Brazil’s foreign policy and health (1995-2010): A policy analysis of the Brazilian health diplomacy – from AIDS to ‘Zero Hunger’

Almeida, Celia; Lima, Thaisa Santos; Campos, Rodrigo Pires de

doi:10.1590/0103-1104202313601I

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ORIGINAL ARTICLE • Saúde debate 47 (136) • Jan-Mar 2023 • https://doi.org/10.1590/0103-1104202313601I copy

Brazil’s foreign policy and health (1995-2010): A policy analysis of the Brazilian health diplomacy – from AIDS to ‘Zero Hunger’

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

This article analyses, from a policy analysis approach, how health entered Brazilian foreign policy between 1995 and 2010 and supported the country’s international position, which is rarely explored in the literature on Brazilian health diplomacy. By drawing on literature review, document analysis and key-actor interviews, we examined policies triggered by far-reaching and complex historical change processes in Brazil. We find significant interrelationships between foreign policy and social policy, including health. The internationalization of Brazilian domestic policies, and South-South cooperation, played a central role during Lula governments (2003-2010). Health found its way into the foreign policy agenda to support Brazil’s growing international presence. These developments were made possible by the activism and engagement of several of State and non-State actors working on two levels: national and transnational advocacy, and coordinated activities of government representatives, including Brazilian diplomats, and civil society activists. The main argument of this study is that national and international policies are intertwined in this process and that domestic dynamics and societal engagement are essential but more is needed: governmental choices are also determinant. Institutional arrangements and policies shift in different conjunctures and are constantly prone to conflicts and change.

KEYWORDS
Health diplomacy; International cooperation; Brazil

Key Features

FHC government’s (1995-2002)

Lula government’s (2002-2010)

Goal / Basic premises

The government embraced ‘orthodox neoliberalism’ and BFP was an instrument of macroeconomic stabilisation policy. Intended to abandon of the ‘Third World thesis’ and previous correlated alliances, to restore Brazil’s international credibility⁸8 Milani C, Pinheiro L. The Politics of Brazilian Foreign Policy and its Analytical Challenges. Foreig. Policy Anal. 2017 [accessed on 2008 Jan 5]; (13):278-296. Available at: https://doi.org/10.1093/fpa/orw027.
https://doi.org/10.1093/fpa/orw027... ,³⁹39 Vigevani T, Cepaluni GA. Política Externa de Lula da Silva: A Estratégia da Autonomia pela Diversificação. Rev. Cont. Intern. 2007 [accessed on 2021 Mar 2]; 29(2):273-335. Available at: http://contextointernacional.iri.puc-rio.br/media/Vigevani_vol29n2.pdf.
http://contextointernacional.iri.puc-rio... ,⁴²42 Fagnani E. A política social do governo Lula (2003-2010): perspectiva histórica. SER Social. 2011 [accessed on 2012 Apr 3]; 13(28):41-80. Available at: https://periodicos.unb.br/index.php/SER_Social/article/view/12682.
https://periodicos.unb.br/index.php/SER_... .

Accepted the ‘rules of the game’ and strived to develop ‘ways to legitimise its own positions’ on economic development within those rules⁴³43 Boito A, Berringer T. Social classes, neodevelopmentalism, and Brazilian foreign policy under presidents Lula and Dilma. Latin Amer. Perspec. 2014; 41(5):94-109.^(14–15).

Expanded macroeconomic adjustment policies, but, adopted a ‘neo-developmentalist’ approach.

Emphasized the inherent contradictions of globalisation and to exploit any room for manoeuvre left by the dispersion of international power as U.S. hegemony began to erode.

Pursuit of ‘political autonomy’.

Opened new opportunities for action abroad to advance Brazil’s interests, whether through development or advancement within the world system.

Established a social agenda on the international stage, in which the issue of health played a prominent role.

Strategies

Less normative weight to motivations of solidarity and identification with countries of the South.

Active ‘presidential diplomacy’.

Domestically: policies of trade liberalisation and privatisation.

Externally: a rapprochement with Western powers, including the United States, and with international regimes.

International cooperation wasn’t a priority, except in HIV/AIDS.

Establishment of ‘strategic partnerships’ or building coalitions with ‘variable geometry’.

Very active ‘presidential diplomacy’.

Domestically: broadening the social base by expanding political citizenship and including the most vulnerable groups through consumption. And projected outward trade interests of large national corporations and conglomerates.

Internationally: broadening participation in a variety of global forums and negotiating arenas in multiple areas, supporting proposals to review and reform multilateral institutions (e.g., the UN Security Council).

