April 2013 Health Policy and Planning ; Brazil and other emerging powers, such as China and India, are becoming increasingly influential world players. As they expand their global recognition and the associated diplomatic influence and access to markets, these countries are multiplying their development co-operation efforts with low-income countries often located in the southern hemisphere (Kragelund 2008). Within this ‘South–South co-operation’ these so-called ‘emerging donors’ are progressively turning to health interventions as effective foreign policy soft-power tools (Feldbaum and Michaud 2010).
In the debate on the relationship between health and foreign policy objectives, it has been argued that the two interact in more than just one way and end up exerting mutual influence (Kickbush 2011). Although the former are often regarded as tools for the latter, public health objectives are also seen as benefiting from foreign policy action, as demonstrated by Brazil’s diplomatic efforts for worldwide tobacco control and access to antiretroviral (ARV) drugs (Lee et al. 2010). However, many take the view that there will always be a tension between global health and foreign policy, and that co-operation projects need to be read through the lenses of foreign policies to understand the potential and limitations of this new form of ‘health diplomacy’ (Feldbaum and Michaud 2010).
The tension between foreign policy and development goals is in part reflected in emerging donors’ questioning of the traditional principles of aid effectiveness affirmed in the 2005 Paris Declaration and subsequent Accra Agenda. Such principles of aid effectiveness aimed, among other things, at separating aid from non-aid goals by seeking traditional donors’ commitment to measurable results and sustainability of co-operation projects. In more than one way, the recent Busan High Level Forum on Aid Effectiveness has come to bridge the existing rift between old and new donors, not only by hailing ‘horizontal partnership’ and ‘development co-operation’ instead of vertical aid (Martini et al. 2012) but also by relaxing contentious aid principles like that of alignment to national governments’ policies, and donor harmonization (HLF4 2011). As a result, the new consensus emerging from Busan puts forward a more inclusive model of development co-operation focused on ownership, focus on results, global partnership, transparency and accountability, but based on donors’ differential commitments (Hill et al. 2011, Russo et al 2013).
This commentary draws on a study on Brazilian projects in Africa (Russo et al. 2011) and the authors’ direct involvement with Brazilian health co-operation to argue that, although shaped by its foreign policy goals, Brazil’s engagement is contributing to a shift in the discourse on health development co-operation, by offering home-grown examples of health development, by adopting new concepts of health co-operation and by leading unusually bold action on key global health issues. The consideration also emerges that Brazilian health co-operation, being relatively young and still learning its trade, would also benefit from a deeper engagement in the discussion on effectiveness and sustainability of development interventions.
Brazil’s record of advancing health and reforming its healthcare sector is compelling and has attracted the attention of academic literature and international media alike. Its decentralized Unified Health System [Sistema Único de Saúde (SUS)] introduced in 1990, currently covers an estimated 80% of the country’s total population, offering services free of charge at the point of delivery (Paim et al. 2011) and bringing to 9% the proportion of GDP spent on health in 2010 (The World Bank 2012).
Some have highlighted the key role played by social movements in shaping and bringing on such a comprehensive social healthcare system (Fleury 2011). Since the ‘movement for health reform’ succeeded in enshrining the right to health in the country’s 1988 Constitution, the development of the health system has been shaped by a powerful ‘SUS epistemic community’ which has brought activists, academics, politicians and bureaucrats together to push for rights-based universal access to health care (Shankland and Cornwall 2007). This ‘epistemic community’ is very influential in key institutions involved in Brazilian health co-operation, including the Oswaldo Cruz Foundation (Fiocruz), home of the national school of public health.
Together with the country’s economic growth and, therefore, improved living conditions, SUS consolidation in the last 20 years is credited with contributing to Brazil’s dramatic reduction of child mortality (estimated to have reduced by 4.4% a year for the last 20 years), coupled with a similar reduction of maternal mortality over the same period (Victora et al. 2011). National immunization programmes have reached near-full coverage, boosted by the SUS reform and an increase in funding for preventive medicine, health– and education-related conditional cash transfer programmes, as well as by the scaling up of national vaccines and drugs production (Barreto et al. 2011).
