International dialogical action: the decolonial potential of structuring cooperation in health promoted by Brazil

Ação dialógica internacional: o potencial decolonial da cooperação estruturante em saúde promovida pelo Brasil.

Abstract

The benefits of an empirical assessment of South-South cooperation (SSC) are currently being debated in the critical literature on this subject. This assessment could distinguish SSC practices from other cooperation practices and increase its transparency, social control, and credibility. In this sense, this paper theoretically assesses the dialogical/decolonial potential of structuring cooperation in health (SCH), a model of SSC created by Brazil; and analyses the applicability of different heuristics for international agreements and interinstitutional projects to empirically assess this potential. In theory, the SCH narrative is compatible with the decolonial literature mentioned in this paper. However, case studies from the fields of International Relations (IR) and Global Health diverge about this compatibility based on empirical observation. Nonetheless, heuristics from the field of International Law and Policy Transfer studies can help to recognize the decolonial potential inscribed in international agreements. In order to advance in the assessment of the dialogic character of SCH through projects, this paper argues that, institutionally, it is necessary to define the categories inscribed in them and make their monitoring and evaluation reports public. It concludes that the IR field needs to absorb the knowledge from the health sector and its technicians – something that does not occur in Latin America given the low interest in this sector.

Keywords
South-South cooperation; structuring cooperation in health; decoloniality; dialogical action; policy transfer

Resumo

Os benefícios da avaliação empírica da Cooperação Sul-Sul (CSS) são atualmente debatidos na literatura crítica sobre o assunto. Essa avaliação poderia diferenciar as práticas de CSS de outras práticas de cooperação e aumentar sua transparência, controle social e credibilidade. Nesse sentido, este artigo avalia teoricamente o potencial dialógico/decolonial da cooperação estruturante em saúde (CS), modelo de CSS criado pelo Brasil, e analisa a aplicabilidade de diferentes heurísticas para acordos internacionais e projetos interinstitucionais para avaliar empiricamente esse potencial. Teoricamente, a narrativa SCH é compatível com a literatura decolonial mencionada neste artigo. Empiricamente, porém, os estudos de caso das áreas de Relações Internacionais (RI) e Saúde Global divergem. No entanto, existem heurísticas do campo do Direito Internacional e estudos de Transferência de Políticas que podem ajudar a reconhecer o potencial decolonial inscrito nos acordos internacionais. Para avançar na avaliação do caráter dialógico da HSC por meio de projetos, este artigo conclui que, institucionalmente, é necessário definir as categorias neles inscritas e tornar públicos seus relatórios de monitoramento e avaliação, e que, academicamente, a área de RI precisa absorver o conhecimento do setor de saúde e de seus técnicos, o que não acontece na América Latina, pois o interesse por esse setor é baixo.

Palavras-chave
Cooperação Sul-Sul; cooperação estruturante em saúde; decolonialidade; ação dialógica; transferência de política

Introduction

Permita que eu fale, não as minhas cicatrizes

Achar que essas mazelas me definem é o pior dos crimes

É dar o troféu pro nosso algoz e fazer nóis sumir [sic]

AmarElo, Emicida ¹

Although several emerging providers of cooperation are promoting South-South cooperation (SSC) and academic studies on this subject are proliferating (Bergamaschi and Tickner 2017; Rizzo 2019), there is still a deficit in the assessment of this form of cooperation (BRICS Policy Center 2017; Rizzo 2019). The SSC assessment could help to distinguish it from other development cooperation initiatives; promote its adaptive management, the recognition of its strengths and weaknesses, the transparency and social control; and increase its bases of support (BRICS Policy Center 2017) or credibility. Categories and indicators for this assessment have been object of debate among the new SSC providers (BRICS Policy Center 2017; Rizzo 2019), once they seek to differentiate themselves from the forms of evaluation of the traditional providers, although their practices also vary internally (Bergamaschi and Tickner 2017; Bergamaschi and Durán 2017). In this context, this paper seeks to assess the decolonial potential of structuring cooperation in health (SCH), a model of technical SSC established in Brazil and theorized by researchers from the Oswaldo Cruz Foundation (Fiocruz).

The assessment proposed here has two dimensions: a theoretical and an empirical one. In the theoretical dimension, the literature that narrates SCH is confronted with the decolonial literature to assess the extent to which their values are compatible. In the empirical dimension, case studies of SSC and heuristics applicable to international agreements and interinstitutional SCH projects are analysed based on the same decolonial literature mentioned above. The analysis of heuristics is intended to promote critical engagement with SSC, verifying possibilities of empirical assessment that go beyond official discourses and theoretical proposals and access human interactions, which is a demand of the critical literature on SSC (Bergamaschi and Durán 2017). Also, in this same dimension are proposed categories in the interinstitutional projects that can be quantifiable. In this sense, it is important to note that in many contexts, categorization and quantification hide the exercise of power through the claim of objectivity (Fukuda-Parr and McNeill 2019). Thus, in this paper, the proposal to assess the decolonial potential of the SCH has the explicit interest of assessing on a large scale the extent to which this cooperation model fosters the production of a horizontal intercultural dialogue.

To this end, the first section of this paper discusses the connections among the theoretical construction of SCH and some proposals for decolonial action. The second section presents studies of SCH assessment conducted in the fields of International Relations (IR) and Global Health that empirically reinforce and challenge the arguments sustained here. This section also discusses the possibilities and limits of some heuristics developed in the International Law field and Policy Transfer studies to assess the decoloniality through international agreements and interinstitutional projects. It also briefly discusses how the assessment of the decolonial potential of SCH can relate to the current political-sanitary context.

