Fiocruz as an actor in Brazilian foreign relations in the context of the Community of Portuguese-Speaking Countries: an untold story* * This article contributes to the Center for the Study of Health Bioethics and Diplomacy Project (NETHIS), pursuant to a PAHO/Fiotec-Fiocruz agreement.

Abstracts

Brazilian foreign policy paradigms and changes in the global scenario since the Cold War created conditions for stronger ties between Brazil and Portuguese-speaking African countries. Recently, Brazil took the lead in regional integration processes and in South-South cooperation initiatives. These strategies and Fiocruz's acknowledged technical expertise resulted in its direct involvement in Brazilian foreign public health policy in the Community of Portuguese-Speaking Countries. Fiocruz developed cooperation projects in various areas, sharing its know-how and best practices in the most critical fields in partner countries, consolidating "public health framework cooperation" and contributing to diversifying Brazil's partners and promoting Brazil as a global actor.

South-South cooperation; Community of Portuguese-Speaking Countries; health diplomacy; Brazilian foreign policy; Fiocruz


Os paradigmas da política externa brasileira e as mudanças no cenário global desde a Guerra Fria criaram as condições para aproximação do Brasil com os países africanos de língua portuguesa. Recentemente, o Brasil tomou a liderança nos processos de integração regional e nas iniciativas de cooperação Sul-Sul. Essas estratégias e a reconhecida expertise técnica da Fiocruz abriram espaço para o envolvimento direto da instituição na política externa do Brasil com a Comunidade de Países de Língua Portuguesa na área da saúde. A Fiocruz desenvolveu projetos de cooperação em áreas diversas, compartilhando seu know-how e melhores práticas em áreas prioritárias dos países parceiros, consolidando a "cooperação estruturante em saúde" e contribuindo para a diversificação de parceiros do país e promovendo o Brasil como ator global.

cooperação Sul-Sul; Comunidade de Países de Língua Portuguesa; diplomacia em saúde; política externa brasileira; Fiocruz


International health cooperation between Brazil and the members of the Community of Portuguese-Speaking Countries (CPLP) is based on a long foreign policy process focused specifically on Africa. This process is related to changes in the global outlook since the Cold War that created conditions for stronger ties between the countries in question and, subsequently, the establishment of the CPLP. In this context, the Oswaldo Cruz Foundation (Fiocruz), as an institution with a well-known tradition and technical expertise in public health, became involved in international cooperation with CPLP countries. This article uncovers some historical elements of Fiocruz's cooperation and involvement as an actor in Brazilian foreign policy (BFP).

To this end, we must contextualize Brazil's relationship with the CPLP in Brazilian diplomatic history, as it is through this channel that Fiocruz found opportunities through which to become involved in BFP, promoting international health cooperation projects. As will be discussed, the establishment of the CPLP was the result of a long, historical process in Brazilian foreign policy with respect to Africa, with this process beginning in the 1960s in the time frame adopted in this study.

Thus, the developments in the history of Brazilian foreign policy in relation to Africa will be addressed in order to contextualize the foundation of the CPLP as a political project aimed at closer ties to that continent. Later, the results of the analysis of documents and photographs will be used to attempt to characterize Fiocruz's initiatives, as early as the 1990s, to participate in this community as an important promoter of international health cooperation.

Brazilian foreign policy in the context of the CPLP

The perception that Africa might represent a privileged dimension of this sphere emerged emblematically only in the 1960s (Ribeiro, 2010RIBEIRO, Cláudio Oliveira. Adjustment changes: a política africana do Brasil no pós-guerra fria. Revista de Sociologia e Política, v.18, n.35, p.55-79. 2010.) with the advent of Independent Foreign Policy (IFP) during president Jânio Quadros' term. In the article "Brazil's New Foreign Policy" (Quadros, 1961QUADROS, Jânio. Brazil's new foreign policy. Foreign Affairs, v.40, n.1, p.19-27. 1961.), president Jânio Quadros outlined the ontological foundations of the policy, arguing that Brazil could not accept a foreign policy grounded only in a bipolar division of the world, characterized by the East-West conflict. The article addresses similarities with developing countries and accentuates the need for them to become closer, instead of automatically aligning themselves with the USA in a special relationship that had prevailed since the times of the diplomat Rio Branco (Castro, Carvalho, jun. 2002, p.109-129CASTRO, Marcus Faro de; CARVALHO, Maria Izabel Valadão de. Globalização e transformações políticas recentes no Brasil: os anos 1990. Revista de Sociologia e Política, n.18, p.109-129. Disponível em: http://www.scielo.br/pdf/rsocp/n18/10705.pdf. Acesso em: 14 out. 2014. jun. 2002.
http://www.scielo.br/pdf/rsocp/n18/10705...
). Jânio Quadros' IFP was consistent with the globalist paradigm of Brazilian foreign policy (BFP) that stressed the need for broader foreign policy (Lima, 1994LIMA, Maria Regina Soares de. Ejes analíticos y conflicto de paradigmas en la política exterior brasileña. América Latina/Internacional, v.1, n.2, p.27-46. 1994.). This led to a desire for greater international autonomy, diversification of economic and political partners, and closer ties to the countries that, at that time, were known as "Third World."1 1 Despite the fact that the term "Third World" and variations on it have fallen out of favor, it is being used in this article on purpose, as the expression used at the time the facts discussed here is not equivalent to the modern alternatives "developing countries," "low-income countries," or "peripheral countries." The term "Third World," coined by the French economist Alfred Sauvy in 1952, became popular after the Bandung Conference (1955), a meeting of countries unaligned with either of the two Cold War blocks. In this context, there is no adequate synonym for "Third World" because it does not refer just to the development or wealth of these countries, but rather to the geopolitical conditions of the international system at the time.

Regarding Brazilian policy with respect to Africa, the guidelines of president Jânio Quadros' government recognized that the continent represented a new dimension for Brazil, not only due to commercial potential, but also due to cultural ties.

