Abstract

The Framework Convention on Tobacco Control (FCTC) is an exemplar result of global health diplomacy, based on its global reach (binding on all World Health Organization member nations) and its negotiation process. The FCTC negotiations are one of the first examples of various states and non-state entities coming together to create a legally binding tool to govern global health. They have demonstrated that diplomacy, once consigned to interactions among state officials, has witnessed the dilution of its state-centric origins with the inclusion of non-governmental organizations (NGOs) in the diplomacy process.

To engage in the discourse of global health diplomacy, NGO diplomats are immediately presented with two challenges: to convey the interests of larger publics and to contribute to inter-state negotiations in a predominantly state-centric system of governance that are often diluted by pressures from private interests or mercantilist self-interest on the part of the state itself. How do NGOs manage these challenges within the process of global health diplomacy itself? What roles do, and can, they play in achieving new forms of global health diplomacy? This paper addresses these questions through presentation of findings from a study of the roles assumed by one group of non-governmental actors (the Canadian NGOs) in the FCTC negotiations.

The findings presented are drawn from a larger grounded theory study. Qualitative data were collected from 34 public documents and 18 in-depth interviews with participants from the Canadian government and Canadian NGOs. This analysis yielded five key activities or roles of the Canadian NGOs during the negotiation of the FCTC: monitoring, lobbying, brokering knowledge, offering technical expertise and fostering inclusion. This discussion begins to address one of the key goals of global health diplomacy, namely ‘the challenges facing health diplomacy and how they have been addressed by different groups and at different levels of governance’ (Kickbusch et al. 2007a: 972).

KEY MESSAGES

  • Contrary to the traditional international relations perspective that sees governments as the principle diplomats on the global stage, non-governmental organizations (NGOs) now find themselves serving a diplomatic role during international health negotiations as evidenced by the negotiation of the Framework Convention on Tobacco Control.

  • This study suggests that the traditional role of NGOs as advocates for civic interests is a pertinent but insufficient characteristic of their role in global health diplomacy.

  • Canadian NGOs played important roles in the development of the FCTC by way of fostering inclusion of developing countries, discussing tobacco-related content with other country representatives at the negotiating forums, providing expertise based on previous domestic policy-making successes due to extensive negotiations, lobbying for an effective FCTC and monitoring content and various actors during meetings.

Introduction

The Framework Convention on Tobacco Control (FCTC) is considered an important achievement in the emerging field of global health diplomacy, and a signal of the World Health Organization’s (WHO) efforts to co-ordinate both domestic and foreign policies of its member nations (Kickbusch et al. 2007a). This binding international treaty seeks to mitigate the detrimental health impacts of a transnational tobacco market through comprehensive guidance for amplifying domestic and foreign tobacco control policy. Its importance as an exemplar result of global health diplomacy stems from both its global reach (binding on all WHO member nations) and its negotiation process. In particular, the process of developing the FCTC is one of the first examples of how various states and non-state entities came together to create a legally binding tool to govern global health (Collin et al. 2002). The WHO developed an International Negotiating Body (INB) to facilitate the FCTC negotiations, which took place between 1999 and 2003. In May of 2003 the World Health Assembly unanimously adopted the FCTC. The FCTC was eventually ratified in 2005, after achieving the requisite 40 state signatories, thus becoming international law. As of 9 November 2009, 168 WHO member states had adopted the FCTC. This type of diplomacy is new to the realm of global health and is marked by complex co-operation among diverse actors to achieve inter- and trans-national health goals.

The construction of the FCTC demonstrated the convergence of both governments and non-governmental organizations (NGOs) around a specific health problem (Lencucha et al. 2010). Research is beginning to recognize the importance of this convergence and document the activities of NGOs during the negotiation of the FCTC. NGOs were an important part of the negotiation of the FCTC in part because of their unprecedented access to the diplomacy process and the ways in which they organized their efforts on a global scale (Mamudu and Glantz 2009). The negotiation of the FCTC provides a unique context to examine the role of NGOs in what recently has been termed ‘global health diplomacy’. Global health diplomacy is described as, first, the processes by which government, multilateral and civil society actors attempt to position health in foreign policy negotiations and to create new forms of global governance for health (Kickbusch et al. 2007b), and second, the processes by which both government and non-government diplomats negotiate health goals on the global scale. This paper focuses on the latter.