SCH as dialogical realisation of the human right to health in the Global South

This section discusses the dialogical, and therefore decolonial, character of the SCH narrative, which is an exponent of SSC and has South America and Africa as its priority regions (Almeida et al. 2010). This discussion is based on SCH close relationship with decolonial action proposals, such as those produced by Césaire (2006); by members of the Modernity/Coloniality Group, such as Quijano (1992), Grosfoguel (2007), Castro-Gomez (2007), Mignolo (2008), and Walsh (2013); by Herrera Flores’ (2009) critical theory of human rights; and mainly by Paulo Freire’s (1996, 2000) pedagogy of autonomy. Caixeta (2015) argues that SSC and the Southern Epistemologies developed in parallel are both processes of epistemic disobedience (Mignolo 2008). Thus, it makes sense that SSC be ‘analysed based on the theoretical proposals of the South’ (Caixeta 2015: 15, our translation), like the ones mentioned above.

SSC emerged in the post-World War II, simultaneously with the greater institutionalization of North-South cooperation (NSC) (Milani 2014), to which SSC opposes and seeks to distinguish itself (Bergamaschi and Tickner 2017). The political context from which SSC emerges is one in which ‘the processes of African-Asian decolonization are accelerating and Latin American consciousness is renewed with regard to its “structural backwardness”, driven largely by the creation of the Economic Commission for Latin America and the Caribbean (ECLAC)’ (Pino 2014: 59, our translation). In the 1950s and 1960s, the historical milestones of the SSC’s beginning took place, such as the Bandung Conference in 1955, and the Non-Aligned Movement, in 1961 (Milani 2014). In this context, some of the main criticisms addressed to the NSC were its vertical, colonizing, non-participatory character (Milani 2012), in addition to the establishment of conditionalities for the beneficiaries of cooperation (Pino 2014).

In the 1970s, the oil crises added to the rise of neoliberalism in the 1980s, and the enlargement of debates on the self-sufficiency and autonomy of the Global South countries, verified at the United Nations Conference on Technical Cooperation between Developing Countries (TCDC) in Buenos Aires, in 1978, served as a justification for the decrease in transfers of financial resources to developing countries (Milani 2014). Also, in this period, the ‘political dimension that the SSC had in its origins was losing strength in favour of its more economic and technical components’ (Pino 2014: 71, our translation). Simultaneously, NSC further institutionalized its practices and absorbed some of the criticisms addressed to them previously, building a paradoxical character that remains to this day (Milani 2014).

At the beginning of the 21st century, there is a new fusion between politics and technique in SSC, and, in Latin America, a rise of progressive governments led to the construction of relations and institutional engineering (several of them with African and Asian countries) based ‘on the assumption that developing countries can and must cooperate in order to solve their own political, economic and social problems based on shared identities [...], common efforts, interdependence and reciprocity’ (Lima and Milani 2014: 33-34 our translation). For Pino (2014), this new fusion is based on the economic growth of these countries; their architecture of successful public policies; affirmative foreign policies; and the virtuous combination of resources and political will. For the same author, however, the interests that guided the Bandung Conference during the Cold War were for the transformation of the international system, while the new affirmative foreign policies aim to insert these countries into the system. This reflection suggests that the antagonistic conceptualization of the NSC and the SSC does not imply an automatic difference in their practices (Lallande 2016). For Milani (2012), the differentiation must go through the empirical analysis of cooperation practices, including the vision of the beneficiaries.

There is no broad consensus on what SSC currently means, since their providers oscillate between pragmatic and contesting positions about the Global North practices (Bergamaschi and Durán 207). Thus, SSC can be ideally represented by the general principles of this cooperation model, produced at various conferences and compiled by Pino (2009) as follows:

[N]on-interference in internal affairs; greater sensitivity to specific contexts; equality among partner countries, including respect for their independence and national sovereignty; promoting self-reliance; the diversification of ideals, approaches and methods of cooperation; the absence of explicit conditionalities; the preference for the use of local resources that generate broader elements of appropriation; greater flexibility, simplicity and speed of execution; ‘unbound’ character, as it does not imply the purchase of goods and services on the offering country; adaptation to national priorities; the preservation of diversity and cultural identity and […] lower cost and greater impact (Pino 2009: 1-2 authors’ translation).

From these principles, it is possible to understand how SCH fits into the larger panorama of SSC, since it is conceptualized as a model of cooperation that is

[F]ocused on the institutional strengthening of health systems in partner countries, combining concrete interventions with the construction of local capacities and knowledge generation, and further promoting dialogue among actors, in order to enable them to take on the leading role in the leadership of processes in the health sector and to promote the autonomous formulation of an agenda for future health development (Almeida et al. 2010: 28 authors’ translation).

According to Ferreira and Fonseca (2017), SCH is situated in the general panorama of capacity building, but innovates in at least two issues, ‘a) integrates the development of human resources with the organizational and institutional, and b) starts from the exploration of the endogenous resources and capabilities of each country’ (Ferreira and Fonseca 2017: 2131 our translation), what is done to enable the sustainability of the built capacities. For Buss and Ferreira (2010), the transformation of vertical cooperation into a truly horizontal health cooperation occurs in the following ways: through the guidance of strategic planning centred on the reality of the partner country; in the passage ‘of “vertical” aid programs (interventions with a focus on diseases or particular conditions and problems) to the “horizontal” approach that focuses on the integral development of health systems’ (Buss and Ferreira 2010: 96, authors’ translation); from focusing on the long-term mixing institutional strengthening and specific approaches for emergencies; and from the incorporation of social determinants, intersectoral actions and with the prioritization of public health. This translates into three conceptual pillars that define SCH’s modus operandis: social determination of health, international cooperation in a collaborative aspect, and strategic planning in health (Fonseca and Buss, 2017). The latter makes SCH ‘a social process, in constant mutation, that does not depend only on the technological dimension, as it involves social actors (people, institutions and governments) and political situations (relation among the actors)’ (Fonseca and Buss 2017: 236 our translation).