Advocated multidimensional diplomacy, involving simultaneous actions in different areas at the global, regional, and bilateral levels.

International cooperation (South-South and triangular) – technical, political, and economic – expanded significantly and gained strategic importance, as a tool to strengthen alliances and coalitions between countries with perceived similar levels of development and aspirations, driven both by Brazil’s improving economic conditions and by the internationalisation of national policies.

Regional policy

Moving away from Mercosul regional interests, BFP advocated greater flexibility in the form of free trade agreements with countries outside the region (e.g., in the European Union).

To link Brazil’s prosperity with that of its neighbour’s countries in order to mitigate the structural asymmetry between them. To promote activities in narrower forums, proposing and supporting the creation of new regional institutions (IBAS in 2003, BRICS in 2006, and Unasul in 2008) and strengthening existing institutions (ex., Mercosul).

Area

FHC government’s (1995-2002)

Lula government’s (2002-2010)

Overall social policies

Restructuring of universal social services continue. Beginning of processes of privatizations in the economic and social areas (mainly in the first one). Basic programmes: to increase redistributive impact and efficacy in combating poverty; and policies to basic education.

Community in Solidarity Programs^a a Comunidade Solidária comprised a series of cash transfer programmes, the most important being: a national minimum income programme, the Bolsa Escola (2001), tied to primary and lower secondary education; a national programme for access to food (2003); a national minimum income programme, the Bolsa Alimentação (2001), tied to health; and a cooking gas allowance programme (2002). (Comunidade solidária, 1995): priority actions linked to cash transfer for groups targeted by territorial criteria and income, under conditionalities and partnerships with states, municipalities and civil society^a a Comunidade Solidária comprised a series of cash transfer programmes, the most important being: a national minimum income programme, the Bolsa Escola (2001), tied to primary and lower secondary education; a national programme for access to food (2003); a national minimum income programme, the Bolsa Alimentação (2001), tied to health; and a cooking gas allowance programme (2002). .

Restructuring of universal social services continue, plus retirement’s reform.

Raising the minimum wage and the social security benefits pegged to it.

Raising levels of education, policies directed to higher education (e.g., quotas for low-income and black students).

Privatization of social services continue (in higher education and health).

Bolsa Família: family allowance cash transfer with two benefits –

Basic, for families in extreme poverty, transfer with no conditionalities, similar to basic income programmes in place in other countries.
Variable, for low-income families with children or adolescents, subject to conditionalities relating to health (vaccination) and education (school attendance).

Health: Implementation of the SUS

Decentralisation and social participation: continued.

Care network: significant expansion of primary health care.

Under-funding: not solved, temporarily offset by the CPMF^b b The CPMF was drafted on the basis of the Provisional Ta x on Financial Transactions (Imposto Provisório sobre Movimentação Financeira, IPMF), which was applied only in 1994. In 1996, major discussions were conducted by the then Minister of Health, Adib Jatene, in an attempt to restore the funding sources of the Social Security Budget and increase funding for health: the CPMF was finally approved and began to be levied in 1997. This tax was charged on all bank transactions – except for trading on the stock exchange, retirement pension withdrawals, unemployment benefit, wages and transfers between current accounts of the same holder – and remained in place in Brazil for 11 years (1997-2007). In late 2000, cross referencing was introduced between banking information and income tax declarations, so as to identify possible discrepancies between amounts declared to the Inland Revenue and movement of money in bank accounts. From then on, the CPMF, because it was a tax that was difficult to evade, began to encounter fierce opposition in parliament. Several studies have shown that both governments used the enormous revenue from the CPMF for other areas, besides healthcare, and perpetuated the underfunding of the SUS, even during the period when the tax was levied. The CPMF was extended several times following hard-fought legislative battles. Despite the considerable volume of funds raised, it was discontinued in 2007. .

National AIDS Programme:

Horizontal Technical Cooperation Group on HIV/ AIDS (HTCG) set up (1996).
National Coordination on Sexually Transmitted Diseases and AIDS (Coordenação Nacional de Doenças Sexualmente Transmissíveis e AIDS, DST/ AIDS) set up (1999) under the then Health Policy Secretariat.
Negotiations with the World Bank (ongoing since 1990) finalised for loans specifically for this area: AIDS I (1994-1998) and AIDS II (1999-2003).
Early treatment with antiretrovirals (highly active triple drug antiretroviral therapy, HAART) begun in the SUS (1996).
13th International AIDS Conference held in Durban (9-14 July, 2000): important participation by Brazil.
Special Session of the UN General Assembly on AIDS (2001): antiretroviral treatment officially recognised.
International Cooperation Programme for Actions to Control and Prevent HIV in developing countries, launched by the MoH and Foreign Ministry (ICP, 2002).