NGOs are an important part of global health diplomacy and their strong presence on the global stage represents one of the trends that have been attributed to the emergence of the field itself (Adams et al. 2008). Diplomacy, once relegated to interactions among state officials, has witnessed the disintegration of its state-centric origins with the inclusion of non-traditional diplomats from both industry and NGOs (Cooper and Hocking 2000). Although ‘the dogma that public diplomacy is government alone carried on well beyond the reality of the situation’ (Snow 2006: 19), the recognition that the field of diplomacy extends beyond state-to-state communication is now widely accepted. NGOs have become regular and often influential participants during international negotiations (Betsill and Corell 2008). Bond (2008: 377) asserts that one of the key goals of global health diplomacy should be to ‘ensure dialogue with affected communities and be more intentional in engaging citizen groups in defining needs and goals’. Frist (2007: 225) notes that ‘health diplomacy can mean building a culture of discourse and collaboration between governments and those NGOs that operate at the grass-roots, community level and have the greatest access to people in need’. Whether and how such ideals have been enacted has not yet received systematic study in the global health diplomacy literature.

To engage in the discourse of global health diplomacy, NGO diplomats, meaning those NGOs who participate in the development and negotiation of policy or legal governance instruments, are immediately presented with two challenges: conveying the interests of larger publics, including the most marginalized; and contributing to inter-state negotiations in a predominantly state-centric system of governance that is often diluted by pressures from private interests or mercantilist self-interest on the part of the state itself. How do NGOs manage these challenges within the process of global health diplomacy itself? What roles do, and can, they play in achieving new forms of global health diplomacy? This paper addresses these questions through the presentation of findings from a study of the roles assumed by one group of non-governmental actors (Canadian NGOs) in the negotiation of the FCTC.

Methods

The findings presented here are drawn from a larger grounded theory study (Lencucha 2009). Triangulation was achieved through the inclusion of two data sources (Charmaz 2006). Qualitative data were collected from 34 public documents pertaining to the Canadian NGOs and the FCTC, and 18 in-depth interviews with participants from both the Canadian government and Canadian NGOs. Participants were included based on their direct or indirect participation in the FCTC negotiations. The data were combined and organized using NVivo8 qualitative software. The data were analysed by the lead author using open coding to develop key themes and sub-themes. Portions of the data were reviewed by the second author and one other individual and then compared with the lead author’s findings to facilitate trustworthiness. A ‘thick description’ of both participant and document quotes is presented throughout the findings section to contribute to the trustworthiness of the research (Geertz 1973).

Findings

This analysis yielded five key activities or roles of the Canadian NGOs during the negotiation of the FCTC: monitoring, lobbying, offering technical expertise, brokering information and fostering inclusion (see Table 1).

Table 1

The five roles of Canadian NGOs observed during the FCTC negotiations

Role Characteristics 
Monitoring 
  • Monitoring content of the FCTC

  • Monitoring global activity of the tobacco industry

  • Monitoring tobacco industry activity during negotiations

  • Monitoring positions of delegations during negotiations

 
Lobbying 
  • Pushing for strong ‘health language’

  • Communicating particular responsibilities:

    • Economic development

    • Morality

 
Offering technical expertise 
  • Drawing from experience

  • Drawing together research evidence to support positions

  • Gathering experts

 
Brokering information 
  • Hosting information sessions

  • Channelling information to governments

 
Fostering inclusion 
  • Channelling funds for NGO attendance at negotiations

  • Highlighting inequalities in participation

 
Role Characteristics 
Monitoring 
  • Monitoring content of the FCTC

  • Monitoring global activity of the tobacco industry

  • Monitoring tobacco industry activity during negotiations

  • Monitoring positions of delegations during negotiations

 
Lobbying 
  • Pushing for strong ‘health language’

  • Communicating particular responsibilities:

    • Economic development

    • Morality

 
Offering technical expertise 
  • Drawing from experience

  • Drawing together research evidence to support positions

  • Gathering experts

 
Brokering information 
  • Hosting information sessions

  • Channelling information to governments

 
Fostering inclusion 
  • Channelling funds for NGO attendance at negotiations

  • Highlighting inequalities in participation

 

Monitoring

The Canadian NGOs monitored four specific areas during the negotiation of the FCTC: (1) content of the FCTC; (2) global activity of the tobacco industry; (3) tobacco industry activity during the negotiation meetings; and (4) the positions of delegations during the International Negotiating Body (INB) meetings.