The South-South Technical Cooperation Management Manual, prepared by the Brazilian Cooperation Agency (ABC) in 2013, absorbed the ideas that make up SCH, applying them to this whole sphere of technical cooperation, by stating, for example, that the main function of a project is to ‘provide access, absorption and application of knowledge that allows local development agents to strengthen their capacities, a process that involves learning in the individual, organizational, and interinstitutional dimensions’ (ABC 2013: 13 authors’ translation). From this, it can be inferred that SCH is mainly an educational process, and the way in which learning occurs can be decolonial or can reproduce the traditional power relations of vertical cooperation models. For Constantine and Shankland (2017), it may produce, for example, institutional isomorphism, characterized by imitation, in all respects, of what is transferred/exchanged, which is contrary to the adaptive learning. For the authors, ‘isomorphism runs counter to the insistence in SSC (including among advocates of structuring cooperation) that policy transfer must be subject to a process of adaptation to fit local realities’ (Constantine and Shankland 2017: 107).

Even though the SCH’s partners are developing countries, all of them object of previous colonization – political, epistemic, and cultural, SSC is not exempt from reproducing the vices of vertical models (Lallande 2016). For Quijano (1992), it is a fact and it is surprising that the European idea of history as an evolutionary continuum, where there are primitives and civilized, and not equals, continues to be very attractive for so many people.

In different words, Paulo Freire (2000) notes that non-liberating education can produce in the oppressed the desire to become an oppressor. Freire (2000) proposes that the traditional educational praxis, which is antidialogical, based in a teacher-student’s vertical relationship, was and continues to be a form of colonization of mentalities and subordination of other knowledges that does not fit in the logic of the modern scientific thought. According to Freire, there is no neutral educational process, as it either works as an instrument to facilitate people’s integration and conformity with the status quo, or it becomes a practice of freedom, whereby individuals deal critically with reality and discover how to participate in the transformation of their world.

The first characteristic of antidialogical action is the need for conquest, which can be done by repressive or solicitous means (Freire 2000). In the conquest, the conquerors ‘impose their own contours on the vanquished, who internalize this shape and become ambiguous beings “housing” another. From the first, the act of conquest, which reduces persons to the status of things, is necrophilic’ (Freire 2000: 138 our translation). A second characteristic of antidialogical action is cultural invasion, when ‘the invaders penetrate the cultural context of another group, in disrespect of the latter’s potentialities; they impose their own view of the world upon those they invade and inhibit the creativity of the invaded by curbing their expression’ (Freire 2000: 152 our translation). In this sense, antidialogical action can also be a category for thinking about international cooperation that occurs through transfers in a non-adaptive – colonial – way, disregarding the identities and endogenous capacities of its partners.

To overcome the logic of oppression and the resulting damages, Freire (2000) suggests the dialogical action, which operates through collaboration and organization, and which leads to cultural synthesis, considering the human beings the very subject of their own historical process. And for that, it is necessary that individual and collective agents are brought into dialogue, which can only be achieved by the decolonization of their mentalities and the claim of the oppressed as political agents. Dialogical action constitutes a pedagogy of autonomy, which makes it necessary to ‘challenge the students with whom one communicates and to whom one communicates, to produce their understanding of what has been communicated. There is no intelligibility that is not communication and intercommunication and that is not based on dialogicity’ (Freire 1996: 17 our translation).

For Freire (1996), not even the most technical knowledge can escape the alternative for autonomy or colonization, given the existence of ‘a dynamic unity between teaching content and teaching what is and how to learn’ (Freire 1996: 47 authors’ translation). In this sense, it is ‘as wrong to separate practice from theory, thought from action, language from ideology, as it is to separate teaching contents from the call to the learner to become a subject of the process of learning them’ (Freire 1996: 47 our translation). This dualism is also a hallmark of Eurocentric rationality (Quijano 1992; 2005). For Moreira (2020), the history of host countries as recipients of NSC is a determining factor to the success of SSC, because they have learned to receive cooperation in a way and have established expectations about it. This means that the way SCH hosts understand what is and how to learn can also be a determinant of its success.

The concept of SCH launched by Almeida et al. (2010) and its pillars (Fonseca and Buss 2017) seem to agree with this idea that the oppressed must speak for themselves in the process of exchange, because, just like the Emicida’s lyrics cited in the epigraph of this text, they are more than the oppressions to which they were subjected. In the words of Freire (1996: 15 authors’ translation), ‘teaching requires respect for the learner’s knowledge’. So, SCH’s ideas of starting from the recognition of endogenous resources of the partners and having as objective that the local agents lead the construction of its own health development agenda (Almeida et al. 2010; Ferreira and Fonseca 2017) seem to represent well these dialogue/learning proposals put forth by Emicida and Freire (1996, 2000).

In addition to the very issue of learning, it is important to note that SCH seeks to develop capacities to implement a human right – health – and that there are specific interpretations under the critical theory of human rights debating what those rights are, which are in line with Freire’s dialogical action. For example, Herrera Flores (2009) understands that human rights, as ‘a cultural product that emerged in a concrete and precise context of relations that begins to expand across the globe [...] under the name capitalist western modernity’ (Herrera Flores 2009: 02 our translation), are not universal. ‘[T]he idea or intuition of human dignity’ (Herrera Flores 2009: 10 authors’ translation) is the true universal component because ‘[e]ach social formation culturally and historically builds its path towards dignity’ (Herrera Flores 2009: 03 authors’ translation).

This specific view implies that human rights are understood as intersectoral and continuous processes that involve struggles for dignity and, understood in this way, human rights ‘requires for improvement to relate and interact with other dignity paths in order to achieve that another better world is possible’ (Herrera Flores 2009: 4 authors’ translation). In this sense, the understanding of those involved in cooperation schemes as equals, not objects to be filled by donations, seems to be a fundamental pillar for the SCH (Buss and Fonseca 2017) to be considered a dialogical narrative. Also, this pillar can make SCH compatible with the idea of building a concrete universalism (Grosfoguel 2007), which is ‘the result of a horizontal process of critical dialogue among peoples who relate to each other in equal terms’ (Grosfoguel 2007: 72 authors’ translation), but not from an abstract starting point.

