Regions as a structure of governance constitute important spaces for the socialisation of groups and individuals. Regions are spaces or arenas for action driven by different actors, motivations, and expectations about regional endeavours. At the same time, regional organisations can create an authoritative set of institutions based on normative principles that structure practices in member states and communities across the region. This makes sense, particularly, as some social harms are inherently cross-border, and are exacerbated or facilitated by regional developments. Regional rules can improve collective management while pulling together knowledge and material resources and thus reducing transaction costs. Yet, as domestic politics become more tightly coupled with regional normative and policy outcomes, regional institutions can also become a ‘fulcrum of contention’.Footnote 1 Social mobilisation is likely to arise out of generalised perceptions of region building as an ‘elite compromise’, where regional policy and politics unduly favour national elites, and when pressures of market competition degrade regulatory protection in social areas.Footnote 2 These sources of contention have explained regionalism and its discontents in the Americas in the 1990s, and more recently in the Eurozone crisis. In both cases, economic and social regional projects unfolded at different speeds, where the search for efficiency and competitiveness, as a key driving force in the process of regionalism, decoupled from values like distribution, rights, and social justice.Footnote 3 But what, if any, are the possibilities for meso-level institutions to provide leadership and direction in support of alternative practices of global governance? Can regional polities become international advocacy actors in support of global justice goals? How can and do regional organisations mediate or transform transnational norms? These questions have received some attention among norm theorists and International Relations (IR) scholars with an interest in EUFootnote 4 and ASEAN regionalism,Footnote 5 but in the case of South American regionalism they have remained largely unaddressed. However, new political economic trends in Latin America, and new regionalist ambitions have given these questions increasing salience. This is most significantly illustrated, or so I will argue, as the Union of South American Nations (UNASUR) carves out a space for new forms of collective action within the region and of concomitant diplomacy to contest the existing order in the global governance of health.
Such developments challenge views of the transnationalisation of politics and norm diffusion that consider states of the global South, as individuals and as groups, simply as ‘receivers’ of global norms or norm-takers.Footnote 6 On such an understanding, regionalism in the South has been seen as an element of a global neoliberal strategy conducted at a regional scale, a process identified as ‘meso-globalisation’.Footnote 7 This perception is now seriously challenged as the political and economic circumstances that gave substance to regionalism in the 1980s and 1990s no longer obtain and the contours of the regional arena are being defined by contentious politics in demand of responsive modes of governance beyond market-led integration.Footnote 8 This doesn't mean that capitalism, liberalism and trade related forms of integration are ceasing to be significant elements of the regional agenda, rather it seems that their centrality is being displaced as new valid social goals are being reclaimed and taking precedence in the politics of region-building and the practice of regionalism in the South. In this context, health is an appropriate field for an approach that focuses not only on social integration between states but also in the capacity of regional organisations to advocate more inclusive models of global health governance.
This article looks at the capacity of UNASUR to enable new policies for collective action in support of social development goals in South America, and to act as a broker of rights-based demands in global health governance. The human right to health is an established part of the international law structuring global health governance. However, critics of international institutions and health aid raised concerns about how issues of representation, transparency, accountability, and effectiveness undermine opportunities to enjoy attainable standards of physical and mental health in developing countries.Footnote 9 In this context, the article argues, the relevance of regional organisations such as UNASUR rests on the capacity to provide a framework that helps diffuse regulations, norms, and practices concerning national health regimes and, at the same time, to act as broker of health norms bridging domestic political concerns and global health governance, advancing demands for better representation and rights within the World Health Organisation (WHO) and vis-à-vis international pharmaceutical corporations. This argument does not assume that UNASUR advances a coherent foreign policy in all areas but, rather, that it has found in health diplomacy a niche area for contesting and reworking the status quo so that regional health diplomacy becomes a project of transformation, rather than an affirmation, of the current global order.
The article is organised as follows. Part One discusses controversies around what defines health and global health governance. It is argued that specific frameworks support policy agendas that open opportunities for policy engagement, contestation, and claiming. Part Two proposes a framework to analyse regional organisations as sites for collective action and pivotal actors in contending global (health) politics. Part Three contextualises the study by analysing the milestones defining global health diplomacy and its inequalities in Latin America. Part Four analyses how UNASUR, as an example of a regional organisation in the South, opens new opportunities for advocacy in support of access to medicines and health in the region and, through external engagement, as an actor contesting the status quo in global health governance. The article closes with a discussion about regional activism and rights followed by concluding remarks summarising theoretical and empirical implications for further analysis of regional organisations in global health governance.