The participants noted that the NGOs monitoring the content of the FCTC did so by reviewing drafts of the different articles of the FCTC text, and providing critiques and suggestions to country delegations. The Canadian NGOs joined together to develop ‘briefs’ prior to each INB meeting, which they used to strengthen the position of the Canadian government in the inter-state negotiating sessions. Two examples include calling for less ‘voluntary language’ and more ‘obligatory language’ (Document 10) and for ‘significant improvement’ in ‘advertising restrictions’ (Document 9) in the FCTC.

Such efforts were not always successful; one particular case involved the trade in tobacco products. Prior to the fifth INB meeting in Geneva, NGOs identified three approaches to how trade could be dealt with in the FCTC text:

“1) Language which gives paramounce to FCTC provisions (health trumps trade), 2) language which subordinates the FCTC to trade (trade trumps health) and 3) no text reference to trade in the FCTC (silence).” (Document 9)

Another function of the monitoring role was to expose industry activity globally, particularly for countries that had less experience in dealing with the tobacco industry in their own efforts to establish stronger tobacco control measures. As one participant noted:

“And this is what they’re going to try next so be forewarned that this is what’s going to happen … if they couldn’t fight advertising in one way then they’d sneakily come up with, well, let’s support the Formula One race or let’s sponsor a dance competition, I mean there’s all these things. So it was, you know, helping them learn all of those things.” (Participant 8)

Certain governments initially included industry representatives on their official delegation; something NGOs monitored closely and vociferously:

“I mean the biggest tobacco producer in the world is the China Tobacco Corporation and they were on the Chinese delegation, until they finally booted them off. And Japan Tobacco was part of the Japanese delegation; I think they finally kicked them off too, kind of an embarrassment.” (Participant 15)

These NGO efforts did not preclude more subtle forms of collusion. As one participant from an NGO in Africa noted:

“There was a problem with the government delegate [who] was committed to the ‘house of tobacco control’ but then we had a government, a person in government that was ready to marry the tobacco industry. So the government delegate had good views of tobacco control, but the government position was not very conducive to implement the FCTC provisions after that.” (Participant 14)

The NGOs utilized various mechanisms to monitor and publicize the positions of the delegations. They came together under an umbrella organization (the Framework Convention Alliance, or FCA), which printed, distributed and web-posted a daily bulletin during the INB meetings in Geneva. Managed by one of the Canadian NGOs, the FCA bulletin included daily ‘ashtray’ and ‘orchid’ awards for, respectively, delegations that the NGOs thought were trying to weaken the health language of the FCTC or had provided support for a strong public health treaty:

“There are certain countries, the United States being one, that like to see themselves as the good cop, never as the bad cop, so to have all of those NGOs writing negative things about them in a newsletter or issuing press releases that said they were blocking an effective treaty, etc., etc. … They seemed to take it personally and in fact in one session I think when they did get the dirty ashtray award … one of the American delegates actually tried to bring that to the floor of the assembly (the World Health Assembly), to say that the NGOs shouldn’t be doing this.” (Participant 11)

All of the participants interviewed regarded the FCA bulletin as both an information source and a means of exposing and shaming delegations that did not support a strong FCTC, while congratulating those that did. The public shaming and congratulating extended to newsletters posted on certain Canadian NGO websites, and did not shirk from critiquing their own government:

“Eight months have passed since the end of the treaty negotiations with no apparent action by government to bring Canada in conformity with FCTC provisions and allow Canada to ratify the treaty.” (Document 16)

Lobbying

Canadian NGOs directed their lobbying efforts towards the language of the FCTC. Specifically they sought stronger and more clear/specific language. This lobbying was partly directed at their own delegation:

“Given the positions of other G7 members, Canada needs to do far more than play a quietly supportive role if the FCTC process is to lead anywhere—it needs to be a leader of the ‘progressive’ industrialized countries on tobacco issues. That means a commitment to bold and simple language, even where this requires re-thinking some aspects of domestic policy.” (Document 8)

The majority of the participants and documents suggest that the NGOs were cognizant of the fact that if the language of the FCTC was ambiguous then countries may have grounds not to implement strong domestic tobacco control.

