Brazilian international cooperation in health in the era of SUS

This paper addresses the role of health in Brazil’s health diplomacy and international cooperation since the emergence of the Brazilian Unified Health System (SUS), focusing in particular on South-South cooperation, in line with the priorities of the country’s international technical cooperation since its creation. It highlights the relationship with the Latin American and Caribbean Countries (LAC) and the Community of Portuguese Speaking Countries (CPLP), more specifically, with the Portuguese Speaking African Countries (PALOP) and East Timor. It emphasizes the roles of the Ministry of Health, through the International Advisory Working Group on Health (AISA) and the Oswaldo Cruz Foundation (Fiocruz), the Brazilian Cooperation Agency (ABC), the Ministry of Foreign Affairs, and the Pan American Health Organization (PAHO). The article points out that the TC-41 Co-operation Agreement is one of the main instruments for enabling cooperation. It presents the cases of the structuring networks of health systems, as well as the paradigmatic negotiations of the Framework Convention on Tobacco Control, the TRIPS Agreement and the establishment of UNITAIDS, in which Brazilian diplomacy had a predominant role.


Introduction
This article addresses the role of health in the diplomacy of health and Brazilian international cooperation since the establishment of the Brazilian Unified Health System, SUS.It focuses on South-South cooperation, in line with the priorities of Brazilian international technical cooperation from that period onwards.It also deals with Brazil's relations with countries in Latin America and the Caribbean (LAC) and the Community of Portuguese Speaking Countries (CPLP), in particular, the Portuguese-Speaking African Countries (PALOP) and East Timor.
The Ministry of Health (MH) has played a significant role in this cooperation, coordinated by the International Advisory Working Group on Health (AISA), together with other institutions such as the Oswaldo Cruz Foundation (Fiocruz), the National Cancer Institute (INCa), the Brazilian National Health Surveillance Agency (AN-VISA) and other bodies within the MH, in conjunction with CAPES [Agency for the Support and Evaluation of Graduate Education]/Ministry of Education (MEC), State and Municipal Secretariats of Health, The National Council of Health Secretaries (CONASS), National Council of Municipal Health Secretariats (CONASEMS) and civil society organizations.
As well as 'technical cooperation in health' , this article analyzes the elements of 'Brazilian diplomacy' during the 30 years since SUS has been formally in existence (1988-2018).It examines the active participation of the health sector in the processes of political integration Brazil is engaged in, in particular the UNASUR (Union of South American Nations), Mercosur and CPLP.
We argue that 'international cooperation in health' is only one of the dimensions of Brazil's 'health diplomacy' .It gained particular importance since the 1988 Brazilian Federal Constitution and the implementation of SUS and was also boosted by the regional integration policies of the last 30 years.

Brazil's International Cooperation
As a public policy, foreign policy is influenced by the dynamics of the formation and transformations of the State and the relations between government and society, with all its inherent challenges 1 .International cooperation policies and activities are one of the most important foreign policy tools.They are both a mechanism for domination and an essential part of an interna-tional insertion strategy, always mediated by the power games that are inherent to the dynamics of the world system.
Brazil's redemocratization, further enhanced by the citizen's 1988 Constitution, brought in a wide range of judicial and legal transformations, including in the area of international cooperation.Article 4, item IX, of the Constitution states that one of the principles governing Brazil's international relations is "cooperation between peoples for the progress of humanity".This is the frame of reference of Brazil's international cooperation.It also steers Brazilian diplomacy in order to defend its national interests while encouraging progress and the welfare of other countries.
During the Post-Constitution years, Brazilian foreign policy (BFP), both in terms of its strategic framework and its agendas, has been "a combination of the institutional dimensions and contents of the past with innovative objectives and inter-bureaucratic interventions and policies 1 .
From the beginning of the 2000s, the historical pillars of BFP were put into operation and alternated between its traditional alliance and alignment with the USA and a search for autonomy and diversification.However, it is in the two Luiz Inácio Lula da Silva governments (2003-2010) that Brazilian Foreign Policy starts to veer toward a different direction, thus enabling the development of a new strategy of international protagonism that both enhances its role in the world and reveals the difficulties inherent to the peripheral insertion of developing countries.
