Twelve interviews (women n=2, men n=10) were secured and completed: a response rate of 100%. The primary institutional affiliation and professional background of participants were collected for consideration as part of the analysis (Table 1 on appendix).
Table 1 on appendix: Interview participant’s affiliation and profession
From the general thematic analysis three distinct main themes and four sub-themes of equal weighting emerged from the data: 1) The absence of a compelling narrative for the UK community operating in the health security nexus; a lack of common language and limited cross sector collaboration has led to concerns amongst participants regarding UK resource prioritisation and allocation, 2) Confusion as to the current architecture of UK governance around the expanding global health security agenda; no clear overarching policy or strategic leadership was noted, and 3) The role of global health security in wider UK health diplomacy.
Theme 1: The absence of a compelling narrative for the UK community operating in the health security nexus
Lack of a common language
When considering the scope of health security, most participants (n=10) drew on the definition of global public health security established by the 2007 World Health Report 4, additionally highlighting the complexity of managing the relationship between human security and health (n=5), and the role of health security as part of a systems strengthening approach (n=10). However, several of the participants (n=10) also emphasized a recent broadening representation of health security in the UK policy and practice landscape due to a resurgence in popularity amongst policy-makers for the normative ‘Health as a Bridge to Peace’ (HBP) narrative, and an increased focus on investment in fragile and conflict affected states. While many of the programmes of work discussed traversed the intersections between these spaces (Figure 1 on appendix, e-Appendix 2), participants mostly defined health security activities and actors in line with the ideology and mandate of the organization that they were primarily affiliated with (Table 1 on appendix).
Figure 1 on appendix: Intersections of programmes considered UK global health security activities by key Informants pre Covid-19.
e-Appendix 2: Activities considered by key informants to be part of global health security agenda pre Covid-19.
Participants were divided as to the potential value of framing threats to health within the wider security narrative in order to broaden the discussion. Both in terms of practical response, and as a frame for creating a higher profile political debate.
“Almost always, security is a highly political ambition and so… more likely
to lead to the discussions about making sure the resources are available.”
Interview 6
Recognition existed that the use of security as a lens for health activity had expanded the opportunity for engagement with a broader range of institutions and funding bodies (n=6). Particular focus existed around activity intersections (Figure 1 on appendix) such as migration, conflict, or the response to resource scarcity affecting the capacity of countries to deal with disease. Yet caution was expressed by participants of; moving the debate away from its place within the UK’s wider global commitments to Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs), of the risk of securitizing resources, and of reducing health to a strategic tool for foreign policy irrespective of health outcomes (n=7).
Ultimately the development of a public position across UK communities engaged in health security activity was considered essential by all participants in order to coordinate decision making, programmes of work, and to justify resource use, both within the community and to the wider British public.
Limited cross sector collaboration
Domestic collaboration was seen as the biggest barrier to progressing the UK national and global health security agenda. As one participant noted:
We are terribly uncoordinated…at the moment I don’t think there is an overarching view on this (global health security activity) ...we need a collective knocking of heads together to have a conversation!”
Interview 4
The broadening of the terminology around ODA, combined with increased competition for resources was reported by many to have dis-incentivised collaboration between institutions bidding for narrower caches of resources. Furthermore, a perceived politicization of aid and a reported disconnect between policy makers and the people implementing them was cited as ‘creating a turf war over resources’. A tacit understanding was indicated that the institutions and departments involved in this agenda often still worked ‘as silos’ and in ‘stove pipe’ fashion. Participants described the need for improved transparency in multi-agency collaboration:
“We need to think collectively about how the UK operates internationally and
how we draw upon our collective resources to achieve the biggest impact.”
Interview 7
Pockets of excellent cross-departmental collaboration for global health security were reported in the form of Zoonosis, Antimicrobial Resistance (AMR) and the UK’s bilateral health alliances. In these projects, clear leadership and strategy meant that a collaboration across domestic organisations had enabled not only good joint working relationships at an operational level but facilitated informal connections and conversations around broader perspectives. These informal connections were reportedly further strengthened by a bridging of communities through intentional appointments of decision-makers into shared posts, secondments and cross institutional responsibilities (Table 1 on appendix). All participants had worked across more than one sector and this was reflected in a breadth of understanding of other sectors roles and values (e-Appendix 2). However, a knowledge of how the system should work was not often translated into a reality of practical collaboration, as reflected by one organisational leader:
“It is very easy to talk about cross-Whitehall collaboration but unless there is a project that does require our collective expertise then we just don’t tend to work together.”