The project of a concrete universalism seeks surpasses abstract western universalisms that are based on the idea of a punto cero, meta-empirical and meta-cultural, in which ‘hypothetical world observers must systematically disconnect themselves from the different empirical observation sites (point 1, point 2, point 3, point n) to locate themselves on an unobserved platform that allows them to obtain certainty of knowledge’ (Castro-Gómez 2007: 88 authors’ translation). Thus, when considering both partners as subjects filled with endogenous resources and capabilities, and responsible for building their own autonomy (Almeida et al. 2010; Ferreira and Fonseca 2017; Buss and Fonseca 2017), the SCH narrative moves away from the idea that there could be a punto cero from which one of them will depart. Due to same reason, SCH seems to open space for the development of a concrete universalism that, as suggested by Césaire (2006: 84 authors’ translation), becomes ‘the depository of all particularities, [the] deepening and coexistence of all particularities’.

This first section exposed how SCH’s narrative carries out, theoretically, the dialogical component of Freire’s (1996, 2000) pedagogy of autonomy, the Herrera Flores’s (2009) critical perspective of the human rights, and, as a narrative of epistemic disobedience (Mignolo 2008), also carries the intention of a horizontal intercultural dialogue that recognizes different points of view, as stated by Quijano (1992), Grosfoguel (2007), Castro-Gómez (2007), and Césaire (2006). However, coloniality is a system composed of elements that reinforce each other, and in which Eurocentric rationality is just one axis (Quijano 1992, 2005). Coloniality covers different spheres, homogenizing basic forms of social existence: ‘in control of work, its resources and products is the capitalist enterprise; in control of sex, its resources and products, the bourgeois family; in control of authority, its resources and products, the nation-state; in control of intersubjectivity, the Eurocentrism’ (Quijano 2005: 125 authors’ translation). Also, these institutions of control are crossed by specific ways of thinking gender and race that were also born with and reinforce modernity (Quijano 2005).

In this sense, the exercise of assessing SCH’s decolonial potential, which acts mainly on the intersubjective/epistemic axis of coloniality, is limited. This exercise follows the arguments of Quijano (1992) that a first step in the destruction of the coloniality of power is epistemic decolonization, which must take place ‘to give way to a new intercultural communication, to an exchange of experiences and meanings, as the basis of another rationality that can claim, with legitimacy, some universality’ (Quijano 2005: 19-20 authors’ translation). Also, Grosfoguel (2007) argues that ‘[a] liberating horizontal dialogue […] requires a decolonization in the global relations of power. [...] However, we can start to imagine alternative worlds, beyond the difference between Eurocentrism versus fundamentalism’ (Grosfoguel 2007: 73 authors’ translation).

For Quijano (2005), even with the destruction of the current system, there is no guarantee that its elements would not re-articulate. So, decoloniality is not a goal that can be completed, but a process that demands constant engagement. In other words, ‘decoloniality is not a theory to follow, but a project to be taken on. It is a process of action to walk pedagogically’ (Walsh 2013: 67 our translation). In this process, it is essential to ‘learn to free ourselves from the Eurocentric mirror where our image is always, necessarily, distorted’ (Quijano 2005: 138 our translation). Latin American regionalism, for example, has suffered from discredit that stemmed from its evaluation by expectations imported from other places and models, and the literature on it argues that the assessment through contextualized criteria could improve its credibility based on its own merits (Riggirozzi and Ryan 2021). In this sense, assessing SCH based on the decolonial literature can help to understand if and how much SCH is managed to realize values defended at its origin, not imposed on it, or imported from elsewhere. So, in the following section, this article explores case studies and some heuristics and documentary sources to assess the extent to which SCH is translated into decolonial practices.

Case studies, heuristics and sources for assessing decoloniality in SCH practice

The fact that SCH is theoretically dialogical, and therefore decolonial, and that the theory that composes it was formulated from empirical observation (Almeida et al. 2010) are factors that bring it closer to a decolonial practice, but are not enough to access the complexity of its effectiveness strategies. This requires an evaluation of the processes by which this narrative is implemented. Thus, this section discusses empirical studies of SCH assessment that endorse and challenge the arguments about its decolonial potential (2.1), as well as heuristics for documentary sources (2.2 and 2.3) that can be mobilized in evaluations in large scale. Lastly, some remaining challenges for this assessment and their possible correlation with the current political-sanitary context are discussed (2.4).

Case studies

Studies that empirically evaluate SSC practices are scarce on the IR field (BRICS Policy Center 2017; Rizzo 2019). Investigations carried out by Milani and Lopes (2014) and Esteves and Assunção (2017) that analyse SSC in health between Brazil and Mozambique through interviews with Mozambican technicians, and by Dri and Silva (2019), that analyse the practices of the Centre of Excellence Against Hunger through interviews with the Brazilian technicians, are exceptions. For Milani and Lopes (2014), ‘belonging to a community of historical sense (countries speaking the same language and sharing colonial experience) can facilitate [cooperation] but does not elude different forms of international insertion and the trajectory of the development’ (Milani and Lopes 2014: 71 our translation). In the same way, Esteves and Assunção (2017) emphasize that the Brazilian health expert community has built a common vocabulary on health in Latin America through participation in regional forums, but has had difficulties in developing this vocabulary in Mozambique. This difficulty originated in the socio-historical context of the cooperation beneficiary and made it difficult to absorb and adapt the transferred technology locally. In turn, the interpretation of the interviews with Brazilian technicians made by Dri and Silva (2019) reinforce the decolonial potential previously advocated here, but also reports challenges in assessing the changes in the beneficiary originated from the cooperation schemes, but implemented after them.

In the Global Health field in Brazil, some qualitative assessment studies have been produced, focusing on SCH and Latin America. Examples of these studies are the ones led by Kastrup and Pêssoa (2012) on Brazil-Venezuela cooperation for the structuring of a School of Government and a Venezuelan Network of Health Training Institutions; by Pêssoa et al. (2013) and Pêssoa et al. (2016) on Brazil-Haiti-Cuba cooperation for structuring the Haitian Network for Health Surveillance, Research and Education; by Tobar et al. (2017) on the Program for Strengthen Cooperation for Health Development (CCHD), which is a partnership between the Pan-American Health Organization (PAHO) and the Fiocruz Global Health Center (CRIS); and by Peres et al. (2020) on the Public Health Training Program for the Brazil-Uruguay border.