Almeida 1 argues that when compared to the Fernando Henrique Cardoso era, diplomacy during the Lula years: became more active and assertive in its form and more emphatic in content, explicitly defending national interests and sovereignty; it sought specific alliances with countries in the Global South; fundamentally criticized free trade; and reaffirmed Brazil's traditional positions in terms of its diplomatic agenda.In political terms, clear efforts were made to expand Brazil's presence in the world and, in economic terms, it sought greater cooperation and integration between countries -other middle-sized powers (India, South Africa and China), as well as regional neighbors -promoting "active political coordination among significant political world players, in particular independent partners within the developing world".(...) Thus, Lula's foreign policy could be defined as "autonomy through diversification".
The creation of the CPLP in 2006, in which Brazil played an active role, encouraged a frame-work of new international cooperation strategies with these countries, including in the area of health.Likewise, the launch of UNASUR in 2008 provided the potential for Brazil to become a main player, in this case, in the regional integration of South America.In a seminal book 2 , the then Brazilian Secretary General of Foreign Affairs, Samuel Pinheiro Guimarães, stated that the most important and greatest challenge for Brazilian Foreign Policy is to reaffirm the country's active presence in the region.
International cooperation came hand-inhand with the country's evolution and the transformations that both redemocratization and the innovative programs of the Lula Government imprinted on Brazilian society.Brazil went from being almost exclusively a receiver, in the traditional North-South model, to a provider of international cooperation to other developing countries, in particular South-South and triangular cooperation.
According to the Brazilian Cooperation Agency 3 -established in 1987 to bring greater agility to the country's international activities -technical cooperation is an indispensable BFP mechanism and a powerful soft power resource for Brazil.In a recently published book 3 , ABC considers its experience in international cooperation in various fields of action, including health.In its website, ABC 4 defines technical international cooperation as an important instrument for development, that support countries to promote social and economic structural changes, including State measures for institutional strengthening.The programs implemented within its remit allow the transfer or sharing of knowledge, experiences and best practices, by developing skills and institutional capacity in order to promote a lasting qualitative leap.
At present Brazil provides technical cooperation 4 i) within the molds of South-South Cooperation (SSC); ii) trilateral cooperation with developed countries or international organizations to benefit third parties; and iii) South-North cooperation, especially in areas of recognized Brazilian expertise.
For ABC 4 , Brazilian international technical cooperation is governed by SSC principles, initially established in the historical Bandung Conference (1955) and further consolidated in the Buenos Aires Action Plan (BAAP) (1978), where the concept of Technical Cooperation among Developing Countries (TCDC) was established, or 'horizontal cooperation' , to complement North-South cooperation.The following principles stand out: it is not welfare based, has no profit goals, nor commercial objectives.It focuses on the institutional strengthening of partners, a fundamental condition for effective transfer and absorption of know-how.Furthermore, it includes the guiding principles of SSC: respect for national sovereignty, national ownership and independence, equality, non-conditionality, non-interference in domestic affairs and mutual benefit.
ABC estimates that until now Brazil has conducted over 3,000 cooperation projects abroad, through partnerships with other countries and international organizations in 108 counties in Africa, Latin America, Asia and Oceania.SSC 5 benefitted 24 countries in Africa, including all the PALOP countries and 23 countries in Latin American, including all South American countries.Santos & Cerqueira 6 carefully analyzed Brazil's SSC with South America and Africa.

Brazilian International Cooperation in Health
An analysis of the different articles in this volume on SUS reveals the advances it has undergone since its creation, with the aim of improving living conditions and health of the population.And these advances have not gone unnoticed by a number of countries, multi-lateral institutions and other players across the world.This "accumulated quality" -our "technical asset", conceptually and methodologically developed at the heart of SUS -became one of the requests as one of the objectives of international cooperation during presidential visits -in particular during the Lula government -and in missions of partner countries to Brazil.Thus, it becomes an important dimension of Brazil's international cooperation.