Interview 7
Moreover, institutional incentive structures were considered to be about institutional growth as defined by Ministries. Where success had been achieved, participants reflected that an intentionality to find areas of overlap and team up for common purpose had existed. Operational collaboration by the increasingly diverse global health, and humanitarian communities responding to global health security emergencies, such as the West African Ebola outbreak, was reported to have facilitated a steep learning curve. Whilst participants recognised the need to work collectively to response to global threats, the complex, and at times controversial, challenges of multi-agency participation in terms of; programme duplication, the use of non-traditional health providers such as the security sector, and the blurring of institutional boundaries had increased awareness in the need for synergy across health security activity.
Theme 2: Confusion as to the current architecture of UK governance around the health security agenda
Unclear Community Leadership
Participants reported the National Security Council (NSC) at the Cabinet Office to be
the nominal leadership of the health security agenda for the UK. However, only two of the senior decision makers currently reported direct engagement with the NSC and three further could testify to historical engagement with the Cabinet Office. Participants expressed frustration at a lack of named individuals for engagement and accountability, confirming that in the last few years there had been significant changes across government resulting in a significant loss of institutional memory and relationships:
“I couldn’t name an institution or person who is leading this from the UK… I
would say there might even be a difference between who they are, as to who
they ought to be...”
Interview 5
Moreover, a general concern existed as to whether the Cabinet Office as the community leaders are sufficiently engaged with the broader elements of the health security agenda, due to the perceived narrowing of focus towards topical concerns around the UK leaving the European Union, securitisation and the national counter-terrorism agenda:
“In terms of understanding the needs for an overarching framework, then Cabinet Office is currently the home for that coordination, but whether it yet fully sees its role as bringing together and coordinating, that action is another question. At the moment, it is very much a functional role that it has. So, responding to threats, anticipating threats, and mobilizing response to it, without necessarily seeing this for the UK to potentially engage with more systematically.”
Interview 7
Although several health security leadership groups were reported to exist across government, little consensus existed about when or where they met, what outputs were envisaged, or who was consistently represented (e-Appendix 2). Public Health England (PHE) was recognized to convene several of these groups, including the Human Animal Infections and Risk Surveillance (HAIRS) group 40, and the Global Health Security Program Board 41. The Global Health Security Program Board was reported to have played an essential role historically in aligning UK health security strategy and activities, under the ‘Health is Global’ policy 42, which finished in 2015, and had ensured that a breadth of community members had a voice around the table. However, participants reported that since 2015, this forum had become narrower in its focus and had reduced to a few key government players at Department of Health, Department for International Development and Public Health England. Why this had occurred was not clear. Besides these traditional actors in domestic and global health, a diverse set of community leaders were reported to have emerged as the health security space expands. Influencers in this space were reported to now range from senior academics, to board members of charities working on global health issues, and civil society advocates with significant social media platforms. Despite this growing diversity, a central leadership and governance framework to engage and coordinate these efforts was noted to be absent from UK global health architecture. As such, participants considered the responsibility for strategy development and implementation, without clear and authoritative leadership, to be at risk of falling between stakeholders, and of the UK global health security nexus being vulnerable to co-opting into other debates and agendas. As one participant explained:
“It is a contentious area and I think leaders have a huge amount of
responsibility here…I think there is an important leadership role in messaging.
I think it needs good communications…one agenda that works across all
(sector) leaders.”
Interview 10
Recognizing this failure, a call for stronger leadership and governance capacity to manage the communication, architecture and programme coordination of the space was conveyed by all participants.