Health as a defining lens of governance
Like most terrains of social policy, public health has traditionally been a sensitive area where the dominant form of political organisation and provision has been the state. However, in recent years health has risen as a strategic policy area with transboundary implications. There is increasing evidence that many determinants of health extend beyond the commonly understood area of public policy and health sector activities, and are associated with transnational pandemics and diseases that trespass national boundaries and migrate from countries to country through porous frontiers and interdependent economies. While the state still exercises undoubted and indisputable regulatory power over public health decisions over societies in their own territorial boundaries, both the reach and scope of health governance has become central to the understanding and practice of global foreign policy. Policymakers and researchers are now familiar with the term ‘global health diplomacy’, which has developed as a field of research and policy action over the last two decades as health is becoming a core feature of global negotiations, whether they relate to trade, economic growth, or social development.Footnote 10
Collective attempts to combat diseases that cross national borders are not new. In fact, health was one of the first transboundary issues to employ multilateral diplomatic mechanisms during the nineteenth century.Footnote 11 But it was only at the end of the twentieth century when health became recognised, academically, as a ‘global’ issue. The HIV/AIDS epidemics in the 1980s, and more recently the outbreaks of severe acute respiratory syndrome (SARS) in China and Canada, and the spread of pandemic influenza A (H1N1) between Mexico and the United States, demonstrated little regard for state borders or notions of sovereignty. In an increasingly globalised world, disease can spread more quickly and more easily than before. In addition to the impact in terms of morbidity and mortality caused by communicable diseases, their capacity to interfere with economic activity and population movement means that communicable diseases fall subject to international coordination.Footnote 12 Similarly, the terrorist and bioterrorist attacks of September and October 2001 in the United States directed the focus of infectious disease to national security.Footnote 13 Such events have increased global political concerns about emerging infectious disease threats and deliberate epidemics, and have highlighted the important connection between global public health and security, what Ingram identifies as a new ‘geopolitics of disease’.Footnote 14
The nexus between health crisis and health security increasingly provided new grounds for international policymaking as well as an important entry-point for analysing the politics of health. In practice, health was recognised as a security threat at the turn of the century by a United Nations Security Council (Resolution 1308, 2000) and subsequently awarded a place in numerous national security documents – particularly in relation to infectious diseases and HIV/AIDS.Footnote 15 This has particularly been so in the case of US policy responses and the subsequent creation of the President's Emergency Plan for AIDS Relief (PEPFAR) and other funding mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria; bilateral programmes; NGOs and civil society groups; and private foundations such as the Bill and Melinda Gates Foundation. The General Assembly's Millennium Summit in September 2000 also brought further attention to the HIV/AIDS pandemic by devoting Goal 6 of the Millennium Development Goals (MDGs) to combat the disease, as well as other prevalent infectious diseases such as malaria and tuberculosis.Footnote 16 To be clear, the WHO has promoted broad debates about global responses to HIV since the late 1980s. But the identification of health as a global security issue, underpinned by the UN Security Council, demarcated rhetorical and disciplinary boundaries in International Relations. Theoretically, this gave substance to three main approaches framing the study of international health politics: (i) a realpolitik approach that suggests that the global scope of health poses security risks to states and citizens and thus defending, as well as advancing, national interests becomes the primary motivation for international health politics;Footnote 17 (ii) an institutional approach which stresses that unintended consequences of global health, and social action, leads to cooperation between formal global international institutions, states and nonstate actors, particularly if states fail to address (state and human) insecurity; and (iii) normative and rights-based approaches claiming that a complementary aspect of realpolitik should reorient global health architecture to the recognition of the morality of health and the right to health.Footnote 18 Despite this range of approaches, the challenge of International Relations, in theory and as foreign policy practice, is ‘to galvanise existing actors and structures into acting on behalf of the voiceless and vulnerable, without succumbing to the logic of securitisation’.Footnote 19
If imperatives of state, social, and economic security exert pervasive influence over the discourses, institutions, policies, and practitioners of public health, the risk is that health moves away from the realm of rights, as ‘right to health’,Footnote 20 to that of ‘securitisation’. This is not to say that the securitisation of health denies the right to health. But it rather delimits the subject of rights, prescribes policy obligations, and steers the allocation of human and material resources.Footnote 21 It can also create a tension between existing normative and legal instruments supporting rights-based approaches to social development and citizenship and the practice of global (health) governance.Footnote 22 In other words, that certain infectious diseases become a matter of security and global threat also means that actors' responses may drift away from an ethos of human dignity to one of self-interest of cost-effective calculations.Footnote 23