They are policy guidelines and successful national programs such as the structure or framework and governance of SUS, HIV/AIDS control -including the right to free medication -the vaccination program, the Family Health Strategy, the Farmácia Popular (People's Pharmacy) Program, in addition to programs such as Zero Hunger, Bolsa Família and Family Farming, outside the area of health, but with a significant impact on health.
Santana & Pires-Alves Below we analyzed some of the main agents of Brazilian international cooperation in health -that is, to a certain extent we examined international cooperation in health governance -and their outcomes during the period in which SUS was consolidated.

Ministry of Health
In the 1970s, the Ministry of Health (MH) started to put in place an organization so as to follow international health matters of interest to Brazil.The 1998 administrative reform led to the current structure of the International Advisory Working Group on Health (AISA) (Decree n. 2477), part of the Minister's Cabinet, that since then has been in charge of international affairs and international technical cooperation within the MH 8 .
AISA's main objective is to draft guidelines, coordinate and implement the MH's international policies.It is also responsible for preparing the Brazilian position on health issues at international level, according to the BFP guidelines, always in liaison with the Ministry's technical departments.
Furthermore, AISA provides advice to the Foreign Minister during missions and international events; plans, authorizes and monitors the execution of international technical cooperation projects; coordinates the Ministry's communication and participation in multi-lateral forums and organizations, as well as regional integration initiatives such as the Mercosur, Unasur, ATCO [Amazonian Cooperation Treaty Organization], CELAC [Community of Latin American and Caribbean States] and the Ibero-American Organization.
Other responsibilities include: supporting technical health units in identifying and drafting cooperation projects, negotiating and capturing resources, and collaborating with humanitarian cooperation actions.
At the multilateral level, AISA coordinates the MH's participation in over 20 international organizations and mechanisms, including WHO, PAHO, the BRICS (Brazil, Russia, India, China and South Africa) Health Ministers' Meetings, the CPLP Health Ministers' meetings, WHO and WIPO.Furthermore, AISA manages bilateral health relations with 47 countries 8 .
It monitors over 30 treaties and multilateral agreements on topics that have either a direct or indirect impact on health such as mercury, chemical substances, biological weapons and human rights.
One of the most important mechanisms for strengthening and funding Brazilian international cooperation in health between 2006 and 2016 was the Terms of Cooperation 41 (TC41), signed between the MH and PAHO and implemented by Brazilian institutions under the leadership of the Ministry of Health, responsible for managing Brazilian financial resources and technical cooperation provided by PAHO 9 .The aim of TC 41 was to contribute to strengthening Brazil's capacity to cooperate with the development of health systems in American and Portuguese-speaking countries, under the CCS framework.
In this period, 51 projects, encompassing over 680 activities in the above-mentioned regions were supported, with emphasis on the expansion of more egalitarian and universal public health systems in partner countries.In return, these projects also helped to improve Brazil's SUS.The general guiding principles aimed to create permanent capacity within these countries' health systems by developing skills and the sustainability of the objectives obtained.One of the most important Brazilian health cooperation programs were implemented with TC 41 support.
According to the assessment document 9 , TC 41 attained expected outcomes, as it enabled the strengthening of national capacity for international cooperation; mobilized collaborative networks and supported SSC projects, in particular in the area of human resources development.
Santana 9 has a broader understanding on the political and technical dimension of TC 41 by recognizing that it contributed in a fundamental way, not only toward the development of governmental projects and plans, but to the development of its own collective health concepts and practices, the Brazilian version of traditional public health transformed by a virtuous miscegenation with the social sciences.

Brazilian Cooperation Agency (ABC)
A simple analysis of approximately 350 completed and ongoing health projects reveals the importance of the technical cooperation agenda for this agency (http://www.abc.gov.br/Projetos/pesquisa).Furthermore, the variety of objectives, the number of countries involved and the mobilization of participating institutions show that health is priory of the Brazilian International Relations' Cooperation Agency.