As to Africa, we may say that today it represents a new dimension in Brazilian policy. We are linked to that continent by our ethnic and cultural roots and share in its desire to forge for itself an independent position in the world of today. ... Our country should become the link, the bridge between Africa and the West, since we are so intimately bound to both peoples (Quadros, 1961, p.24).

It is in this context that José Aparecido de Oliveira came on the scene. President Jânio Quadros' private secretary and probably the most important individual in the context of cooperation between Portuguese-speaking countries (Figure 1). José Aparecido de Oliveira's efforts are widely recognized (Miyamoto, 2009, p.33MIYAMOTO, Shiguenoli. O Brasil e a comunidade dos países de língua portuguesa (CPLP). Revista Brasileira de Política Internacional, v.52, n.2, p.22-42. 2009.), as he created the project to increase involvement between Portuguese-speaking countries back in the early 1960s.

Figure 1:
José Aparecido de Oliveira and Jânio Quadros in the office, n.d. (Branco, 1996, p.121)

The 1964 coup profoundly changed these foreign policy arrangements. At the start of president Castelo Branco's mandate, there was a radical return to the Americanist paradigm, emphasizing the East-West conflict to the detriment of the globalist perspective, which had proposed the pragmatic alignment of Brazil with other Third World countries. In the new national policy context, Brazil projected itself, internationally, as part of the capitalist bloc. The fear of the expansion of the communist world can be perceived in Brazil's international position then, to the extent that Brazil began to support Portugal's colonization of Africa as a way to suppress the independence movements there, which were seen as acts of soviet expansionism (Pinheiro, 1988PINHEIRO, Letícia. Ação e omissão: a ambiguidade da política brasileira frente ao processo de descolonização africana, 1946-1960. Dissertação (Mestrado) - Instituto de Relações Internacionais, Pontifícia Universidade Católica do Rio de Janeiro. 1988.). These factors were unfavorable to the continuity of both projects to form a community of Portuguese-speaking countries, as José Aparecido de Oliveira had envisioned, and plans to form partnerships with African countries in order to advance a South-South solidarity cooperation project rooted in historical and identity ties.

Despite this, during the first military governments Brazil-Africa relations became substantially stronger (Ribeiro, 2010, p.56-57RIBEIRO, Cláudio Oliveira. Adjustment changes: a política africana do Brasil no pós-guerra fria. Revista de Sociologia e Política, v.18, n.35, p.55-79. 2010.). However, this deepening of ties was of a different nature than that of those created by IFP. Portuguese-speaking territories - especially those in the South Atlantic - came to be seen as strategic in terms of international security in the Cold War context, which led to a new posture by these governments in order to defend the region and take advantage of the potential of those markets (Gonçalves, Miyamoto, 1993, p.227-228GONÇALVES, Williams da Silva; MIYAMOTO, Shiguenoli. Os militares na política externa brasileira: 1964-1984. Estudos Históricos, v.6, n.12, p.211-246. 1993.).

The situation changed once again under the presidency of Ernesto Geisel, in 1974. His government represented a return to the globalist paradigm with the adoption of responsible pragmatism in foreign policy, emphasizing a separation of policy and ideological precepts - important variables in the East-West conflict. This resulted in rapprochement with the "third world" bloc and in a commitment to international democratization, which required a review of the Brazilian position on Portuguese-speaking African territories, recognizing the independence of the colonies (Gonçalves, Miyamoto, 1993, p.229GONÇALVES, Williams da Silva; MIYAMOTO, Shiguenoli. Os militares na política externa brasileira: 1964-1984. Estudos Históricos, v.6, n.12, p.211-246. 1993.).

The 1980s were marked by the reaffirmation of Brazil's African policies (Cardoso et al., 2009CARDOSO, Ana Graziele et al. CPLP: uma vertente da diplomacia brasileira para o continente africano. Monografia (Graduação) - Universidade Anhembi Morumbi, São Paulo. 2009.). The independence of Portugal's colonies paved the way for closer relations between Brazil and the new Portuguese-speaking countries. Thus, during the government of president José Sarney, African policies became more oriented towards cultural diplomacy, and engagement increased towards the creation of the CPLP. In 1989, in the city of São Luís, in the state of Maranhão, a meeting of the heads of state of Portuguese-speaking countries was held, which served as the embryo for the foundation of the Community, and during which the International Portuguese Language Institute was established. Near the end of president José Sarney's term, the plan to establish the Community became even more clearly defined with the involvement of José Aparecido de Oliveira as minister of Culture, who began taking regular trips to Portuguese-speaking countries to advance discussions in this direction (Ribeiro, 2010, p.62-63RIBEIRO, Cláudio Oliveira. Adjustment changes: a política africana do Brasil no pós-guerra fria. Revista de Sociologia e Política, v.18, n.35, p.55-79. 2010.).

The 1990s were marked by international and domestic reconfigurations with the end of the Cold War, the consequent unipolar order and the consolidation of globalization, on the one hand, and with the redemocratization process and the enactment of a new Brazilian constitution on the other. BFP suffered from the globalist and Americanist paradigm crises. In this scenario, two approaches for Brazil's international policies arose as new versions of the previously adopted paradigms, albeit implemented in a nonlinear manner: the liberal approach and the autonomist approach. The former maintained characteristics of the globalist policies practiced up until then, concerning itself with the North-South dichotomy and emphasizing Brazilian cooperation with the South and Brazil's international leadership role. The autonomist approach, however, attempted to place more emphasis on prevailing international regimes, supporting the "autonomy through participation" ideal. This approach became favored during the presidency of Itamar Franco and, later, during the terms of president Luiz Inácio Lula da Silva (Saraiva, 2007, p.46SARAIVA, Miriam G. As estratégias de cooperação Sul-Sul nos marcos da política externa brasileira de 1993 a 2007. Revista Brasileira de Política Internacional, v.50, n.2, p.42-59. 2007.).

