully developing primary health-care services in rural areas, its record of assisting neighbours in the wake of natural disasters and its aspirations to act as an advocate for the interests of developing countries all point to an increasing altruistic role in international health. Many of the region's poorer countries, and those farther afield, stand to benefit from Malaysian assistance and technology transfer in the field of health. 
Competing interests: None declared.
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(Submitted: 3 October 2006 - Final revised version received: 15 January 2007 - Accepted: 17 January 2007)