Decentralisation and social participation: continued.

Care network: no progress in secondary care or coordination among levels; little progress in regionalisation.

Underfunding: not solved, culminating in suspension of the CPMF in 2007. Minor expansion in public health spending, municipalities’ and states’ relative shares increased and federal share decreased.

Private medical insurance coverage increased: from 18.9% in December 2004 to 26% in December 2014^c c Possible explanations for this increase are the inclusion of medical care in employment contracts (which had been on workers’ and trade union agendas since the 1970s) and partly the growth in formal employment and the government’s maintaining the heavy subsidy on tax waivers arising out of related payments, i.e., individuals’ and businesses’ spending on private health care was discounted from their tax base67(139). In Brazil, several other tax waiver factors benefit the private sector. .

National AIDS Programme:

Beginning of the implementation of the ICP (2003).
Approval and implementation of the third World Bank loan (AIDS III, 2004-2007) and approval of the fourth and final loan (2007, AIDS SUS).
Creation of the International Centre for Technical Cooperation on HIV/AIDS (ICTC) (2005), the name given to a new Technical Support Facility involving Unaids and the national programme, establishing Brazilian cooperation on HIV/AIDS and a leading role for Brazil in the international arena.
First use of a compulsory licence to produce generic antiretroviral drugs in Brazil (2008).
Creation of the National Department of STDs/AIDS and Viral Hepatitis, including the coordinating offices of the National DST/AIDS Programme (PN-DST/ AIDS) and the National Viral Hepatitis Programme, all under the National Health Surveillance Secretariat (Secretaria Nacional de Vigilância em Saúde, SVS) (2009), similar to the structure of the programmes at the state and municipal levels^d d The coordinators of the two programmes, DST/AIDS and Viral Hepatitis, became, respectively, head and deputy head of the new department. .

Source: prepared by the authors.
^a Comunidade Solidária comprised a series of cash transfer programmes, the most important being: a national minimum income programme, the Bolsa Escola (2001), tied to primary and lower secondary education; a national programme for access to food (2003); a national minimum income programme, the Bolsa Alimentação (2001), tied to health; and a cooking gas allowance programme (2002).
^b The CPMF was drafted on the basis of the Provisional Ta x on Financial Transactions (Imposto Provisório sobre Movimentação Financeira, IPMF), which was applied only in 1994. In 1996, major discussions were conducted by the then Minister of Health, Adib Jatene, in an attempt to restore the funding sources of the Social Security Budget and increase funding for health: the CPMF was finally approved and began to be levied in 1997. This tax was charged on all bank transactions – except for trading on the stock exchange, retirement pension withdrawals, unemployment benefit, wages and transfers between current accounts of the same holder – and remained in place in Brazil for 11 years (1997-2007). In late 2000, cross referencing was introduced between banking information and income tax declarations, so as to identify possible discrepancies between amounts declared to the Inland Revenue and movement of money in bank accounts. From then on, the CPMF, because it was a tax that was difficult to evade, began to encounter fierce opposition in parliament. Several studies have shown that both governments used the enormous revenue from the CPMF for other areas, besides healthcare, and perpetuated the underfunding of the SUS, even during the period when the tax was levied. The CPMF was extended several times following hard-fought legislative battles. Despite the considerable volume of funds raised, it was discontinued in 2007.
^c Possible explanations for this increase are the inclusion of medical care in employment contracts (which had been on workers’ and trade union agendas since the 1970s) and partly the growth in formal employment and the government’s maintaining the heavy subsidy on tax waivers arising out of related payments, i.e., individuals’ and businesses’ spending on private health care was discounted from their tax base⁶⁷67 Singer A. Raízes sociais e ideológicas do lulismo. Novos Estudos Cebrap. 2009 [accessed on 2010 Oct 30]; (85). Available at: https://doi.org/10.1590/S010133002009000300004.
https://doi.org/10.1590/S010133002009000... ⁽¹³⁹⁾. In Brazil, several other tax waiver factors benefit the private sector.
^d The coordinators of the two programmes, DST/AIDS and Viral Hepatitis, became, respectively, head and deputy head of the new department.

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[1] Conflict of interests: non-existent