With regard to cooperation in social policies within ABC, Milani 10 argues that the health sector stands out because of the wider reach of its development cooperation programs.They reflect the advances obtained by national public health policies in various Latin American countries, including Brazil.Given these advances, the horizontal transfer of health policies experiences is now more frequent (...), as they have become part of the regional integration agenda, in particular from May 2009, when the UNASUR Health Council was established.
ABC highlights, among health projects, the Human Milk Bank Program (www.redeblh.fiocruz.br/cgi/cgilua.exe/sys/start.htm?t-pl=home), an important contribution of Brazilian and Fiocruz cooperation for reducing mortality in the first year of life.It has already benefitted over 300,000 children in 24 countries in LAC, Europe and Africa 4 .

International cooperation in health at Fiocruz
International Cooperation has been a part of Fiocruz's work since 1900.More recently it was boosted and further consolidated with the establishment of the Center of International Health Relations (CRIS), part of the organization's Office of the President.CRIS is the body that coordinates international cooperation initiatives within Fiocruz's various institutes.In 2014, it became an WHO/PAHO World Health Collaborating and South-South Cooperation Center.
Fiocruz guidance on the integration of international cooperation is the "structuring cooperation for health" [11][12][13][14][15] .Its concepts and practices were established with the creation of CRIS in 2009, as a critique of the predominant model of cooperation.As Buss & Ferreira 11 emphasize, the adopted model is mainly targeted toward full institutional development of partners' health systems, based on rights, universality, comprehensiveness, quality and equity.In order to do so, it seeks to build the capacity and generate local knowledge, as well as promote dialog between actors, so as to lead processes in the health sector and build a policy and technical agenda that is appropriate to sectorial development.Among Fiocruz's main inter-institutional cooperation initiatives is the establishment and development of the UNASUR and CPLP Networks of National Health Institutes (NHIN), Technical Health Schools (THSN) and Public Health Schools (PHSN).These institutions considered to be "structuring of health systems" 11,12 have significantly contributed to studies on health and social determinants, the expansion of cover-age, epidemiological and health surveillance and laboratorial support to national health systems, as well as to the training of strategic human resources and the production of knowledge at national and regional levels 16,17 .
Fiocruz acts as a technical secretariat for these "structuring networks" since their creation, under the responsibility of CRIS (NHIN), the National School of Public Health (PHSN) and the Joaquim Venâncio Polytechnic Health School (THSN).It brings together human, technical and financial resources from practically all the Institutes that make up the Foundation 18 .Another network that operates with the support of Fiocruz is the Human Milk Bank Network.While, INCa [Brazil's National Institute of Cancer] operates as a sort of technical department for the UNASUR Network of National Cancer Institutes (http://www2.inca.gov.br/wps/wcm/connect/acoes_programas/site/home/internacional/red_ institutos_nacionales_cancer).
The MH and ABC supported Fiocruz in setting up a Regional Office for Africa and contributed to the construction of a factory for the production of antiretroviral and other medications, both in Mozambique.
A large number of health professionals and foreign C & T staff, in particular from PALOP and South America, were enrolled in specialization courses, master's and Ph.Ds. at the Institution which occurred due to a process of internationalization, encouraged by the current management of the institution.

Other relevant cooperation initiatives
In terms of the importance and the innovative character of international cooperation in health, it is important to mention ISAGS (South American Institute of Governance in Health) and the two integration universities set up during the Lula government: UNILAB (University of International Integration of Afro-Brazilian Portuguese-Speaking Countries) and UNILA (Federal University of Latin-American Integration).
ISAGS (http://www.isags-unasur.org/) is part of the integrating structure of UNASUR.It has been in regular operation since 2011.Its headquarters are in Rio de Janeiro and plays an essential role in health governance leadership development, knowledge management and technical support for the health systems of Unasur countries.It is also important for setting out Unasur's Strategic Five-year Health Plan, in its various dimensions and Technical Groups.This is one of the most important diplomatic initiatives in the areas of diplomacy and international cooperation in health, in Brazil, for the region in recent years.Fiocruz was the Institute's 'incubator' , mobilizing significant amounts of MH funds for the establishment and operation of ISAGS during its first five years (2011-2015).