During the rise of the liberal approach, the foreign policy of president Fernando Collor de Mello - marked by the opening of Brazil and its integration into globalization processes and the search for growing involvement with the "First World" (Saraiva, 2007, p.45SARAIVA, Miriam G. As estratégias de cooperação Sul-Sul nos marcos da política externa brasileira de 1993 a 2007. Revista Brasileira de Política Internacional, v.50, n.2, p.42-59. 2007.) - set aside the CPLP project in order to prioritize other initiatives, such as the Common Market of the Southern Cone (Mercosur). Under president Itamar Franco, the autonomist approach to foreign policy was favored and brought South-South cooperation with it (Saraiva, 2007, p.46SARAIVA, Miriam G. As estratégias de cooperação Sul-Sul nos marcos da política externa brasileira de 1993 a 2007. Revista Brasileira de Política Internacional, v.50, n.2, p.42-59. 2007.). Relations between Brazil and Portuguese-speaking African countries took on new momentum (Ribeiro, 2007RIBEIRO, Cláudio Oliveira. Relações político-comerciais Brasil-África (1985-2006). Tese (Doutorado) - Faculdade de Filosofia, Letras e Ciências Humanas, Universidade de São Paulo, São Paulo. 2007.) with the relaunch of the South Atlantic Peace and Cooperation Zone and, later, with the appointment of José Aparecido de Oliveira as ambassador to Portugal, who worked almost exclusively on his mission to found the CPLP (Figures 2 and 3) (Mota, 2009, p.35MOTA, Mariana V. Brasil, Portugal e a CPLP: possíveis estratégias internacionais no século XXI. Dissertação (Mestrado) - Faculdade de Filosofia, Letras e Ciências Humanas, Universidade de São Paulo, São Paulo. 2009.).

Figure 2:
Joaquim Chessano, president of Mozambique, receiving Ambassador José Aparecido de Oliveira, in Maputo, n.d. (Braga, 1999, p.73)

Figure 3:
Presidents Itamar Franco and Mario Soares reaffirming support for the CPLP, in the presence of ambassadors José Aparecido de Oliveira and Pedro Ribeiro de Menezes, in Brasília, n.d. (Braga, 1999, p.69)

The strategy for Brazil's positioning on the global scene under president Fernando Henrique Cardoso was based on the concepts of "shared sovereignty" - a vision of the world marked by universal values, in which countries should allow themselves to be guided by international regimes (Saraiva, 2007, p.46SARAIVA, Miriam G. As estratégias de cooperação Sul-Sul nos marcos da política externa brasileira de 1993 a 2007. Revista Brasileira de Política Internacional, v.50, n.2, p.42-59. 2007.) - and "selective partnerships" - which entails building relationships with important countries in the international system capable of joining together to transform the world, contributing to increasing Brazil's status abroad (Miyamoto, 2009, p.37MIYAMOTO, Shiguenoli. O Brasil e a comunidade dos países de língua portuguesa (CPLP). Revista Brasileira de Política Internacional, v.52, n.2, p.22-42. 2009.).

President Fernando Henrique Cardoso's mandate began in the context of a considerable reduction in investment in African foreign relations - the number of Brazilian diplomats on the continent dropped from 34 to 24 between 1989 and 1993. The institutionalization of the CPLP2 2 On July 17, 1996, in Lisbon, the Summit of Heads of State and Government was held, marking the foundation of the Community of Portuguese-Speaking Countries, an entity bringing together Angola, Brazil, Cape Verde, Guinea-Bissau, Mozambique, Portugal and São Tomé and Príncipe. Six years later, on May 20, 2002, East Timor became the eighth member of the Community when it gained its independence. on June 17, 1996 is emblematic because it occurred during a period in which Brazil-Africa relations were being deemphasized. This was evidence of the important role that the government planned for the CPLP as the focus of Brazil's relationship with the continent, together with stronger ties with South Africa as part of a strategic partnership (Ribeiro, 2007, p.164RIBEIRO, Cláudio Oliveira. Relações político-comerciais Brasil-África (1985-2006). Tese (Doutorado) - Faculdade de Filosofia, Letras e Ciências Humanas, Universidade de São Paulo, São Paulo. 2007.).

Under president Luiz Inácio Lula da Silva, there was an incisive rise in the autonomist approach. Seeking greater autonomy, Brazil promoted a multipolar international system, strengthening multilateralism as a means to reduce power asymmetries and promote the claims of developing countries. At the same time, in the economic realm, it sought to preserve and enhance its potential for growth (Ayllón Pino, abr. 2012, p.192AYLLÓN PINO, Bruno. Contribuciones de Brasil al desarrollo internacional: coaliciones emergentes y cooperación Sur-Sur. Revista CIDOB d'afers internacionals, n.97-98, p.189-204. abr. 2012.).

This represented a large change in BFP regarding Africa, with African countries meriting greater attention from Brazilian diplomacy (Ribeiro, 2010, p.67RIBEIRO, Cláudio Oliveira. Adjustment changes: a política africana do Brasil no pós-guerra fria. Revista de Sociologia e Política, v.18, n.35, p.55-79. 2010.). The importance placed on the Brazil-Africa relationship by the president can seen in the relevant statistics. In a little more than two years, during his first term, president Luiz Inácio Lula da Silva made four trips to the continent, visiting a total of 17 countries, in contrast to the seven trips made by preceding presidents. He also established 35 new diplomatic offices on the continent during eight years in command. "Between 2003 and 2008, exports to Africa increased threefold, from $2.4 million to $7.5 million" (Visentini, Pereira, s.d., p.7VISENTINI, Paulo G. Fagundes; PEREIRA, Analúcia Danilevicz. A política africana do governo Lula. Disponível em: http://www.ufrgs.br/nerint/folder/artigos/artigo40.pdf. Acesso em: 15 out. 2014. s.d.
http://www.ufrgs.br/nerint/folder/artigo...
). Figures from the Brazilian Ministry of Foreign Affairs (MFA) on countries emphasized for cooperation in 2005-2010 show Brazil's preferential treatment of Portuguese-speaking African countries (PALOPs) (Brasil, 2010BRASIL. Ministério das Relações Exteriores. Balanço da política externa brasileira (2003-2010). Brasília: Ministério das Relações Exteriores. 2010.).