Who frames what and why depends on how the actors in global health governance, including government officials, nongovernmental organisations (for example, Medicins Sans Frontieres, Oxfam, the Gates Foundations), institutions (for example, the WHO, World Bank, UNICEF, UNAIDS), public-private partnerships (for example, GAVI), define their goals and objectives, institutional mandates and rationales, and exercise use of material and knowledge resources to support actions accordingly.Footnote 24 As argued by Fidler, the ways germs are tackled, norms addressed, and power exercised, are linked to both moral responsibilities as well as a more pragmatic understanding of powerful actors' interests.Footnote 25 From this perspective, the linkages between global health, aid, trade, diplomacy, and national/global security motivates foreign policy based on strategic calculations – economic (protecting trade), diplomatic (preventing epidemics), strategic (preventing bioterrorism) – as much as by a desire to promote health equity and wellbeing.Footnote 26 As such, it is expected that the donor community, advocacy organisations, wealthy countries, and the UN system, for instance, strategise not only on the basis of moral principles, but also driven by their understandings of what constitutes ‘problems’, ‘solutions’, and ‘best’ practices. These considerations are often filtered by what is considered globally relevant and cost-effective in health cooperation and technical assistance programmes.Footnote 27 These interests are salient even in current times of rising development aid for health and groundbreaking global health treaties increasingly addressing the right to health.Footnote 28 The risk is that what is ‘visible’ and ‘urgent’ leads over what is ‘marginal’; that so-considered high politics in health prevails over low politics; or simply that global pandemics render peripheral diseases that disproportionately strike the poor and vulnerable, creating situations of marginalisation and inequality across societies.Footnote 29
This is even more the case as many deliberations and declarations about rights, development aid, and the right to health take place in global institutions with limited participation of right-bearers – rural and indigenous community leaders, migrants, etc.– in those deliberations or within the institutional structure of the relevant organisations. Lack of participation in the structure of health governance closes the political opportunity, in the words of Tarrow,Footnote 30 for ‘rights bearers’ and activists to set up political agendas and to contest how subjects of rights are defined, their needs established, and problems of poverty and marginalisation addressed.Footnote 31 Harman argues that the highly centralised nature of decision-making and delivery in global health governance, led by a statecentric and hierarchical mode of organisation, has the effect of ‘pigeon-holing issues and prescribing interventions’ while reproducing a power gap between international institutions and donors (that is, the World Bank, the Bill and Melinda Gates Foundation, states within the G8) and the governments and civil society actors within developing countries. The latter have less opportunity to influence terms of agenda-setting and decision-making, priorities of research, and delivery of services.Footnote 32 According the Lancet-University of Oslo Commission on Global Governance for Health, power asymmetries between actors with conflicting interests, as well as reduced spaces for policy dialogue in contemporary global governance, are political determinants of health, marginalised diseases, and populations.Footnote 33
In recognition of this, a puzzling question arises: can regional normative and institutional frameworks structure practices in support of broader equality and rights to healthcare and access to medicines? Relatedly, can regional organisations become activist in support of the right to health in developing countries? Constructivist scholarship in International Relations and the literature on contention politics and social movements have acknowledged the dynamic role of NGOs and transnational advocacy networks seeking to alter existing political structures, particularly in relation to human rights.Footnote 34 According to these perspectives, when communication between domestic actors and the state are blocked, NGOs can search out international partners who will pressure the state from the outside. Risse, Ropp, and Sikkink, for instance, argue that the referential point for policy change is at the intersection of macro and micro relations of power where international institutions are key to the policy impact of transnational actors; not only because they facilitate the formation of transgovernmental coalitions but also because transnational actors working in international institutions gain visibility and influence, gaining access to the governments of member states.Footnote 35
Furthering these arguments, yet with a focus on regional organisations, this article argues that regional organisations have a crucial role providing opportunities and incentives for individuals or groups to undertake collective action, contesting, reworking and spreading (human rights) norms, and fundamentally engaging as ‘regional actors’ in (health) diplomacy. Little has been speculated about the opportunities for multilateral and regional organisations (that is, G-20, IBSA, ASEAN, SADC, MERCOSUR, and the Community of Portuguese Speaking Countries) to act as norm sponsors championing alternative practices and viewpoints on global health. Some empirical work on the ways Southern in support of health cooperation has been produced,Footnote 36 however current scholarly writings tend to emphasise diplomatic interactions led by singular ‘regional powers’, primarily Brazil, South Africa or China, in international diplomacy and within the WHO. While important global players in health diplomacy, the challenge is not depicting how member states' interests play out in the global system, or the role of NGOs – mainly operating from major Western countries, but rather to explain how regional organisations can become political structures providing opportunities and incentives for individuals or groups to undertake collective action, and fundamentally how a regional polity can itself become a policy entrepreneur brokering demands and reworking (global) rights to health.