Likewise, control of some of Brazil’s most burdensome infectious diseases, such as cholera, diarrhoea and Chagas disease, has been achieved through extensive immunization campaigns and policies aimed at improving living conditions for the poorest quintiles of the population. Although still far from neutralized, the HIV/AIDS epidemic in Brazil has been stable since 2000, with a mean national seroprevalence of around 0.6% (Barreto et al. 2011). A range of aggressive prevention campaigns—such as syringe-exchange programmes, targeted condom distribution, referral to treatment centres—and universal access to ARV treatment have been used to contain new infections and reduce the viral load in those living with the disease, halving the predicted disease associated mortality and hospitalization rates between 1998 and 2005 (Smallman 2007).
Brazilian government officials dispute the traditional dominant model of aid, development assistance and donor–recipient relations, seen as reflecting Northern countries’ efforts to impose their own worldviews, agendas and pre-defined objectives (Buss and Ferreira 2010a). Brazil instead claims to promote ‘South–South’ or ‘horizontal co-operation’, with mutual learning and exchange between countries. In its officials’ views, this is why Brazilian health co-operation projects are almost always demand driven—that is, expressly requested by recipient countries—rather than part of externally designed health aid packages.
Official government co-operation publications link Brazil’s engagement in health co-operation to the importance attributed by the country’s own constitution to health as basic human right (ABC 2007). The corollary of such constitutional foundations is that Brazil’s perspective holds access to health to be more important than economic gain, and social equity and solidarity among countries to be the prime driver of co-operation in health (Bliss 2010). However, some argue that Brazil’s engagement in international health co-operation is probably better understood within its use of health-related interventions as soft-power tools for its foreign policy objectives (Lee et al. 2010).
Long active in global health issues such as international medicines trade and tobacco control Brazil has been quick to understand how effective a tool health interventions can be to achieve non-health goals, following the example of foreign policy-savvy countries such as the USA and Cuba (Feldbaum and Michaud 2010). Brazil was one of the key signatories of the 2007 Oslo Declaration calling for the integration of global health in foreign policies, and recognizing health’s key role in international relationships (Ministers of Foreign Affairs 2007). The way Brazil’s former president Lula turned the country’s experience and expertise in HIV/AIDS into a geopolitical opportunity represents further evidence of such an approach (Gómez 2009).
In this respect, Brazilian diplomats and co-operation officials appear to have fully embraced the ‘health diplomacy’ concept, explained by some as foreign policy action informed by health-specific expertise, and expressing the view that in today’s world, many global health goals can only be achieved through the articulation between health and foreign policy actions (Kickbush et al. 2007).
Brazil’s concept of health co-operation also explicitly promotes national self-reliance and technological independence through its co-operation projects. What Gadelha (2006) terms the ‘health–industrial complex’ links a country’s health development with the development of its own healthcare industry, claiming that supporting national pharmaceutical, biotechnology and medical industries not only carries a clear economic benefit but also increases investment in the national health system. In the same vein, Brazilian emphasis on ‘structuring co-operation in health’ focuses on coupling human resources for health capacity building with institutional development (Almeida et al. 2010), with the objective of breaking developing countries’ dependency on traditional technical assistance from industrialized countries (Buss 2011).
Brazil’s interaction with international health organizations
Soares de Lima and Hirst (2006) argue that involvement with multilateral institutions has been a constant of Brazilian foreign policy since the creation of the League of Nations, and that such involvement may be growing stronger with Brazil’s aspiration for a permanent seat at the UN. In the health sector, unlike China, Brazil has a history of engaging with health-focused multilateral organizations such as the World health Organization (WHO) and its American sister organization Pan American Health Organization (PAHO), the United Nations Children Fund (UNICEF), and more recently, the Global Fund for AIDS, Malaria and Tuberculosis (Lee and Gómez 2011). Some observers even suggest that, thanks to Brazil’s already consolidated health institutions, the country’s health policy has been able to benefit comparatively more from the influence of global financial initiatives such as the Global Fund (Gómez and Atun 2012).