Note that, from 2004 to the present, Brazil has taken a leadership role in integration processes and in South-South cooperation initiatives (Saraiva, abr. 2012, p.87-100SARAIVA, Miriam G. Procesos de integración de América del Sur y el papel de Brasil: los casos del Mercosur y la Unasur. Revista CIDOB d'afers internacionals, n.97-98, p.87-100. abr. 2012.; Ayllón Pino, abr. 2012, p.189-204AYLLÓN PINO, Bruno. Contribuciones de Brasil al desarrollo internacional: coaliciones emergentes y cooperación Sur-Sur. Revista CIDOB d'afers internacionals, n.97-98, p.189-204. abr. 2012.). Both actions, based on soft power, made possible the internationalization of Brazilian companies and of some government policies, as well as increased Brazil's international influence, reinforcing national interests in relation to development and autonomy.

This international and domestic reconfiguration contributed to the emergence of a new international relations agenda and, therefore, to diversification in foreign policy. Due to this new reality and to diplomats' lack of technical ability to deal with such diverse issues, the ministries that had previously focused only on domestic policy began to broaden their activities to include international policy. This made possible the internationalization of an extensive set of Brazilian public policies in recent years, favoring international cooperation and regional integration. Although the MFA continues to coordinate these actors, it does not prevent the horizontal decentralization of the process of formulating and carrying out BFP (Pinheiro, 2009, p.19PINHEIRO, Letícia. Autores y actores de la política exterior brasileña. Foreign Affairs Latinoamerica, v.9, n.2, p.14-24. 2009.; Pinheiro, Milani, 2012, p.335-336PINHEIRO, Letícia; MILANI, Carlos. Conclusão. In: Pinheiro, Letícia; Milani, Carlos. Política externa brasileira: a política das práticas e as práticas da política. Rio de Janeiro: FGV. p.331-345. 2012.).

Fiocruz entered the scene in this context, linked to the Ministry of Health, as an institution with well-known technical expertise and relevant experience in various fields of interest to Community member countries. This allowed Fiocruz to be invited by the MFA to participate in Brazil's foreign policy with respect to CPLP member countries in the area of public health (ABC, mar. 2007, p.5ABC. Agência Brasileira de Cooperação. Cooperação técnica brasileira em saúde. Disponível em: http://www.abc.gov.br/intranet/Sistemas_ABC/siteabc/documentos/viaABC-baixa.pdf. Acesso em: 24 fev. 2011. mar. 2007.
http://www.abc.gov.br/intranet/Sistemas_...
).

Fiocruz: international cooperation in public health within the CPLP

The first meeting to debate cooperation options and needs took place during the Second Meeting of Health Ministers of Portuguese-speaking African Countries, held at Fiocruz in Rio de Janeiro in 1994. This meeting was important for two reasons. On the one hand, it defined priority areas for public health cooperation that were of immediate interest for these countries (epidemics; sanitation; epidemiological monitoring of vaccine-preventable diseases and zoonoses and health information systems; human resources development, Aids and mental health) (Palop, 1994PALOP. Países de Língua Oficial Portuguesa. Ata final do 2º Encontro de Ministros da Saúde dos Países de Língua Oficial Portuguesa. Rio de Janeiro: s.n. 12 ago. 1994.). On the other hand, this meeting of PALOP Health ministers was a further step in the consolidation of the CPLP, which was still being negotiated.

Two concerns that still arise in Community public health cooperation were made explicit in this meeting: the emphasis on the local situation and on the interests of the African countries and the need for sources of financing (Palop, 1994PALOP. Países de Língua Oficial Portuguesa. Ata final do 2º Encontro de Ministros da Saúde dos Países de Língua Oficial Portuguesa. Rio de Janeiro: s.n. 12 ago. 1994.). Brazil made a broad offer of cooperation, consisting of programs adaptable to the specific needs of these countries, taking into consideration their deficient infrastructure and human resources, as well as the methods used for each country. Nevertheless, this offer did not include guarantees of Brazilian resources to finance programs, hindering the development of cooperation (Rubarth, 1999, p.169-170RUBARTH, Ernesto O. A diplomacia brasileira e os temas sociais: o caso da saúde. Brasília: Instituto Rio Branco. 1999.).

This difficulty sometimes resulted in the postponement of projects. The release of starter funds, provided by the Perez Guerreiro Trust Fund (PGTF), which financed Fiocruz's first mission to the PALOP, took about two years (1995-97). During this time period, a third Meeting of Ministers of Health (1996) was held in Lisbon by the Portuguese government and by the World Health Organization. The African representatives stressed the need for the technical autonomy of their public health systems and demanded health-care training at the secondary and university level in their countries in order to avoid brain drain (Rubarth, 1999, p.170-171RUBARTH, Ernesto O. A diplomacia brasileira e os temas sociais: o caso da saúde. Brasília: Instituto Rio Branco. 1999.). This demand was affirmed one year later by the Foundation's mission to the PALOP (1997).

Despite the bilateral nature of Fiocruz's visits to each of the countries, the technical report provided an overview of the region as a whole. The members of the mission observed3 that the living and public health conditions and the way in which public services were organized in the various countries were very different, which led them to reflect on the feasibility of a proposal addressing them as a whole (Fiocruz, mar. 1998FIOCRUZ. Fundação Oswaldo Cruz. Cooperação da Fiocruz com países da África. 2008.) (Figure 4).