These five studies share analytical categories similar to the decolonial characteristics previously claimed here: horizontality/collaboration, search for sustainability/appropriation and adaptation to the local context. Some of them also highlight the flexibility of international agreements and projects to fit into the demands and interests of the partners during the implementation of cooperation (Kastrup and Pêssoa 2012; Pêssoa 2016). Moreover, they point to diverse means and indicators to fulfil these analytical categories, which are also guiding values ​​of SCH. Example of this diversity is the range of pedagogical approaches in the activities, exposed by the use of ‘active methodologies on health education (eg, dramatizations, case studies, problematization of real situations) that aimed to portray daily work and highlight the possibility of incorporate new tools and knowledges’ (Peres et al. 2020: 3 our translation).

These studies also report the ‘training of trainers’ (Peres et al. 2020) who act as multipliers of knowledge and permanent health education (Pêssoa et al. 2013; Pêssoa et al. 2016), being, therefore, a strategy to produce sustainability. Also, local recognition and leadership by trained institutions after the implementation of cooperation are mentioned as indicators of sustainability (Kastrup and Pêssoa, 2012). Furthermore, the construction of new training, research, discussion and even work agendas and projects are mentioned by technicians from different countries as results of these strategies (Kastrup and Pêssoa 2012; Pêssoa et al. 2013; Pêssoa et al. 2016; Tobar et al. 2017; Peres et al. 2020).

IR studies dealing with cooperation schemes between Brazil and Mozambique exposed the challenges of SCH in generate absorption and local adaptation (Milani and Lopes 2014; Esteves and Assunção 2017). In turn, Dri and Silva (2019) mentioned the existence of an effort by Brazilian technicians to overcome colonial practices of cooperation. Global Health studies promote a satisfactory evaluation of analytical categories in line with the decolonial literature. However, because these studies exist in small quantities (four cooperation schemes are mentioned here), they are still not enough to confirm the decolonial practices as a SCH pattern, especially outside Latin America. In this sense, the following subsections address possible heuristics and documentary sources to conduct the empirical assessment on large scale.

International agreements

Pozzatti and Farias (2019) conduct a survey of international agreements of health among Brazil and the other independent South American countries and provide at least three findings relevant to ponder about how international agreements can be useful for assessing the decoloniality of SCH. (1) The verification of the institutionalization of SCH through international agreements. (2) The organization of the analytical categories of Torronteguy (2010) – that deal with cooperation in health between Brazil and the Lusophone Africa – in a heuristic whose indicators can be found in the agreements and quantified to verify the alignment of the terms of cooperation with SSC principles. (3) And the identification of the mixed character – the approach to institutional strengthening added to that of specific diseases – of the Brazilian health agenda.

The institutionalization of SCH via international agreements confirms that it is a narrative of international law, not only because it proposes itself to implement human rights, but also because it is born when it is positivized in its sources. Thus, these sources also can be analysed to assess the decoloniality of SCH. Pozzatti and Farias (2019) organized two thematic regimes of SCH, inside the sample of 129 international agreements, one referring to general institutional strengthening (IS) (18 agreements), and another to specific subjects or capacities, that they called sectoral strengthening (SS) (50 agreements). Pozzatti and Farias’s (2019) heuristic helps to understand the levels of horizontality and democratization of international cooperation positivized in the agreements. On the horizontality, five indicators were listed: position in the relationship, financial charges, consensus for publicity, political consultation mechanisms and sustainability forecast. On democratization, two indicators were chosen: the forms of evaluation and the triangulation.

Two other indicators are listed by the authors but have not been quantified with the others: objectives and conditionalities. The former help to group the agreements into thematic regimes. Conditionalities are not included in the agreements, and in general their absence in Brazilian practices of international cooperation is verified by empirical research based on agreements and interviews (Torronteguy 2010; Milani and Lopes 2014; Bergamaschi and Durán 2017; Dri and Silva 2019).

The existence of the SS regime is the main argument about the mixed agenda, because the agreements of this regime seek building very specific capacities (including on specific diseases) inspired by Brazilian public policies. Thus, the strengthening proposals arises from the idea of ‘sharing lessons learned and successful practices available in Brazil, generated and tested for facing similar challenges to socioeconomic development [in partner countries]’ (ABC 2013: 13 our translation). In this sense, Milani and Lopes (2014) recognize the transfer of policies as a privileged tool in the international cooperation promoted by Brazil and the power of the policy-transfer heuristic in understanding the complexity of these transfers.

Policy transfer is ‘a process in which knowledge about policies, administrative arrangements, institutions, etc. in one time and/or place is used in the development of policies, administrative arrangements and institutions in another time and/or place’ (Dolowitz and Marsh 1996: 344). The term ‘transfer’ is not itself an obstacle to Freire’s understanding that ‘teaching is not transferring knowledge but creating the possibilities for its production or construction’ (Freire 1996: 12 our translation), because it is part of the pedagogy of autonomy that ‘the freedom to build with itself, in itself, with materials that, although coming from outside, are reworked by its autonomy’ (Freire 1996: 36 authors’ translation). So, it is the very existence or not of that freedom for adaptation, which only exists when everyone is a subject in the policy transfer process, which distinguishes passive/antidialogical transfer from learning.