Health Security in UK Policy
No overarching strategic framework or policy, for either the health security agenda or wider UK global health strategy, was identified by participants. Concerns were raised that the policy vacuum left by the internationally heralded UK ‘Health is Global’ strategy 42 has left the UK without strategic direction and leadership essential for activity accountability and delivery, around not only health security, but the wider global health agenda. As several key participants highlighted:
“We (UK) don’t have a coordinated strategy that says this is what we are going to do. These are the minimum standards for consideration for any programmes we are going to do. These are the areas we are going to work in. We’ve just simply not got that.” Interview 4
“So, you need to get the UK bit right. We would really need as a country, as we discussed, a common policy that can be translated into everybody’s language so that we are all behind it.” Interview 3
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The National Security Strategy 2 was referenced as the principal contemporary document to set out transnational threats to health as a national priority, but operationalizing this mandate was subject to institutional interpretation and priority. Public Health England’s ‘Global Health Strategy’ 43, and the Department for International Development’s latest ODA strategy 1 were felt to go some way in making the vision of these UK institutions more transparent. However, much of the available documentation focused at a top tier level of institutional objectives and therefore were lacking in an accessible community narrative, programmatic detail or measurable outcomes. Therefore, with the overarching ‘One HMG Overseas’ strategy 44 asserting a closer relationship between UK stakeholders, a need for planning models and a strategy were considered timely in order to create conditions for cross government cooperation. As one participant noted that:
“Yes, there are commonalities, but I don’t think they are articulated as common
objectives.”
Interview 8
Fundamental political and normative differences amongst participants were bridged by the need for an agreed strategy to both support and justify decisions around the expanding domestic and global health security agenda. Diverse suggestions included; a broad strategic thinking group, development of a national plan, a mapping of the declared ‘UK contribution’ to GHS, a review of the UK health capacity as a public good, a minister accountable for global health and a broader series of coordinated process’ to mitigate risk. However, all participants agreed with the sentiments of one who proposed that:
“It is much more useful to look at the global health approach of which security is a part…These all need to be captured in a strategic document that brings it all together and then we individually as different departments with an interest will have a responsibility to cascade from there.”
Interview 6
Theme 3. The role of global health security in wider UK health diplomacy.
The UK was considered by all participants to be a key figure in the wider global health security domain. Both in terms of its commitment to the 0.7% GNI goal for ODA, and as a key member and contributor to multilateral organizations including the G7, Munich Security Council 45 and United Nations 46. However, several participants reported concern that a lack of an agreed national strategy for global health security as it relates to wider policy and practice both i) threatens to undermine the UK’s reputation as a leader in the field (n=8), and, ii) risks leaving the UK with a poverty of negotiating power at high-level health and foreign policy platforms (n=5). Although many participants were hesitant to comment on the potential impact of the UK’s decision to leave the European Union, a unanimous agreement existed that the coming years would be ones of concerted effort to ensure that the global health security agenda remained centre stage for the UK and its position as a global influencer. With one participant noting that,
“I think there is a need to think more strategically not only about how we
build up the UK’s capability, both for our own use but also how we become
a much stronger international player.”
Interview 6
Consensus existed of the need to align behind a coordinated UK contribution to the evolving health security agenda globally (n=12). A need to mitigate against the risks created by contemporary political pressure to balance domestic interests with overseas spending was stated by several participants (n=5). Getting this right was considered as vital in ensuring the UK’s ongoing global position as a leader in biological sciences and in health diplomacy efforts.
The UK governments’ increasingly transparent move towards a position of ‘enlightened self-interest’ was considered by several participants (n=6) an opportunity to move discussions away from the historical donor-recipient approach, in favour of a more mature conversation around partnering with countries to share technical health security expertise and build mutually beneficial capacity. Activities mentioned included the championing of transnational health security initiatives such as Global Health Security Agenda (GHSA)41, Antimicrobial Resistance (AMR)47 and the International Health Regulations (IHR)48 as part of the UKs wider global health commitments to international solidarity and stabilisation programmes. However, although considered a valuable tool in terms of developing UK ‘soft power’, the inflated health security agenda was felt by many participants (n=7) to come with challenges for a harmonised UK One HMG approach. Particular reference was made to issues around duplication of activity (n=9), the reliance on permissive political conditions and confusion regarding expressed motivations (n=7). A model of coordinated UK response for global health security was considered essential, not only for the development of health security governance, but as an effective tool for synergising UK’s diplomatic policies with the wider global health agenda.