Figure 4:
Community gathering during the inauguration of a health center in a rural area, first Fiocruz PALOP mission, in Guinea-Bissau, 1997 (Courtesy of Paulo Sabroza, Ensp/Fiocruz, and Júlio César F. Lima, EPSJV/Fiocruz)

The visits took place in the context of the Angolan civil war, which was at its most fierce in the 1990s, the result of partisan struggles between Angolan independence movements, which continued until the start of the twenty-first century. Meanwhile, other African countries were in the process of liberalizing their economies and establishing democracy. The transition to a multi-party political system in Guinea-Bissau, Cape Verde, Mozambique and São Tomé and Príncipe was characterized by repeated political crises (coups, military insurgencies, civil wars and refugees).

Despite the perceived differences between the countries, the report highlighted that the lack of trained human resources, including teachers, and the dependence on foreign aid were problems common to all, and for this reason national systems largely consisted of staff with basic and technical training. The report also showed that providing training abroad was unsatisfactory, as many students failed to return to their homelands. Consequently, there was a need for courses given locally. Among the recommendations, the report stressed respect and methodological consideration of local competencies, seeking to work in partnerships and to avoid ready-made models full of technicalities foreign to the African institutions (Fiocruz, mar. 1998, p.25FIOCRUZ. Fundação Oswaldo Cruz. Relatório da primeira missão da Fundação Oswaldo Cruz aos Países de Língua Oficial Portuguesa (outubro-novembro, 1997). mar. 1998.). All of these issues were revisited in later Fiocruz cooperation actions, and thus this report is considered to have been very useful (Fiocruz, 2008, p.3FIOCRUZ. Fundação Oswaldo Cruz. Cooperação da Fiocruz com países da África. 2008.).

Armed conflict and political instability in some countries contributed to postponing the implementation of the project for another two years. However, during this period ties were strengthened with departments of the World Health Organization (WHO), initially with the Pan American Health Organization (PAHO/WHO) and with the Regional WHO Office in Africa, both interested in promoting technical cooperation with the PALOP countries. These institutions, together with representatives from Portuguese-speaking African countries, the Brazilian Cooperation Agency (BCA) of the MFA, the Federal University of Rio de Janeiro and the Fiocruz National Public Health School (Ensp/Fiocruz), participated in the Workshop on Technical Cooperation for the Development of Human Resources, held in 2000 in Rio de Janeiro, at Fiocruz (Ensp, maio-jun. 2000ENSP. Escola Nacional de Saúde Pública. Boletim Cedoc. maio-jun. 2000.).

The recommendations of the prior mission were discussed at the workshop and action plans were drawn up based on the needs of each country and on what the Foundation could supply: specialization courses; health management and surveillance; teacher training; and structuring of teaching networks (Figueiredo, Fonseca, 2009, p.11FIGUEIREDO, Maria C.; FONSECA, Luiz. Capacitação como processo de cooperação internacional. Saúde e direitos humanos, ano 6, n.6, p.7-18. 2009.). This workshop represented a bridge between two stages, the change in focus from the goals proposed by the PGTF to future cooperation with other potential donors. "In an interview, Luiz Fonseca said, 'cooperation between Fiocruz and the PALOP countries is based on partnerships. Neither Brazil nor the PALOP countries have resources allocated for this type of project. So, at each meeting we must develop a proposal or concrete step to be submitted to financing sources.'" (Ensp, maio-jun. 2000, p.5ENSP. Escola Nacional de Saúde Pública. Boletim Cedoc. maio-jun. 2000.)

This partnership strategy for developing cooperation initiatives as a response to financial limitations later became known as triangular cooperation, which would be particularly important together with PAHO/WHO beginning in 2006 when the second phase of cooperation between Fiocruz and African countries in the context of the CPLP began.

Still in the first phase and based on definitions from the workshop, the BCA and the Japanese International Cooperation Agency (JICA) financed the training of African teachers at Ensp/Fiocruz in four public health specializations. This cooperation resulted in a significant increase in the number of African students at Ensp/Fiocruz4 4 In the 1990s, there was a total of 25 African students at Ensp. Between 2000 and 2008, this number rose to 100 (Figueiredo, Fonseca, 2009, p.12). and, at the same time, in inter-institutional relations in public health between CPLP countries, contributing to the emergence of new cooperation projects (Figueiredo, Fonseca, 2009, p.12FIGUEIREDO, Maria C.; FONSECA, Luiz. Capacitação como processo de cooperação internacional. Saúde e direitos humanos, ano 6, n.6, p.7-18. 2009.). This triangular cooperation with JICA to train CPLP human resources lasted five years (2001-2005) (Fiocruz, 2008, p.3FIOCRUZ. Fundação Oswaldo Cruz. Cooperação da Fiocruz com países da África. 2008.).

During this period and in the same sphere of cooperation, the BCA negotiated financial support with the CPLP for the project entitled "Healthcare Human Resources Training Support Program for Portuguese-speaking African Countries." As a result, Fiocruz undertook a second mission to Africa in 2002 and coordinated a workshop in Maputo. Representatives of the ministries of health and alumni from the PALOP countries and East Timor participated in the first management course financed by JICA. At this workshop, representatives concluded that conditions were not sufficient for distance education, given: (a) the technology available in the countries, and (b) the need to train local teachers on how to build curricula and teaching methods. For this reason, the project was redesigned, prioritizing the teaching aspect with the goal of "teaching local teachers how to design curricula based on competencies" (Figueiredo, Fonseca, 2009, p.13FIGUEIREDO, Maria C.; FONSECA, Luiz. Capacitação como processo de cooperação internacional. Saúde e direitos humanos, ano 6, n.6, p.7-18. 2009.).