All of the participants emphasized the ability of the Canadian NGOs to push for more. As one government delegate highlighted: “I had to be more nuanced and could not push like the NGOs could push, because obviously the NGO’s role is to push for more … they know their roles very well” (Participant 10). As one government participant noted about negotiations over the size of warning labels on cigarette packages:

“The NGO rep would … push for more. I do not necessarily push for more, but I could share with them the experience of Canada, the challenges we have, the things they should take into consideration. So typically … country delegates are less in the black and white [than] the NGOs. Rather they [the NGOs] have to be more black and white because … if you want to push for more … you make things more black and white.” (Participant 10)

Many of the participants suggested that the NGOs acted as ‘perspective makers’ by presenting issues in particular ways to support a strong FCTC. Our findings identified two such ways that were used during their lobbying efforts: (1) economic development/sustainability and (2) morality.

In terms of economic development/sustainability, one participant noted that they “did a lot of research in different areas toshow[emphasis added] that tobacco is a development issue” (Participant 8). Another document points to the environmental and community sustainability frame:

“A representative from an NGO drew attention to the fact that the link between financial assistance for economic transition is made in the guiding principles, but this theme is not carried through under the general obligations. In countries such as Zimbabwe, much of the available land is used for tobacco crops, including land which historically grew food crops. As well, money from the tobacco industry is used to build schools. The Convention must go deeper in terms of how the transition from tobacco crops will be made, especially in developing countries.” (Document 3)

Another participant highlighted that tobacco has become a primary crop in certain countries, to the exclusion of crop diversity, and suggested that this is contraindicative of sustainability:

“ … Like the British American Tobacco Company coming into Zimbabwe removing or convincing people to not plant food but grow tobacco. Supplying the area with schools and primary health centers and then of course, then the kids stay out of school during harvest time, the women, they’re pregnant, get green tobacco disease you know, and the whole country becomes dependant on one crop, so that was a lot of the stuff that we were talking about in here.” (Participant 9)

This frame was also used to discuss the relationship between trade, economic development and health protection within the context of the FCTC:

“An NGO representative stressed the need for a sustainable development model that balances economic development, environment sustainability, health and well-being. There are concerns around the global trade agenda and the impact of the World Trade Organization (WTO) and regional trade agreements. A question was posed regarding the statement that the Convention may be able to supersede trade agreements, the role of the treaty bodies and how this may be balanced regarding human rights issues.” (Document 3)

In terms of morality, the role of NGOs to enforce a moral standard was one recognized even by government. Although the Canadian NGOs were coming from a different context of tobacco control and government relations compared with many other countries, the findings suggest that the general role of NGOs was to expose ‘bad behaviour’ of governments and industry, and take “measures to hold the tobacco industry accountable” (Participant 6).

One NGO representative asked for “more emphasis on ‘industry conduct’ which includes, but is not limited to, its products” (Document 3). As one government official noted:

“What I’ve observed is that in developing countries or very poor countries, NGOs play an extremely important role in terms of being the conscience of the government, and because a lot of poor, developing countries are bought by tobacco companies, a lot of money is given to them … and so the NGOs become the conscience and the voice of dissent in the country.” (Participant 16)

Offering technical expertise

One of the features of the Canadian NGOs was their “very high level of technical capacity” (Participant 4). Many of the participants noted that NGOs played a role in identifying problems in the content of the FCTC or the positions of governments and presenting solutions based on knowledge rather than opinions. One government official articulated this point:

“They have a superb knowledge base, that’s their great strength, they work on knowledge not from opinion or just opinions, they can be a very good spokesperson, they are very good both with government and media and with the public so they can get their messages across, they’re very forceful, and they have, I think, learned to target, you know in terms of what they want to get across at any one point in time. I think those are the three strengths, and certainly their biggest strength is that they work from knowledge.” (Participant 15)

The NGOs were involved in positioning ‘research’ throughout the process. Much of this research was in support of strong tobacco control policy and generally pushed a previously established position. The NGOs synthesized research to address a specific topic pertaining to the FCTC content (because they knew that research-based policy arguments would be more likely to win over opposing views—they focused on the policy-making process).