Dolowitz and Marsh (1996, 2000) developed an analytical structure based on the eight following questions: why transfer? (1), who is involved in the transfer? (2), what is transferred? (3), from where (4), what are the transfer levels? (5), what are the transfer restrictions? (6), how to demonstrate the transfer? (7), and how can it lead to policy failures? (8). Questions (3), (5) and (6) seem the most promising to inspire heuristics that could reveal decolonial/dialogical processes. International agreements could answer questions such as (2) and (4) and are a way of demonstrating the policy transfer (7), being a source of research to be added to those listed by the original heuristic. However, these questions are insufficient to reveal the complexity of the transfer process and the verification of its dialogical operationalization. The agreements seem, in fact, to be necessary in the assessment of decoloniality, since they link two countries to a greater pattern of interaction, which leverages or restricts the decolonial potential, as demonstrated by Pozzatti and Farias (2019)’ heuristic. Nonetheless, this pattern alone is not enough to imply that it is a relationship as decolonial as it could be. That is why Pozzatti and Farias (2019) consider that the outcomes of their quantification reveal only possibilities for structuring effectiveness.

For Bucci (2001: 12 our translation), the path to the realization of a right, goes ‘from its birth, when it is written in the norm, until its emancipation, when it is inserted in a specific government action program and becomes part of its implementing’. For Pozzatti and Farias (2019), when this path takes place through SCH, it is composed of two dimensions. The first is the input, when international agreements are born. In the second dimension occurs the output, when ‘the international act is a source of instruments, so that the national institutions can build local public policies’ (Pozzatti and Farias 2019: 368 our translation). In this sense, to assess the decolonial potential of SCH is also necessary to move to the second dimension, questioning how it is intended to transfer these instruments.

Interinstitutional projects

For a more empirical assessment of SCH’s decoloniality, this study carried out a survey of the interinstitutional projects established in the scope of the international agreements that formed the IS and SS regimes in Pozzatti and Farias’s (2019) study. The SS agreements also covered some of the agreements included in the IS regime, so, there were 51 bilateral international agreements for SCH. In their scope, 14 interinstitutional projects to implement them were available on the website of the International Cooperation Actions and Project Management System² (SISCOOP), whose structure features a detailed front page, an official document attached, and various inconsistent information on the same page. For this reason, the data used here is always the data found in the document³.

From an institutional point of view, the projects are mainly located below complementary agreements (46) that arise from framework agreements. Sometimes memorandums of understanding (5) also mention structuring projects, but this was not the case of the projects discussed here. From framework agreements to projects, the specificity of terms increases and the main agents involved change. The projects are signed by the coordinating institutions defined in the complementary agreements and their technicians, and not by ministers, for example. The 14 projects date from 2007-2012 and are signed with Argentina (2), Bolivia (1), Colombia (2), Ecuador (4), Paraguay (1), Uruguay (1), and Venezuela (3). Only three of them are signed by the coordinating institutions of both partners and 11 of them were available only in the edition format. The diagram below organizes the moments and documents through which SCH is implemented.

Figure 1
SCH’s development diagram

One of Pino and Leite’s (2010) criticisms on Brazil’s SSC is the lack of information about the financial resources allocated to it. Some costs are shown in the reports of the Ibero-American General Secretariat (SEGIB), but even then, this information is not complete or organized project by project (SEGIB 2018). The interinstitutional projects help measure some of these costs. For example, the 14 projects analysed cost US$1,482,298.75 to Brazil. In 11 projects, the largest financial contribution is from Brazil⁴, while in three projects only Brazil contributes⁵. In all the sample of projects already signed by both institutions (3) Brazil is the largest contributor⁶.

However, it cannot be assumed that the asymmetric financial contribution is in itself colonial, unless it is used to establish conditionalities or to subordinate the progress or outcomes of the project. In this sense, this indicator can gain greater relevance if it is related to others that inform how the costs of a project are employed, not only what is paid (as equipment, for example), but also what is done (the actions of transfer and exchange among agents). In the case of the Brazil-Cuba-Haiti trilateral cooperation, for example, there was incorporation of technologies in Haiti by Brazil, but the training processes are described as horizontal in the analysis of Pêssoa et al. (2013) and Pêssoa et al. (2016). In turn, in the case of the construction of an antiretroviral factory in Mozambique, the study of Esteves and Assunção (2017) demonstrates that there was no local adaptation or adequate use of the factory because Mozambican technicians did not agree with Brazilians about its importance or feasibility in the local context.

The projects also contain information on the demand for cooperation – which is considered the basis on which Brazil’s SSC operates (Milani and Lopes 2014; Bergamaschi and Durán 2017). However, only nine of the 14 projects contain the information on the demand from the partner country⁷. Nevertheless, the absence of information in the other five interinstitutional projects can be seen as just that: absence of information, since the documents never made it to being analysed by researchers. Possible resolutions on documentary deficits will be discussed in subsection 2.4.

An issue of the Dolowitz and Marsh’s heuristic that projects can access is transferred objects (3), which can be ‘policy goals, policy content, policy instruments, policy programs, institutions, ideologies, ideas and attitudes and negative lessons’ (Dolowitz and Marsh 2000: 12). The projects mention the content of training and exchange activities, which are instruments and programs of Brazilian policies, as well as institutions (notably the Human Milk Banks). However, this information is useful for assessing decoloniality only when it is completed by other information, such as: does a certain object have a connection with more or less horizontal transfer? Or, does the exchange of a particular object generate more copy or institutional isomorphism, rather than adaptive learning?

This matters because Dolowitz and Marsh’s (1996, 2000) categories to answer what are the levels of transfer (5) carry with them decolonial and colonial positions. For example, emulation, mixtures or inspirations seem to be desirable results for decolonial approaches, since human rights, as paths to dignity designed in each social context, need to interact with other ways to improve themselves (Herrera Flores 2009). Meanwhile, in the case of copying, the application of a policy or institution to a different context from which it was initially successful, assuming that it is a universal recipe for local problems, producing institutional isomorphism (Constantine and Shankland 2017), is certainly not what is expected from decolonial interactions.