The "dialog with existing knowledge," among other principles, guided the activities of this cooperation process, which concluded in 2008 with the joint preparation by Fiocruz and CPLP of the teaching material "Health, work and education: conceptual and methodological framework for building training curricula in public health". This material, revalidated in Lisbon, aids in the construction of specific curricula tailored for the conditions in each country (Figueiredo, Fonseca, 2009, p.15FIGUEIREDO, Maria C.; FONSECA, Luiz. Capacitação como processo de cooperação internacional. Saúde e direitos humanos, ano 6, n.6, p.7-18. 2009.).

According to the BCA and Fiocruz itself, 2005 and 2006 marked the start of a second phase of cooperation in public health with CPLP member states. In this phase, cooperation was consolidated through actions to establish institutions in African countries to continue carrying out priority public health activities (ABC, mar. 2007, p.5ABC. Agência Brasileira de Cooperação. Cooperação técnica brasileira em saúde. Disponível em: http://www.abc.gov.br/intranet/Sistemas_ABC/siteabc/documentos/viaABC-baixa.pdf. Acesso em: 24 fev. 2011. mar. 2007.
http://www.abc.gov.br/intranet/Sistemas_...
).

Two important facts underlay this new dynamism in public health cooperation between Fiocruz and CPLP countries. The first was the strengthening of the partnership between the Ministry of Foreign Affairs and the Ministry of Health that, in 2005, signed a memorandum of intent with the objective of "improving coordination between the MFA and the Ministry of Health on technical cooperation provided to developing countries in the field of public health" (Brasil, 2005BRASIL. Ministério das Relações Exteriores. Ministério da Saúde. Protocolo de intenções entre o Ministério das Relações Exteriores e o Ministério da Saúde. Brasília: Ministério da Saúde. 25 jul. 2005.). This partnership is so important that international cooperation became one of the eight axes of intervention in the institutional plan "Better Health: A universal right" adopted by the Ministry of Health for the 2008-2011 period (Brasil, 2009BRASIL. Ministério da Saúde. Mais saúde: direito de todos 2008-2011. Brasília: Ministério da Saúde. 2009.).

The second fact was the addition, in 2006, of PAHO/WHO participation in Fiocruz cooperation with African CPLP countries through cooperation agreement no.41, which promoted human resources training activities and technical support for projects undertaken by framework institutions in the countries involved (Santana, 2011, p.2998SANTANA, José Paranaguá de. Um olhar sobre a cooperação Sul-Sul em saúde. Revista Ciência e Saúde Coletiva, v.16, n.6, p.2993-3002. 2011.). Triangulation was one of the mechanisms that the federal institutions - in this case the Ministry of Health and Fiocruz - found to respond to the financial limitations and increase cooperation, skirting the restrictive Brazilian law (Ayllón Pino, abr. 2012, p.200AYLLÓN PINO, Bruno. Contribuciones de Brasil al desarrollo internacional: coaliciones emergentes y cooperación Sur-Sur. Revista CIDOB d'afers internacionals, n.97-98, p.189-204. abr. 2012.; GHSI, 2012, p.23GHSI. Global Health Strategies Initiatives. Shifting paradigm: how the BRICS are reshaping global health and development. Disponível em: http://www.g20civil.com/documents/199/472/. Acesso em: 28 mar. 2012. 2012.
http://www.g20civil.com/documents/199/47...
; Vazquez et al., 2011, p.13VAZQUEZ, Karen et al. From a fledging donor to a powerhouse. Columbia: School of International and Public Affairs. Disponível em: http://api.ning.com/files/fH6my883OIbtHJ0U7Nsc7Grias7i0V93k2LoBlQfZTZyLoCFblyQFXb*YqsvXtEngEV3PLq1RzsWsSO0VaQstAmlTC9MWoAD/FromaFledgingdonortoapowerhouseBrazilsdevelopmentcooperation2. pdf. Acesso em: 1 set. 2012. 2011.
http://api.ning.com/files/fH6my883OIbtHJ...
). This new triangular cooperation method was driven by successful experiences in the national context. The participation of an intergovernmental organization like PAHO/WHO favors the consolidation of enduring international public health cooperation (Santana, 2011, p.2998SANTANA, José Paranaguá de. Um olhar sobre a cooperação Sul-Sul em saúde. Revista Ciência e Saúde Coletiva, v.16, n.6, p.2993-3002. 2011.). Both facts, in turn, were contextualized by the Brazilian foreign policy of president Luiz Inácio Lula da Silva, guided by the South-South cooperation paradigm that prioritizes structural actions promoting the development of partner countries, ensuring greater ownership and sustainability. During this period, Brazilian diplomacy assumed the role of integration paymaster, increasing the government's financial support for international cooperation with Africa and using triangulation with institutions such as PAHO/WHO as a means to transfer these resources.

In public health, Brazil adopted the "framework cooperation" model that "integrates human resources training, organizational strengthening and institutional development, instead of the traditional passive transfer of knowledge and technologies" (Almeida et al., 2010, p.28ALMEIDA, Celia et al. Brazil's conception of South-South "structural cooperation" in health. Revista Eletrônica de Comunicação Informação & Inovação em Saúde, v.4, n.1, p.23-32. Disponível em: http://www.revista.icict.fiocruz.br/index.php/reciis/article/view/343/528. Acesso em: 30 abr. 2011. 2010.
http://www.revista.icict.fiocruz.br/inde...
). Based on this model, Fiocruz implemented several public health cooperation projects in the CPLP, principally by offering graduate programs in critical health areas. Some examples are: Master's in Public Health (Angola, 2007, Ensp); Master's in Health Sciences for the areas of Cellular and Molecular Biology, Parasite Biology and Tropical Medicine (Mozambique, 2008, Instituto Oswaldo Cruz - IOC); Master's in Parasite Biology and Tropical Medicine (for Angolan students in Brazil, 2008, IOC);5 5 Supported by the Eduardo Santos Foundation. Specialization in Professional Education in Healthcare (Guinea-Bissau, Mozambique, Cape Verde and Brazil, 2010, EPSJV); among others (Figures 5 and 6) (Fiocruz, 2008FIOCRUZ. Fundação Oswaldo Cruz. Cooperação da Fiocruz com países da África. 2008.).