Most of the participants suggested that much of the expertise brought by the Canadian NGOs to the development of the FCTC was associated with their domestic tobacco control policy successes:

“I think that the knowledge about tobacco control among the Canadian NGOs, I think Canada is quite far ahead of other countries in NGO involvement. … I mean there are people that devote their lives to it [tobacco control] so I think it makes sense for the government to call on this advice even … whether they take it or not, to listen to NGOs.” (Participant 6)

“Mostly he was there as part of the FCA and I think [name], because of his technical knowledge, especially on the health warning issue and advertising … they drew upon his technical expertise to help in the negotiations.” (Participant 7)

This experience with tobacco control included knowledge of industry practice, an understanding of effective policy and practices in Canada, and experience with advocacy techniques.

“I mean you had enough problems, you had enough experiences with loopholes and failures, and tobacco industry tactics and manoeuvres that you knew what to anticipate, and you knew how to draft things and prepare a treaty in anticipation of the industry because you know we had enough experience in trying to get around things, and so you try and draft things so they can’t.” (Participant 4)

Prior to and during the development of the FCTC, the Canadian NGOs, often in collaboration with government, helped other countries develop their domestic tobacco control legislation. As one participant commented, “and here NGOs, they were very involved when we wrote those regulations, extremely involved. So obviously there they were bringing expertise” (Participant 10). One participant frequently assisted South American countries with their tobacco control activities stating that “I go down there every six months or so, but I mean there’s a certain amount of technical assistance which is basically telling (them) a little bit about my experience” (Participant 5); while another worked with countries in South Asia: “I helped them with technical assistance on specific issues where they needed it” (Participant 8).

During the INB meetings, technical assistance was shared with country delegations and with NGOs from countries who had limited experience with tobacco control. The Canadian NGOs appeared to be in a unique position of having an extensive history with domestic tobacco control, the resources to engage in such activity and credibility with other countries because of Canada’s successes. One government participant stated:

“They were certainly a good force for teaching delegations about issues because a lot of the delegations didn’t know much about tobacco frankly and didn’t have the benefit of a well-developed infrastructure like Canada had, so they were starting from scratch and the NGO community was very good at teaching, they were information sharers, teachers, influencers, and they did the whole range, they did what NGOs should do.” (Participant 15)

Brokering information

One of the NGO contributions to the negotiation of the FCTC was the brokering of information. During the INB meetings the NGOs held various “workshops and training sessions” (Participant 11), luncheons and presentations during the breaks. A statement by one participant helps to characterize the time in-between the formal meetings, in relation to the NGO’s role. He stated:

“ … That conversation around the hallways … that’s kind of where the action happens.” (Participant 5)

“Part of my role was to work the room if you want, so I got to know quite a few delegates by doing this, saying okay it sounds like you may benefit from having the background on this issue, that issue and so on.” (Participant 10)

This latter quote points to the importance of the informal interactions between NGOs and government delegations. As another participant noted:

“There were a lot of notes going back and forth and discussions after hours, between meetings with the supportive countries … ” (Participant 3)

The role of the NGOs as information broker was attributed by the participants to the access the NGOs had to both government delegations and the NGO community. One government participant noted that:

“They had very good access … better access to some delegations than we did because there were other NGOs on some of those delegations, they certainly had better access to the NGO community as a whole than delegations did because there was a fair amount of distrust I think in the governments in general … they had good access there’s no doubt about it.” (Participant 15)

One of the formal mechanisms for information sharing was the inclusion of an NGO representative on the Canadian delegation. This representative was the formal ‘conduit’ (Participant 10) between the Canadian delegates, the Canadian NGOs and the NGOs who were members of the FCA. NGOs were tightly connected throughout the INB meetings: the Canadian NGOs would often stay informed of the Canadian delegation position and then transfer this information to other NGOs, including the FCA.