However, issues such as the institutional isomorphism (Constantine and Shankland 2017) and the transfer levels (Dolowitz and Marsh 1996, 2000) mainly refer to the outcome of transfer. If a policy is a copy, emulation, mixture or inspiration of another (Dolowitz and Marsh 1996, 2000), it depends of the implementation of transferred capacity. Nevertheless, in the case of SCH, the policy transfer has no conditionalities, so it occurs as the learning of capacities which may or may not be implemented by the partner country (ABC 2013; Dri and Silva 2019). For this reason, transfer levels cannot be identified just by projects, and are difficult to verify in the short term. This obstacle could be reduced by the contact with the technicians from the partner countries, who may report the changes promoted domestically and their origins in the cooperation scheme, as revealed by the studies mentioned in subsection 2.1.

When Pozzatti and Farias (2019) verify the possibilities of structuring effectiveness, the authors illustrate, at least, a movement of international law and Brazilian foreign policy towards the construction of the autonomy of partner countries. However, for the assessment of SCH decoloniality to be as complete as possible, it is necessary to access the methodologies of the activities, and, from the more or less horizontal/decolonial processes, attempt to understand the nature of the products and the outcomes that each activity produces. For example, the case of ‘training of trainers’ is capable of catalysing ongoing health education processes in partner countries (Peres et al. 2020).

In the analysed projects, some activities are frequently mentioned, and because they are named differently in the same document, it is understandable that they refer to different forms of interaction and learning. Among them are advisory and technical support, technical training, workshops, exchange of legislations, feasibility studies⁸, and adaptation and multiplication actions. However, for none of them there is qualitative description that allows to classify them as indicators of horizontality/ dialogical action among the agents involved. Therefore, to understand the extent to which the SCH promoted by Brazil establishes decolonial activities, it would be necessary to have a definition of each of these categories, so that they could be quantified.

The evaluation contributions produced in different countries, such as India, South Africa, and Brazil – notably the production of the BRICS Policy Center (2017) – mainly indicate values to be evaluated, and theories that could help to produce case studies on SSC, but not indicators that are both qualitative and quantifiable (Rizzo 2019). The efforts of Torronteguy (2010) and Pozzatti and Farias (2019) are innovative in this regard, focusing on the documentary dimension of the cooperation processes and proposing quantifiable indicators, trying to envision what role international law can play in this scenario. Even so, studies like these are exceptions.

Proposing indicators for quantification is a political – not just a technical – exercise, as these indicators can undermine or leverage specific objectives (Fukuda-Parr and McNeill 2019). In this sense, many emerging cooperation providers avoid associating themselves with forms of evaluation implemented by traditional providers in the NSC, especially those promoted by the Organization for Economic Cooperation and Development (OECD) (Bergamaschi and Durán 2017), among which are the quantification and monetization of cooperation (Rizzo, 2019). Thus, the proposal of the assessment here is that the quantification can be made through indicators based on categories that descend from a decolonial literature. So, the exercise here is to discuss which indicators can reveal - or could reveal if were properly conceptualized – how far SCH has gone in the development of horizontal methodologies. In this sense, quantification has no value in itself, nor can it claim an objectivity deriving from numbers (Fukuda-Parr and McNeill 2019), but matters insofar as it reveals how much a specific value – horizontality - is being realized.

The table below brings together the indicators present in the projects, discussed so far, in an attempt to assess the decoloniality of SCH:

Table 1
Possible indicators from interinstitutional projects

Demand for Cooperation	Division of Financial Resources	Object of Transfer9	Activities
Yes	Brazil has the largest contribution	Policy Tools Policy Programs Institutions	Advisory and technical support Technical capacitation
No	Partner country has the largest contribution		Workshops Exchange of laws Feasibility studies Adaptive actions Multiplication actions

• Source: authors, based on the 14 interinstitutional projects, available at SISCOOP until 11/11/2020.

Regarding the problem of the conceptualization of the indicators, if the monitoring and evaluation reports of the cooperation projects were published with open access, it would also be valuable sources. It is known that this publication has obstacles related to the need for consensus between the parts of the agreements that originates each project, clause signed in 47.28% of the international agreements surveyed by Pozzatti and Farias (2019) and an indicator of horizontality between partner countries in their heuristic. If this consensus were pursued in a standard way, disseminating as many reports as possible, there would be gains related to the benefits resulting from the evaluation of international cooperation, such as the improvement of transparency and strategies, and the strengthening of support bases (BRICS Policy Center 2017).

Possible paths to the assessment of decoloniality

The previous subsections reveal the existence of at least one heuristic to assess the horizontality of SCH through international agreements, and also that its categories are quantifiable and may expose broadest standards of cooperation schemes (Torronteguy 2010; Pozzatti and Farias 2019). Nonetheless, if this type of evaluation revels the commitments that give rise to cooperation projects, it is insufficient to affirm that they are carried out in a decolonial way. In turn, in the interinstitutional projects, its indicators’ lack of qualitative description represents a deficit to be resolved institutionally. For that, at least three different responses can be listed: (1) the official standard description of each type of activity or (2) the official description of each type of activity in each project, responses that allow ex ante assessment, and (3) the greater availability of monitoring and evaluation reports that inform how these activities occurred in practice, which allows for an ex-post evaluation.

Other sources and research methods, such as interviews and process-tracing, can also offer valuable information about the indicators mentioned above, if they are oriented to do so. The interviews can even put the demands of scholars and technicians in dialogue. In Policy Transfer studies, for example, there is a tradition of case studies and strategies such as process-tracing, but these studies tend to have little categorization, which is more common in policy diffusion studies (Marsh and Sharman 2009) that deal with a greater number of political units (Oliveira and Faria 2017). However, for Marsh and Sharman (2009), these two types of strategies should be exchanged, and even mixed, both in the cases of policy transfer and policy diffusion, which seems to be a prosperous path to be taken in this case. What looks fundamental is that to access the complexity of the realization of human rights via SCH and to understand how far its structuring/horizontal/dialogical/decolonial character goes, it is necessary to cover and exceed the study of agreements.