The headquarters of UNILAB (http://www.unilab.edu.br/) are in Redenção, in the state of Ceará.It mainly focuses on Portuguese-speaking students from Africa.It currently provides graduation courses in biological sciences and nursing, as well as other courses which, because of their curricular content, are associated with health.A medicine course is expected to be launched in 2018 The importance of CAPES/Ministry of Education must be highlighted, in the area of education, in particular its PEG-PG program (Student Post-Graduate Agreement Program) (http:// www.capes.gov.br/cooperacao-internacional/multinacional/pec-pg).Every year it provides a large number of grants for foreign students to pursue their Masters' and Ph.Ds. in Brazilian Institutions, in particular in the field of health.

Brazilian health diplomacy
As we have stated above, international technical cooperation is only one -although a very significant -element of health diplomacy of both countries and international organizations.The term "health diplomacy" refers to providing solutions to existing problems and issues in both the technical and political spheres of "global health" [19][20][21] .Although the term came into use only very recently, approximately 20-30 years ago, its practice dates back to the international agreements between different nations, first drafted in the middle of the 19th century to protect the health of their population (and trade interests) affected by epidemics such as cholera and bubonic plague spread by trade and travel modes characteristic of "ancient globalization".The international conferences that occurred after the second half of the 19th century and the creation of international organizations such as the Pan-American Health Office (1902), and the League of Nations Sanitary Bureau (1920s) are examples of the history of diplomacy of health 20 .The current globalization period has added new and enormous challenges to health diplomacy in our times 22 .
As the eminent Brazilian Ambassador Celso Amorim explains in the preface of his book Diplomacia em saúde e saúde global [Diplomacy and Global Health] 19 , "international health policy sometimes involves other conflicting issues, where interests threaten and overrides health demands as a fundamental human right" 23 .
Almeida 24 and Buss & Ferreira 11 , among others, have argued that more recently health policy cooperation has gained greater relevance with the establishment of Councils and sectors addressing health in regional integration processes, as Buss et al. 25 show in relation to UNASUR, Mercosur, the Andean Community of Nations (CAN), the Amazonian Cooperation Treaty Organization (ATCO), the Central-American Integration System (SICA) and Caribbean Community (CAR-ICOM), to mention but a few in LAC, CPLP 26 and BRICS 27 .
Brazil's participation was decisive for establishing some of these regional and sub-regional organizations, together with their health sectors, encompassing a complex process of technical cooperation in various health areas, as part of broader political agreements.
Brazil was also intensely involved in cooperation in Haiti, after the earthquakes that occurred in this Caribbean country.It not only led the UN Stabilization Mission in Haiti (UNSTAMIH), but also provided significant humanitarian aid and health technical cooperation 28 .
In a recent article, Tobar et al. 29  The Doha Declaration on the TRIPS agreement and Public Health recognized that "the TRIPS Agreement should not and does not prevent Members from taking measures to protect public health" and that the "Agreement can and should be interpreted and implemented so as to benefit the right of WHO members to protect public health and, in particular, to promote access to medicines for all" 30 .The Brazilian delegation at Doha was combative and negotiated to ensure 'protection of public health' 23 .
The WHO's Framework-Convention on Tobacco Control (FCTC/WHO) is the first international public health treaty in WHO's history, representing a global response to the growing smoking epidemic worldwide.It was adopted by the 192 Member-States of the Organization during the 56th World Health Assembly, on 21st May 2003, and came into force on 27th February 2005.Since then, this treaty has led to the largest number of adherences in the history of the WHO: currently, 181 countries have ratified their adherence to the treaty.Internationally renowned for its leadership in the fight against smoking, Brazil coordinated the process of drafting and implementing the Framework-Agreement between 1999 and 2003 23 .