The information practices NGOs engaged in appeared to involve ‘information push’ rather than simply providing information access. As one participant noted, “we’d provide them with our positions on a particular issue … we would run down [during the negotiation sessions] and provide them with a particular study that shows, yeah, this is exactly how taxation effects consumption” (Participant 1). This information push overlapped with NGO roles in offering technical expertise:

“By the time we were finished with the process it was a very sophisticated group that wrote phenomenally well-researched position papers on the various issues that were being discussed.” (Participant 11)

“We tried to put together a group of sort of scientists to write a position paper which we eventually published … so what we do is, going into every single meeting, we put together a position paper which we make publicly available.” (Participant 12)

And in monitoring and publicizing:

“We circulate our [FCA] report and the feedback that we have is [that] it provides sort of good context for them [delegations] to interpret some of the discussion and debate.” (Participant 12)

Fostering inclusion

One of the prominent roles of Canadian NGOs was to channel funding for the participation of NGOs from low- and middle-income countries to facilitate national tobacco control activities in these countries; and to provide for training, information, report development and domestic research. As one participant highlighted:

“You know their government would say, oh well, that was done in India so it’s not relevant here. It’s like, okay, well this is how you do a little tiny research study in your own country to produce local data to support the argument that you’re making. So there were a lot of little things like that.” (Participant 8)

A government official spoke about the recognition that the Canadian NGOs received regarding the support for other country’s tobacco control efforts:

“I think if you were talking to people in other countries they’d tell you how important civil society in Canada has been … I mean when I’m in other countries I often have people say, oh you know, we’ve got this small grant from [organization] or they gave us money to do this or that.” (Participant 12)

One participant noted that inclusion and broad participation are necessary to strengthen tobacco control:

“It’s the fundamental nature of tobacco control. It can’t be done; itcannotbe done by individuals or individual effort. Tobacco control requires social change, that’s really the essence. We need, it needs a lot of work, it needs laws and regulations and programming activities that require broad support from the community. You don’t get broad support from the community unless you involve lots of people, all the time and at every level.” (Participant 2, emphasis by participant)

The structural inequality between countries seemed to be one of the entry points for Canadian NGOs. One of the ways the NGOs fostered inclusion was to find ways to shift the terms of support:

“I mean it’s not money laundering you know, but you know what I mean, it’s the flow through for them [developing countries] to do what they need to do, but us providing the support only as they defined that they needed it, rather than us defining for them what their problems are and how to fix it.” (Participant 8)

Instead of traditional methods of providing one-time funding for a specific activity, NGOs often advocated for a more systemic means of supporting countries to develop their tobacco control activities in line with the FCTC. NGOs pushed governments to provide sustained resources to countries that lacked them. One participant who had been involved in government work to support the development of tobacco control legislation in other countries and now worked for a Canadian NGO noted that:

“If we scale up and start spending over a million dollars a year, as we hope to do, well then, the Canadians who are involved in that work will be helping a lot of other people improve their tobacco control which will cause people in other countries to think highly of Canada, because Canada in their mind, Canada has helped them to improve their policies, and the people who work on those projects who are Canadians will gain more experience and be more effective at their domestic work too, because they can put what they’re doing domestically in a broader international context.” (Participant 2)

As a Canadian NGO press release announced shortly after completion of the FCTC: “Having played a major role in convincing developing country governments of the need to tackle this issue [tobacco control], Canada now has the moral obligation to ‘walk the talk’ and supply substantial assistance” (Document 25).

A document compiled from the stakeholder consultations with Health Canada highlighted this point:

“The FCA advocates for a mechanism to provide financial and other resources to assist countries in their tobacco control efforts and to use tobacco tax policy as a public health tool to achieve continuous decreases in tobacco consumption.” (Document 3)

As one participant summarized:

“The approach is … not about us, that is northerners, going to teach people how to do things. It’s about providing them [poorer countries attempting tobacco control] with sources of money and training on what they need to learn, so that they can carry on.” (Participant 8)

Discussion

In this study, Canadian NGOs played important roles in the development of the FCTC by way of fostering inclusion of developing countries, discussing tobacco-related content with other country representatives at the negotiating forums, providing expertise based on previous domestic policy-making successes due to extensive negotiations, lobbying for an effective FCTC and monitoring content and various actors during meetings.