Advocacy and regionalism in health governance
Activism and advocacy of civil society groups and networks have been corrective devices and moral vectors in global (health) governance.Footnote 37 Similarly, increasing South-South cooperation and alliances are said to strengthen less developed countries collective bargaining position, influence, and negotiation outcomes in critical areas in global health politics.Footnote 38 High economic growth rates in emerging economies such as Brazil, Russia, India, and China have certainly increased their presence and political influence in global governance, and thus their political willingness to challenge traditional structures of power and norms in strategic areas such as the Trade Related Intellectual Property Rights Agreement (TRIPS) regime, curtailing the interests of traditional powers while introducing new international normative, such as the Framework Convention on Tobacco Control.Footnote 39 Similarly, but with a focus on social actors, Jönsson and Jönsson show how firm advocacy of NGOs fighting against HIV/AIDS profoundly changed impacted on global health institutions in terms of mobilising unprecedented amount of funds and framing the discourse about HIV as a matter of human rights and socioeconomic inclusion, downplaying medical and security emphasis that particularly defined the issue in the 1990s.Footnote 40 Furthermore, changes in the international regulatory framework with the multilateral adoption of the Millennium Development Goals under the umbrella of the UN system, catalysed the activism of transnational advocacy groups endorsing the framing of HIV as human rights also within domestic contexts, particularly in Africa.Footnote 41 As the WHO recognised NGOs as legitimate partners promoting and protecting rights, HIV/AIDS activists have been able to make use of global opportunity structures granting access to important governance institutions, mainly within the UN system, but also in public-private partnerships like the Global Fund to Fight AIDS, Tuberculosis, and Malaria. While these developments do not mean that power asymmetries and exclusionary decision-making have been reverted, they are important steps towards transformations in the multilateral policymaking. This may also explain the unprecedented focus on health as a foreign policy, confirmed in a special issue of the Bulletin of the WHO and the ‘Oslo Declaration’.Footnote 42
However, not all countries or social organisations are able to craft (influential) health foreign policies, in the same way that not all diseases generate the same level of interest in health diplomacy and global health responses. In this regard, communicable diseases, such as HIV/AIDS, tuberculosis, and malaria tend to receive a disproportionate share of attention and resources compared to other communicable diseases such as dengue, chagas, and parasitic diseases that do not lead to global epidemiological emergencies.Footnote 43 This is also the case in relation to the corridors of research and development funding. While nonstate actors and funders, whether the Gates Foundation, the Welcome Trust, private charity or international organisations, may be led by noble and ethical considerations, pursuing a human rights agenda may concentrate resources on dealing with one disease while delinking the problem from the political economic environment affecting societies' access to health systems and medicines in many developing countries. Likewise, the US President's Emergency Plan for AIDS Relief (PEPFAR) or the Gates' initiatives to eradicate polio and malaria often support laboratory research and work in the field, setting up clinics, treatment centres, home visits, and so on, but their money, effort, and good intentions do not always have a significant effect on the lack of technical expertise, professionalisation of health workers and health policy makers; or the different capacity and leverage of developing countries in health negotiations within international organisations and vis-à-vis international pharmaceuticals.Footnote 44 Despite a recognition that transnational alliances and advocacy efforts of NGOs, and global rights-based regimes can make a difference in terms of pro-poor development and rights,Footnote 45 political considerations, institutional mandates, private interests, and distributional consequences may create perverse incentives making it difficult to address and advance (international-led) responses to tackle poverty, hunger, gender, discrimination, and production/consumption habits.Footnote 46
In view of that, the hypothesis proposed here is that there is a new kind of political opportunity structure emerging if we consider that the regional space represents a critical platform to enhance visibility and recognition of marginalised societies (and neglected diseases) in global politics. I therefore propose to look at both the opportunities institutions of regionalist governance allow for collective action within the region, and activism of regional institutions advanced through diplomacy as a unified actor. These are different ways through which regional actors can actually promote health policies and practices, from framing public policy debates to providing different set of incentives for actors involved in the domestic and global policymaking process. That is, regional organisations can become sites for collective action and pivotal actors in contending (global) politics, in three main different ways: (i) providing a normative framework structuring new practices in support of rights-based development governance; (ii) facilitating the (re)allocation of material and knowledge resources and creating new institutions in support of claims making and advocacy of actors; and (iii) enabling representation and claims-making as a unified regional actor in global governance. In short, regional actors can change policymaking and the policymaking arena. They can also play the role of deal-broker and mediator between developing countries and international organisations by engaging in new forms of regional health diplomacy.