Case studies such as the ones carried out by Milani and Lopes (2014), Esteves and Assunção (2017), and Dri and Silva (2019) are examples of qualitative analysis and conduct different and complementary possibilities of interviews, namely with individuals who receive the transfer, in the formers, and with those who offer the transfer, in the latter. However, although the majority (38%) of the SSC projects implemented bilaterally in Latin America in 2016 (latest data available) was focused on the social sphere, mainly the health sector (SEGIB, 2018), global health is among the least research interests of IR researchers in the region (Villa et al. 2017).

Most of this 38% of cooperation focused on the social sphere was implemented through professional training aimed at institutional strengthening (SEGIB, 2018). So, in addition to the negligence on the health sector in the IR field, there are obstacles regarding to which type of agents are considered relevant in its studies. Those interviewed by Dri and Silva (2019) were mostly employees of the Centre of Excellence Against Hunger, while the protagonism of technicians and their sectorial expertise were listed by Milani and Lopes (2014) and Esteves and Assunção (2017) as a characteristic of Brazilian practice. The prominence of technicians/bureaucrats was also verified by Schleicher and Platiau (2017)’s analysis of the cooperation among Brazil and African countries in the area of public administration. However, for the same authors, ‘from the International Relations’s theoretical point of view and the analysis of the official Brazilian discourse, the roles of bureaucrats and street bureaucracy remain invisible’ (Schleicher and Platiau 2017: 16).

The Covid-19 pandemic can catalyse academic productions on global health in all areas of knowledge. However, what happens in the IR discipline is that, ‘[n]aturally, if our purpose is to understand the world, current change will drive changes in theory building, but often the swings in academic fashion are excessive and lack balance’ (Nye 2008: 597). Also, one obstacle in the approximation of science in IR field and real-world problems is that ‘research agendas often mirror contemporary events rather than reflect on them from a distance’ (Lepgold 1998: 46). In this sense, academic production made during the emergency period run the risk of not lead to scientific progress involving models of health cooperation, but resume debates that have already been overcome by disregarding the previous production in the health sector. In this sense, it is essential to reaffirm the state of the art on SCH, and to think about where to go from there. Research agendas need to be increasingly intersectoral, taking as an example how robust a construct on international cooperation outside the IR field can be, as is the case of SCH.

Final considerations

As verified in the first section, SCH can be theoretically considered a decolonial narrative, since it proposes intercultural dialogical communication, considering the partner countries as agents of their own development; emphasizing the local construction of action plans to effect human rights; and doing this based on endogenous resources and capabilities. Regarding the empirical assessment of decoloniality, what is covered in the second section, case studies from the fields of IR and Global Health diverge on the decolonial potential of SCH practices. The potential seems smaller when the study deals with the relations of Brazil and African countries and focuses on the perspective of technicians from these countries, and seems bigger when deals with the relations of Brazil and Latin American countries and focuses on the knowledge of Brazilian technicians or from both countries.

To assess the decoloniality on large scale, there is at least one quantifiable heuristic for international agreements, and this assessment is necessary since these documents carry the originating commitments of the cooperation schemes. However, it is insufficient to verify decolonial implementation. There are also possible and quantifiable heuristics to assess decoloniality through interinstitutional projects, if the descriptive deficiencies of the suggested indicators are met institutionally, which may involve or combine at least three types of responses: official and standard description of each type of activity, in general or in each project, and availability of monitoring and evaluation reports. Moreover, the attempts to solve these needs through interviews or process-tracing, for example, requires approaching the knowledge and the agents from the health sector, which does not reflect the current scenario in the IR field in Latin America.

Regarding the relevance of assessing SCH, the possibility of altering SSC routes based on serious assessments and promoting their transparency and social control has been recognized as relevant for some time (BRICS Policy Center 2017). Also, the importance of assess forms of cooperation based on its own merits has already been addressed by the literature on Latin American regionalism (Riggirozzi and Ryan 2021). However, the Covid-19 pandemic reinforced the urgency of connection between IR field and the knowledge developed and implemented in health sector. Also, the Union of South American Nations (UNASUR)’s inaction in the pandemic context indicates that it is also urgent, at least in South America, to pay attention to bilateral agreements and projects, as they can reveal greater patterns of action in health cooperation. The pandemic also put obstacles to field research and interviews in the Global South, increasing the need for reliable and complete documents. Even though this study has launched a decolonial path to evaluate SCH practices, there are many other paths and guiding values to be followed in order for such an assessment to be conducted.

Notes

• 1
  “Allow me to speak, not my scars. To think that these ills define me is the worst of crimes. It’s giving the trophy to our tormentor and making us disappear”. Emicida is a brazilian singer and songwriter whose songs address questions about the experiences of black and poor people, among other social issues.
• 2
  Available on http://aplicacao.saude.gov.br/siscoop/.
• 3
  Except for the estimated financial cost to Brazil in the project ‘Technical support for the expansion and consolidation of the Argentine Human Milk Banks Network’ (2012), that does not appear in the project, only on the details page of SISCOOP.
• 4
  As in the project ‘Strengthening in the molecular diagnosis and in the typification of Leishmania species, their georeferencing and spatial analysis’ (2009), in which estimated cost for Brazilian government is US$46,255.00 and for Colombian government is US$42, 280.00.
• 5
  As in the project ‘Strengthening the National Health System of Uruguay (SNIS)’ (2012).
• 6
  As in the project ‘Strengthening the dengue control program’ (2009), in which the estimated cost for the Brazilian government is US$136,690.00 and for Argentine government, US$1,800.
• 7
  As the project ‘Support for the implementation of the Human Milk Bank’ (2009), in which the Ministry of Health and Sports of Bolivia is identified as a requesting institution.
• 8
  ABC (2013) informs what feasibility studies are for, but not how they are made.
• 9
  There are other objects mentioned in Dolowitz and Marsh’s (1996, 2000) heuristic. Other projects outside the sample accessed here may have other objects.

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Publication Dates

• Publication in this collection
  09 Dec 2022
• Date of issue
  Sep/Dec 2022

History

• Received
  26 Feb 2021
• Accepted
  06 Apr 2022