NGOs have become more prominent players on the global stage (Mathews 1997) and contrary to the ‘two solitudes’ approach to international relations, governments and NGOs increasingly cohabitate spheres of policy discourse (Cooper and Hocking 2000). We support Snow’s assertion that ‘how [NGOs] react and what they have to say about policy certainly is one of the central considerations’ (Snow 2006: 21). The growing intersection of various groups creates a complex diplomacy in the construction of tools to protect and promote health at the global level. The increased intersection between states and non-state actors challenges scholars and practitioners of global health diplomacy to consider the different roles played by each group of actors.

It seems fair to assert that, drawn from the findings of this study, NGOs have taken on a greater role in the diplomacy process. Although not explicitly stated by the study participants, we may infer from the findings that the NGO role is no longer situated outside the walls of international negotiations, but is becoming more integrated in the diplomacy process. Where the former required NGOs to speak loudly to be heard by governments, the latter seems to require a more nuanced, and perhaps more carefully managed, confluence of roles during the negotiation process. The findings further suggest that the traditional role of NGOs as advocate for civic interests (Jasanoff 1997) remains relevant but is not sufficient to characterize the multifaceted roles they now play in global health diplomacy. As health diplomats, the Canadian NGOs drew on a varied skill set, including the ability to organize expertise around and generate information for the infusion of specific language in the treaty text through interaction and developed relationships with governments.

The ‘knowledge’ and monitoring role of NGOs has also been observed in global environmental diplomacy, where NGOs have formed epistemic communities around particular issues and have sought to shape diplomacy through the provision of knowledge around these issues (Betsill and Corell 2008). The most prominent allusion to NGO contributions to global health diplomacy is their role in injecting ideas into dialogue. Fidler (2008) asserts, although implicitly, that governments represent power in diplomacy whereas NGOs represent ideas and knowledge. Although a clear dichotomy between these representations is unlikely, our findings support the knowledge function of the Canadian NGOs in the context of the FCTC. This knowledge function involved a general recognition that the NGOs integrated experience with tobacco control, research activities and diverse expertise within the group of NGOs. This function was facilitated by the monitoring role that involved publicizing the diplomatic process, such as exposing country positions in documents distributed to diplomats and on the Internet for the general public. This role seemed to work towards a more transparent negotiation process. The publicizing of the diplomatic process is a prominent tool for NGO diplomats in other realms of governance (Raustalia 1998; Betsill and Corell 2008).

Not only did the NGOs provide specific knowledge claims and function as monitors within the negotiations, they also added an emotive force behind such claims. The emotive force is reflected in the ways that the NGOs communicated their position to government delegations, in particular their use of a morality frame. Inferring from such findings, it may be that NGOs provide the break in the realist position that power and state interests are the dominant force in global diplomacy (Erikson 2008; Lencucha et al. 2010) and foster the ideal of global health diplomacy that is ‘reflected in a country’s sensitivity to the priorities of poor countries and its willingness to participate in global health governance’ rather than ‘self-interest’ (Gostin 2008: 10). Although the realist position may manifest in global health diplomacy, the prominence of NGOs on the global stage suggests that their efforts may provide a counter force leading to a more balanced and health-beneficial diplomatic process.

The other salient feature of the role of the Canadian NGOs is their efforts to enhance the representation of NGOs from different regions of the world. Although it is difficult to assert whether this role enhances global health diplomacy, it seems reasonable to suggest that these efforts reflect the current ‘open-system’ of global health diplomacy (Fidler 2008). It also suggests that if we are to build a ‘culture of discourse and collaboration between governments and those NGOs that operate at the grass-roots, community level and have the greatest access to people in need’ (Frist 2007: 225) then it may be the NGOs themselves that foster a more comprehensive and globally representative inclusion. In a small way this role of the Canadian NGOs worked to address a recognized imbalance between low- and high-income countries in the diplomacy process (Kickbusch et al. 2007b).

Wise (2009: 127) states that ‘public diplomacy is the diplomacy of deeds’. We have presented how the Canadian NGOs engaged in the FCTC negotiations by gathering and brokering knowledge to delegations—knowledge about the technical process of policy-making as well as about the substantive topic of tobacco control—while working to enhance the representation of NGOs from different regions of the world. We have also discussed the contributions that these findings provide to the consideration of the concept and practice of global health diplomacy. This discussion begins to address one of the key goals of global health diplomacy, namely ‘the challenges facing health diplomacy and how they have been addressed by different groups and at different levels of governance’ (Kickbusch et al. 2007a: 972).