Latin American health inequalities
It is now commonplace to assert that Latin America has begun to move away from strictly neoliberal models of growth as a consequence of an unprecedented economic boom, based on global demand for the region's abundant natural resources. Despite important differences in current economic conditions within the region strong external demand (especially from emerging economies like China), in combination with vigorous internal demand, resulted in an average annual GDP growth rate of almost 5 per cent during 2003–8 and an average of 4 per cent during 2011–13 for the entire region.Footnote 47 New economic opportunities intersected with the rise of populist Leftist governments across the region, redefining projects of economic and social development.Footnote 48
Notwithstanding this, around 168 million still live in poverty, that is almost 30 per cent of the population subsists with less than two dollars a day, while 66 million live in extreme poverty earning less than one dollar per day.Footnote 49 The most economically and socially vulnerable populations, that is indigenous, rural poor, slum residents, migrant workers, the elderly, women and children, face unfavourable conditions and the greatest burden of infectious diseases and disabilities.Footnote 50 Many studies have reported the close links between tuberculosis, infectious diseases, malnutrition, and other communicable diseases, and the lack or insufficient access to drinking water, sanitation, adequate housing, education, and health services across Latin America.Footnote 51 The poverty-health link is also manifested in reduced learning capabilities and socioeconomic and income earning capacity opportunities. Some alarming figures show that in low-income countries, such as Bolivia, Paraguay, and Peru communicable diseases exert the most important influence on quality of life and life expectancy. In Haiti, the incidence of tuberculosis is seven times that of the region; while dengue and HIV, although a significant and growing problem across the region, disproportionately affects Brazil. Malaria is endemic in 21 countries.Footnote 52 This bleak situation is worsened by low levels of social service delivery and limited access to medicines particularly affecting populations in rural and tropical areas and, significantly, women in the region. Deeper levels of poverty have been associated with distortions and transformations caused by the manner in which many countries in Latin America have been integrated into a globalising world economy with high rates of poverty and inequality in income distribution and access to public services accentuated by a legacy of neoliberal reforms in the 1990s that reduced public spending in welfare policies and state participation in the provisions of health, education, and social security.Footnote 53 Additionally, access to medicines has been hampered by unfavourable trade negotiations with developed countries and exporters of high-value patented drugs. Numerous public health experts, academics, and practitioners have expressed concerns about the impact of TRIPS, part of the normative order of the World Trade Organisation, limiting availability and increasing prices of drugs in favour of the pharmaceutical sector.Footnote 54 Although the TRIPS Agreement allows developing countries to override drug patents by issuing ‘compulsory licenses’ to manufacture generic drugs in exceptional cases, for instance when drugs are not sufficient or affordable domestically, these flexibilities have sometimes been curtailed.Footnote 55 Restrictive bilateral frameworks have been applied to a number of US and EU-sponsored FTAs with Central America, Chile, Peru, and Colombia curtailing the flexibilities for compulsory licensing and parallel imports of medicines at lower prices from other countries, circumventing the WTO framework.Footnote 56
In the struggle for the right to health and access to medicines, South American countries started collectively bargaining for price reductions in the procurement of pharmaceuticals needed for national health programmes, particularly in response to the escalation of HIV in Brazil in the 1990s and the mobilisation of social actors demanding rights honouring the Constitution of 1988.Footnote 57 In fact, attempts to embed social issues in relation to health, education, and labour regulations within regional frameworks, particularly in the Andean Community and the Common Market of the South (MERCOSUR) have been significant.Footnote 58 Nonetheless, in practice collective action on social goals drifted away from the attention of authorities and consequently regional mechanisms had limited or no influence on policymaking in regards to such issues. In the end, these initiatives remained rather ad hoc and severely limited by the realities and pressures of economies highly dependent on international cooperation and conditional loans demanding fiscal austerity and ‘less state’ through privatisation and deregulation of markets, including health.Footnote 59 Delivering social protection, welfare, and human development remained seen as the responsibility of (seriously constrained) domestic spending choices, often to mitigate the effects of market reforms or to secure political support of citizens. In this context, South American nations failed to build fixed and effective regional institutions protecting and promoting health rights, and creating opportunities for individuals and groups to access, enjoy, and reproduce those rights.