A recent report from the National Institute for Applied Economic Research (IPEA) shows that between 2006 and 2009 Brazil has contributed United States Dollars 106.5 million to international health United Nations agencies such as WHO/PAHO, UNICEF and United Nations Drugs Purchase Facility (UNITAID). WHO and PAHO have long been considered key partners, but Brazil has recently used its influence in emerging global fora such as Brazil, Russia, India, China and South-Africa(BRICs) to push for a greater say in their governance. In the 2011 BRICS Health Ministers’ Meeting in Beijing, Brazil helped to shape a declaration calling for WHO to expand its role in global governance, playing a greater role in access to medicines, capacity building and technology transfer and in the pre-qualification of medicines—and also for reform of WHO’s decision-making process to make it more driven bymember states (BRICS Health Ministers 2011).
Brazil has also been very active in developing the strategic health co-operation plans of the Community of Portuguese-speaking Countries (CPLP) and of the Union of South American Countries (UNASUR), two groupings between them including the main recipients of Brazil’s health projects (Buss and Ferreira 2010b). In the former, Brazil pledged to act upon the social determinants of health by addressing countries’ needs in terms of training and development of the health workforce, development of the health industrial complex and epidemiological surveillance (CPLP 2009). In the latter, Brazil pledged support for developing a regional policy for the surveillance and control of health events and strengthening universal health systems (UNASUR 2009).
Brazilian international co-operation is also seen as a source of relevant expertise by foreign development agencies, who have increasingly come to make use of ‘triangular’ co-operation, according to which a developed country organization—such as the Japanese Cooperation Agency (JICA), the United States Aid Agency (USAID) or the German International Cooperation Agency (GIZ)—provides funds and works together with Brazil in a low-income third country (Buss and Ferreira 2010b). Such involvement with traditional ‘Northern’ donors is not new for Brazil, and its revival reflects both the outside world’s recent interest in engaging with Brazil in several domains and the increasingly active expression of Brazil’s own ‘desire to expand its presence within international arenas’ (Abdenur 2007).
Brazilian health co-operation projects
A recent report (GHSi 2012) claims that Brazil’s health co-operation projects are equally determined by its foreign policy goals, health specific expertise and requests from partner countries. According to the Brazilian Ministry of Health (MoH) and Co-operation Agency (ABC), in 2009 there were 137 health co-operation projects worldwide at a different stage of implementation and negotiation, with Latin American and African countries benefitting from the largest share—97 and 41, respectively (MoH 2010). One recent study found 31 Brazilian health projects either ongoing or in the immediate pipeline in Portuguese-speaking African countries alone (Russo et al. 2011). A government study (IPEA 2011) estimated Brazilian health co-operation to be worth R$13.8 million (USD 6.9 million) in 2009, although some authors argue that such a figure may be a gross underestimate, as it does not capture the totality of projects and human resources costs (Russo et al. 2011).
A multiplicity of government agencies are currently involved in funding, managing and implementing Brazilian health co-operation projects, from Ministries of Health, Education and Foreign Affairs, to institutions such as ABC, the National Surveillance and Food Quality Control Agency (ANVISA) and Fiocruz (MoH 2010). In 2008, a Fiocruz Regional Office for Africa was inaugurated in Mozambique to co-ordinate the health co-operation work in the region (Almeida et al. 2010). The Ministry of Health and powerful agencies such as Fiocruz and ANVISA have a considerable degree of autonomy in their development co-operation partnerships, as ABC’s role focuses on diplomatic, financial and logistical support rather than strategic agenda setting. This allows considerable scope for projects to be shaped not only by foreign policy goals but also by the institutional interests of these agencies and by the ideological and policy preferences of the SUS ‘epistemic community’.