Funding

This study was funded in part by a grant from the Canadian Tobacco Control Research Initiative. The lead author was supported by a doctoral award from the Canadian Institute of Health Research and the Canadian Occupational Therapy Foundation. The first author was funded by a Social Sciences and Humanities Research Council of Canada postdoctoral fellowship at the University of Ottawa when this article was written.

References

Adams
V
Novotny
TE
Leslie
H
Global health diplomacy
Medical Anthropology
 , 
2008
, vol. 
27
 (pg. 
315
-
23
)
Betsill
M
Corell
E
NGO Diplomacy: The Influence of Nongovernmental Organizations in International Environmental Negotiations
 , 
2008
Cambridge, MA
The MIT Press
Bond
K
Health security or health diplomacy? Moving beyond semantic analysis to strengthen health systems and global cooperation
Health Policy and Planning
 , 
2008
, vol. 
23
 (pg. 
376
-
8
)
Charmaz
K
Constructing Grounded Theory: A Practical Guide through Qualitative Analysis
 , 
2006
Thousand Oaks, CA
Sage Publications Ltd
Collin
J
Lee
K
Bissell
K
The Framework Convention on Tobacco Control: the politics of global health governance
Third World Quarterly
 , 
2002
, vol. 
23
 (pg. 
265
-
82
)
Cooper
AF
Hocking
B
Governments, non-governmental organizations and the re-calibration of diplomacy
Global Society
 , 
2000
, vol. 
14
 (pg. 
361
-
76
)
Erikson
SL
Getting political: fighting for global health
The Lancet
 , 
2008
, vol. 
371
 (pg. 
1229
-
30
)
Fidler
DP
Global health jurisprudence: a time of reckoning
The Georgetown Law Journal
 , 
2008
, vol. 
96
 (pg. 
393
-
412
)
Frist
WH
Medicine as a currency for peace through global health diplomacy
Yale Law & Policy Review
 , 
2007
, vol. 
26
 (pg. 
209
-
29
)
Geertz
C
Geertz
C
Thick description: toward an interpretive theory of culture
Interpretation of Cultures: Selected Essays
 , 
1973
New York
Basic Books
(pg. 
3
-
30
)
Gostin
LO
International assistance for health: ten priorities for the next president
Hastings Center Report
 , 
2008
(pg. 
10
-
11
)
Jasanoff
S
NGOs and the environment: from knowledge to action
Third World Quarterly
 , 
1997
, vol. 
18
 (pg. 
579
-
94
)
Kickbusch
I
Novotny
TE
Drager
N
Silberschmidt
G
Alcazar
S
Global health diplomacy: training across disciplines
Bulletin of the World Health Organization
 , 
2007
, vol. 
85
 (pg. 
971
-
2
)
Kickbusch
I
Silberschmidt
G
Buss
P
Global health diplomacy: the need for new perspectives, strategic approaches and skills in global health
Bulletin of the World Health Organization
 , 
2007
, vol. 
85
 (pg. 
230
-
2
)
Lencucha
R
A theory of institutional gaps. Health and Rehabilitation Sciences, PhD thesis
2009
 
University of Western Ontario, London, Ontario, Canada
Lencucha
R
Labonte
R
Rouse
M
Beyond idealism and realism: Canadian NGO/government relations during the negotiation of the FCTC
Journal of Public Health Policy
 , 
2010
, vol. 
31
 (pg. 
74
-
87
)
Mamuda
HM
Glantz
SA
Civil society and the negotiation of the Framework Convention on Tobacco Control
Global Public Health
 , 
2009
, vol. 
4
 (pg. 
150
-
68
)
Mathews
JT
Power shift
Foreign Affairs
 , 
1997
, vol. 
76
 (pg. 
50
-
66
)
Raustiala
K
States, NGOs, and international environmental politics
International Studies Quarterly
 , 
1997
, vol. 
41
 (pg. 
719
-
40
)
Snow
C
Public diplomacy practitioners: a changing cast of characters
Journal of Business Strategy
 , 
2006
, vol. 
27
 (pg. 
18
-
21
)
Wise
K
Public relations and health diplomacy
Public Relations Review
 , 
2009
, vol. 
35
 (pg. 
127
-
9
)