Figure 5:
Angolan master's student in Parasite Biology and Tropical Medicine at IOC, in Rio de Janeiro, 2008 (Courtesy of IOC/Fiocruz)

Figure 6:
Professional Education in Healthcare Specialization Class in Maputo, 2011 (Courtesy of EPSJV/Fiocruz)

In addition to graduate courses, ESPJV/Fiocruz develops cooperation projects to strengthen the training of health technicians, including: guidance on structuring technical training in biodiagnostics and equipment maintenance (Cape Verde, in 2007); guidance on restructuring the Regional Public Health Development Center (Mozambique, in 2007); training of professionals and support for training teachers of community agents (Angola, in 2006) (Fiocruz, 2011, p.7FIOCRUZ... Fiocruz tem novo representante no continente africano. Informe ENSP. 27 maio 2011.). ESPJV/Fiocruz also coordinates the CPLP Network of Vocational Healthcare Schools, founded in 2009.

All of these activities were to strengthen framework health institutions (national institutes of health, public health schools, vocational health schools etc.), improving local qualifications and promoting ownership so that partner countries could take over running their own processes. At the same time, these initiatives contributed to convincing Community member States do participate in the program. As will be discussed later, they called for Fiocruz's active participation in defining the CPLP Strategic Public Health Cooperation Plan for 2009-2012 (SPHCP).

The Foundation also increased the international cooperation developed by the Brazilian network of human milk banks to encompass CPLP member States, with the approval of the "CPLP Human Milk Bank Network Implementation Project" in 2008. Note that the first human milk bank was established in Cape Verde6 6 Supported by the BCA, the Ministry of Health, the Fernandes Figueira Institute and the Scientific and Technological Communication and Information Institute. in 2011, which was a historical milestone as it was the first in Africa.

In the pharmaceutical area, Fiocruz, through the Drug Technology Institute (Farmanguinhos), leads an unprecedented international cooperation project to transfer Brazilian technology: The Antiretroviral Factory in Mozambique that aims to reduce Mozambican dependence on foreign drug donors, especially drugs to treat HIV/Aids. This initiative arose due to a request from the Mozambican government that was supported by Brazil in 2003, beginning a negotiation process that ended in 2004 and resulted in the "Study of technical-economic feasibility of a Mozambican factory," carried out by the Foundation (Fiocruz, 2011, p.13FIOCRUZ... Fiocruz tem novo representante no continente africano. Informe ENSP. 27 maio 2011.). The schedule for this project was extended for various years due to difficulties of various types: "Bureaucratic procedures involving actions between the two governments; uncertainties in funding for some activities and the lack of local technical staff able to quickly absorb the intended technology transfer" (Siqueira, 2008SIQUEIRA, Marcos T. Cooperação internacional com a África: o projeto de instalação da fábrica de anti-retrovirais e outros medicamentos em Moçambique. Disponível em: http://www.paho.org/bra/index.php?option=com_docman&task=doc_view&gid=842&Itemid=614. Acesso em: 5 nov. 2014. 2008.
http://www.paho.org/bra/index.php?option...
). In 2012, they formally finalized the construction of the factory, but before it can produce all of the drugs for which it was designed, it must undergo a long inspection process for which Fiocruz will continue to provide support to Mozambique in the coming years (Figures 7 and 8).

Figure 7:
Packaging of drugs in antiretroviral drug factory, in Maputo, 2010 (Photo: Ricardo Stukert)

Figure 8:
Authorities displaying test batch of antiretroviral drugs in visit to factory in Maputo in 2010. From left to right: Roberto Camilo, head of production and quality assurance of Mozambican factory; Alexandre Manguele, Mozambican Minister of Health; Luiz Inácio Lula da Silva, President of Brazil; Paulo Gadelha, President of Fiocruz; José Gomes Temporão, Brazilian Minister of Health; Maria Jonas, Governor of the province of Matola (location of factory) (Photo: Ricardo Stuckert)

Given this broadening of Fiocruz's participation in cooperation with CLP member States, the Foundation was invited to the first Meeting of CPLP Ministers of Health (2008), to participate in the technical group to develop the Strategic Public Health Cooperation Plan. Thus, Fiocruz and the Portuguese Hygiene and Tropical Medicine Institute (IHMT) were responsible for preparing the first version of the SPHCP, finally approved in 2009 during the second Meeting of CPLP Ministers of Health, in Estoril (Buss, Ferreira, 2010, p.109BUSS, Paulo M.; FERREIRA, José Roberto. Diplomacia da saúde e cooperação Sul-Sul: as experiências da Unasul saúde e do Plano Estratégico de Cooperação em Saúde da Comunidade de Países de Língua Portuguesa (CPLP). Revista Eletrônica de Comunicação Informação & Inovação em Saúde, v.4, n.1, p.106-118. Disponível em: http://www.reciis.icict.fiocruz.br/index.php/reciis/article/view/351. Acesso em: 14 out. 2014. 2010.
http://www.reciis.icict.fiocruz.br/index...
). The bases of the Plan are the Millennium Development Goals and cooperation to face the social determinants of public health, with the principal objective defined to be "contribution to reinforcing healthcare systems in CPLP member states, in order to guarantee universal access to quality healthcare" (CPLP, 2009CPLP. Comunidade dos Países de Língua Portuguesa. Declaração do Estoril. Estoril: CPLP. 2009.). The training of human resources and the reinforcement of healthcare system institutional capacity stand out as the principal strategies of the SPHCP7 (Buss, Ferreira, 2010, p.110BUSS, Paulo M.; FERREIRA, José Roberto. Diplomacia da saúde e cooperação Sul-Sul: as experiências da Unasul saúde e do Plano Estratégico de Cooperação em Saúde da Comunidade de Países de Língua Portuguesa (CPLP). Revista Eletrônica de Comunicação Informação & Inovação em Saúde, v.4, n.1, p.106-118. Disponível em: http://www.reciis.icict.fiocruz.br/index.php/reciis/article/view/351. Acesso em: 14 out. 2014. 2010.
http://www.reciis.icict.fiocruz.br/index...
).