In a rare example of joint action between developing and developed countries that resulted in great political mobilization 23 , Brazil was a main player, in 2006, together with France, Chile, the United Kingdom and Norway in launching Unitaid.This body brought together a number of governmental and, subsequently, private foundations, to improve access of the poorer population to medication at affordable prices.Its remit originally encompassed only the treatment of Aids, but it now covers treatments for tuberculosis and malaria, and, more recently, medications for Hepatitis C.
It is also important to mention the significant participation Brazil and some of its main health institutions, such as Fiocruz, have had in discussions on social determinants of health (SDH) 31 , with the almost simultaneous co-existence of the National Commission on Social Determinants of Health 32 and, finally, in Rio de Janeiro, the World Conference on social determinants of health that took place in 2011 and resulted in the seminal Rio Political Declaration 33 on this topic.
Another topic of cooperation in the international agenda is the 2030 Agenda and the Sustainable Development Goals (SDG).Brazil has been a leading country in this area since Rio 92 and, more recently, in Rio+20.Its diplomatic efforts also led to the integrated implementation of the SDG, including SDG 3 that refers to health 34 .

Current challenges for the implementation of Brazilian international cooperation
Current challenges have to do with the lack of political will of the incumbent international relations and health Ministers and their departments in continuing with Brazil's recognized role in providing international solidarity to developing countries, in particular where it has been predominant, LAC, CPLP and other regions in Africa, with initiatives such as the ASA (South America-Africa) 25 and even in the Middle East with the ASPA (South America-Arab Countries) Initiative 25 , as well as strengthening countries in the Global South in terms of global governance.These efforts were already in decline during the Dilma government and have taken a dramatic turn for the worse in the inconceivable Temer Government: efforts are ineffective in terms of time, legitimacy and in its political ambitions to address the economic crisis.
Meanwhile, the swing toward conservatism of Latin American countries and the hardening of USA international relations in general, point to times of stagnation, if not setbacks in international cooperation.Perhaps the commemorations that will take place in 2018, such as 30 years of the Brazilian citizen 1988 Constitution -with its positive proposals in favor of international cooperation and the Brazilian SUS, with its impressive trajectory in health cooperation; Brazil's commitments to national, draw attention to the need to improve the skills of MH staff for the important role of health diplomacy, describing the experience of PAHO and CRIS/ Fiocruz leadership in relation to the internation-al relations departments in health within other American MH.Brazil's paradigmatic participation in world health diplomacy The first decade of the 21st century provided extraordinary opportunities for Brazilian global diplomacy in health, amongst which the central and decisive role in discussions and the approval of the Doha Declaration on the TRIPS agreement and Public Health, at WHO in 2001; the Framework Convention on Tobacco Control, at WHO, in 2003; and the creation of Unitaid (2006).
regional and global 2030 Sustainable Development Agenda; the commemoration of 40 years of the Buenos Aires Action Plan (PABA) on South-South Development Cooperation (1978-2018); 40 years since the Alma Ata Declaration on Primary Health Care (1978-2018); the reestablishment of the CPLP Strategic Plan for Cooperation in Health (PECS- 7edited a special issue of the periodic Ciência & Saúde Coletiva [Science and Collective Health], published by ABRASCO [Brazilian Association of Collective Health].It provided some important critical contributions on international cooperation for development in face of health inequalities that were extremely valuable for this article. -2019.It provides for over 800 PALOP students, amongst whom are those from Guinea Bissau.It also provides Lato Sensu (Specialization) post-graduate courses in Municipal Public Management, Public Management, Health Management, Family Health and Water, Environmental and Energy Resources Management, in both faceto-face and distance learning modes.The M.Sc. in Nursing, with 16 spaces, specializes in issues of relevance to the Portuguese-speaking countries.UNILA (https://www.unila.edu.br) is based in Foz do Iguaçu/PR.Its main public is made up of the students from the Triple Border (Argentina, Brazil and Paraguay).It provides 29 graduation courses in a number of subject areas including Medicine, Collective Health, Biological Sciences (Ecology and Biodiversity) and Rural Development and Food Security which, given their content, are associated with health.Furthermore, it runs post-graduate course programs in Multi-professional Residence in Family Health, Specialization in Medical Education and a M.Sc. in Biosciences.