Brazilian technical co-operation projects currently focus on providing expertise, training, goods, equipment and typically do not carry either a grant component or conditionalities. Brazilian health co-operation’s main areas of focus are HIV/AIDS, malaria and dengue control, maternal and child health care, technology transfer for production of medicines, pharmaceutical surveillance and regulation, health professionals’ higher education and technical training. Centred on strengthening recipient-countries’ health systems, Brazil’s health co-operation projects aim at combining practical interventions with local capacity building and knowledge generation in institutions such as MoHs, National Health Institutes, National School of Public Health and Technical Schools of Health, which were seen as pivotal in Brazil’s own experience of developing a system of health governance (Almeida et al. 2010).
A wide range of projects aim at supporting recipient countries response to HIV/AIDS, including donation of ARV drugs to Guinea Bissau and São Tome and Principe, the establishment of a factory for production of ARVs and related medicines in Mozambique, or HIV surveillance in Bolivia and Peru. Besides supporting training of professionals from low-income countries in health and medical sciences in its national universities, Brazil is currently running projects aimed at building institutional capacity in health in African and Latin American countries. Setting up human milk banks in Latin America and Africa is another example of the country’s high-visibility projects, where Brazilian technology to store human milk is transferred to those countries’ where natural breastfeeding practices need consolidating (Giugliani 2002).
Like those of other emerging donors, Brazil’s international development co-operation activities are openly inspired by foreign policy objectives and are already influencing the global health debate in a number of ways. Brazil’s domestic health record has already set an example of how a middle-income country can successfully fight infectious diseases that are seen as holding back development, as well as how it can dramatically expand population healthcare coverage. By popularizing concepts such as the ‘health–industrial complex’, ‘health diplomacy’ and ‘structural co-operation’, Brazil is already having an impact on the way health development co-operation is conceptualized and implemented (Bliss 2010). As an alternative to traditional aid packages, Brazilian health projects in Africa and Latin America offer bold and domestically tested solutions, such as ARV manufacturing, strengthening key health institutions and human milk bank networks. Its interaction with multilateral health agencies and regional co-operation bodies is already increasing Brazil’s worldwide influence in the health arena. Given the Busan Conference’s shift in focus from aid to more inclusive action for ‘development effectiveness’ (HLF4 2011), there are grounds to argue that, together with the other BRICS, Brazil has already contributed to moving forward the discourse on development co-operation.
However, as its health programme is quickly expanding and increasingly subject to public scrutiny, a few issues are likely to require greater attention. Brazil currently lacks a legal framework to underpin donations to foreign governments (Bliss 2010). This is likely to complicate its co-operation activities in the future, as suggested by the ARV factory experience, where an ad hoc law had to be passed by Brazil’s Congress to authorize Fiocruz to develop this initiative in Mozambique. Neither has Brazil comprehensively developed its health co-operation policy as yet. Its ability to establish strategic criteria for priority setting is limited by its emphasis on national governments’ requests and ownership. This demand-driven approach serves Brazil’s foreign policy agenda well, by making it an attractive partner for low-income countries. However, the tendency of its projects to be mostly driven by foreign policy objectives and/or the ideological agendas of the ‘SUS epistemic community’ may have contributed to the fact that Brazil has also shown little interest in assessing projects’ results and sustainability so far, and has not developed a monitoring and evaluation system for its co-operation activities (Cabral and Weinstock 2010).
To a large extent, our analysis is consistent with that part of the literature which suggests that, given its current size and limitations, Brazilian co-operation hardly represents a major paradigm shift in the debate on aid effectiveness (Cabral et al. 2012, Russo et al. 2013). However, we also suggest that in the health co-operation area Brazil has been able to punch above its weight by challenging established models and presenting an alternative to traditional health projects. In the current development co-operation landscape, Brazil is already a significant presence to be reckoned with, and promises to become even more influential. Seeking its greater engagement with traditional health players could bring mutual benefits, both in strengthening Brazil’s ability to contribute to changing the terms of the co-operation debate, and also in helping the country to avoid repeating the mistakes made by others in the past.