Thus, the SPHCP was enriched by the cooperation initiatives developed by Fiocruz before it was conceived, and became the first CPLP strategic public health planning experiment. Thus, Fiocruz consolidated Brazil-PALOP cooperation in the broader CPLP context, aligning sector objectives with Brazilian foreign policy guidelines (Santana, 2012SANTANA, José Paranaguá de. Cooperação Sul-Sul na área da saúde: dimensões bioéticas. Tese (Doutorado) - Universidade de Brasília, Brasília. 2012.).

The Foundation's internationalization was realized with the inauguration, in 2008, of the Fiocruz Regional Office in Africa,8 8 On November 23, 2011, the Brazilian Senate approved legislative degree no.235/2011, an agreement between the Brazilian government and the Mozambican government, to establish the headquarters of the Fiocruz Regional Office in Africa (Fiocruz, 2011). the Foundation's first international representation office abroad. This office, based in Mozambique, strengthens Fiocruz's presence in Africa and enhances healthcare cooperation between Brazil and CPLP member countries. The office, however, still faces several challenges related to its institutionalization and the establishment of internal mechanisms for managing international cooperation in order to ensure technical and political coherence with government and institutional guidelines (Fiocruz..., 27 maio 2011FIOCRUZ... Fiocruz tem novo representante no continente africano. Informe ENSP. 27 maio 2011.).

Final considerations

Fiocruz is an important actor in the internationalization of Brazilian domestic public health policy through international cooperation initiatives begun in the 1990s as part of the South-South cooperation paradigm. Political, financial and institutional challenges have been faced throughout the history of Fiocruz's international cooperation with the CPLP member countries, through the application of innovative solutions such as financial triangulation and the development and definition of the SPHCP. The accelerated dynamic of this cooperation, however, has introduced new challenges to be overcome, including: the definitive institutionalization of Fiocruz's Regional Office in Africa and the renewal of the CPLP Strategic Public Health Cooperation Plan, both important for the consolidation of the public health framework cooperation program, aligned with Brazilian foreign policy. The role of the Oswaldo Cruz Foundation is becoming increasingly important for Brazilian foreign policy, contributing to diversifying Brazil's partners and promoting Brazil as a global actor.

ACKNOWLEDGMENTS

We would like to thank doctor Luiz Fonseca, Fiocruz Center for International Relations in Healthcare (Centro de Relações Internacionais em Saúde/Fiocruz [CRIS]), for his valuable contribution and supply of important information that formed the basis for these images. We would also like to thank the various Fiocruz departments for providing the images, especially: Paulo Sabroza, Júlio César F. Lima, Elizabeth Artmann and Célia Almeida. And finally, we would like to thank Maria Cecilia Aparecido de Oliveira for her assistance.

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  • *
    This article contributes to the Center for the Study of Health Bioethics and Diplomacy Project (NETHIS), pursuant to a PAHO/Fiotec-Fiocruz agreement.
  • 1
    Despite the fact that the term "Third World" and variations on it have fallen out of favor, it is being used in this article on purpose, as the expression used at the time the facts discussed here is not equivalent to the modern alternatives "developing countries," "low-income countries," or "peripheral countries." The term "Third World," coined by the French economist Alfred Sauvy in 1952, became popular after the Bandung Conference (1955), a meeting of countries unaligned with either of the two Cold War blocks. In this context, there is no adequate synonym for "Third World" because it does not refer just to the development or wealth of these countries, but rather to the geopolitical conditions of the international system at the time.
  • 2
    On July 17, 1996, in Lisbon, the Summit of Heads of State and Government was held, marking the foundation of the Community of Portuguese-Speaking Countries, an entity bringing together Angola, Brazil, Cape Verde, Guinea-Bissau, Mozambique, Portugal and São Tomé and Príncipe. Six years later, on May 20, 2002, East Timor became the eighth member of the Community when it gained its independence.
  • 3
    The members of Fiocruz's first mission to the PALOP were: Paulo Sabroza of the National Public Health School (Escola Nacional de Saúde Pública) (Ensp/Fiocruz), Carlos Tobar (Ensp/Fiocruz) and Júlio César F. Lima of the Joaquim Venâncio Polytechnic School of Health (Escola Politécnica de Saúde Joaquim Venâncio) (EPSJV/Fiocruz).
  • 4
    In the 1990s, there was a total of 25 African students at Ensp. Between 2000 and 2008, this number rose to 100 (Figueiredo, Fonseca, 2009, p.12).
  • 5
    Supported by the Eduardo Santos Foundation.
  • 6
    Supported by the BCA, the Ministry of Health, the Fernandes Figueira Institute and the Scientific and Technological Communication and Information Institute.
  • 7
    The Plan advocates for priority projects, especially: (1) a network of vocational healthcare schools; (2) a network of national public health schools in the CPLP; (2) specialized medical training; (4) technical centers for installation and maintenance of equipment (CPLP, 2009).
  • 8
    On November 23, 2011, the Brazilian Senate approved legislative degree no.235/2011, an agreement between the Brazilian government and the Mozambican government, to establish the headquarters of the Fiocruz Regional Office in Africa (Fiocruz, 2011).

Publication Dates

  • Publication in this collection
    Jan-Mar 2015
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