By 2000, renewed attitudes to tackling the critical state of global health saw a proliferation of players, resources, and policy frameworks such as the Millennium Development Goals, with health as an issue cutting across its eight objectives; the Global Health Initiatives for the increase of funds for infectious diseases, such as AIDS, Tuberculosis and Malaria, and for immunisation; the Commission on Social Determinants of Health (2005–8) defining health not simply as a sanitary problem but one determined by socioeconomic conditions; and the Oslo Ministerial Declaration (2007) which called for more attention to health as a foreign policy issue and a stronger strategic focus on the global health agenda. These new frameworks intersected with the changes in the political economy of Latin America where more confident and resourced nationalist governments have been highly consequential for a new cycle of contention politics – in the language of Sidney Tarrow – through government-sponsored welfare policies and a significant change in the regional agenda to respond to the legacy of past neoliberal policy reforms. Indeed the commitment with the integration process was reaffirmed in the early 2000s by the new South American governments who saw the regional space a platform for redefining consensuses around autonomous development through regional social policies in health, the management of natural resources, and infrastructure integration.Footnote 60 The creation of UNASUR in this context was manifestation of a new model of development and a political platform to strategically place South America in a stronger and unified position to address health issues and promoting new rights in global governance, and creating opportunities for policy coordination for the access and enjoyment of those rights.
Contesting norms, brokering rights: Regional health diplomacy in UNASUR
UNASUR crystallised as a model of governance in 2008, yet its origins must be traced back to the beginning of the decade when Brazilian president Fernando Henrique Cardoso called in the first Summit of South American Presidents, in 2000. The aim was an ambitious integration project beyond notions of market expansion with renewed commitments on democratic principles and a broader sense of development. The creation of UNASUR was the result of a combination of national level statecraft and the reshaping of the regional political economy based on new commitments for social development principles, and rights together underpinning institution-building, and giving new impetus to ambitious projects focusing on inclusion and human rights. Its Constitutive Treaty established a broad acceptance of social policy as an important catalyst for new models of integration and the need to institute a Health Council to coordinate effective governance.Footnote 61 UNASUR official documents speak of a new morality of integration linked to a right-based approach to health as it is considered a transformative element for societies, a vehicle for inclusion and citizenship, and an active aspect in the process of South American integration.Footnote 62 Health from this perspective became a ‘locus for integration’ and a new framework to advance historically constituted claims of social and rights-based medicine, as well as innovative legal paradigms linking citizenship and health. Although these commitments materialised in the late 2000s, the seeds of these developments must be traced to Brazilian activism around HIV/AIDS, tobacco control, and the promotion of policies concerning the impact intellectual property rights on access to medicines.Footnote 63 Furthermore, rights claims in relation to HIV/AIDS treatment in Brazil were developed in a setting where the country was transiting from authoritarian rule to democracy. The repertoire of protest unfolded as a struggle for democratisation and social rights combined demands for political reform and the universalisation of social insurance, in a context of pubic campaigns against discrimination of AIDS patients.Footnote 64 These campaigns were advanced by an alliance between activists and health professionals, movimento pela reforma sanitária (movement for health reform or public health movement), known as sanitarista movement, which emerged in the 1980s across Latin America carving out a public space reclaiming rights to health as part of democratic rights. The sanitarista movement framed health reform as a ‘key demand of the popular sectors’.Footnote 65 The inclusion of representatives of the sanitarista movement in key posts in the Ministry of Health during the process of redemocratisation in Brazil, allowed the right to health to become a constitutional right in the Constitutional reform in 1988, which led in turn to the adoption of the universal public health system in Brazil. In this case, social activists and practitioners in the health sector acted upon the opportunities created by the imminent HIV risk and the context of democratisation in Brazil, linking, or ‘brokering’ in the language of McAdam et al.,Footnote 66 two ‘sites’ of contentious politics – HIV patients’ rights and demands for democracy – framing the claims for health under the slogan ‘Democracy is Health’, creating a ‘meta narrative’ that also shaped subsequent interpretations of the right to heath across the region.Footnote 67 In tandem, health as rights, as advocated by UNASUR, also grew from the notion of ‘wellbeing’ (buen vivir or sumak kawsay in the Quechua language) included, as a right, in new constitutions of Bolivia and Ecuador, two influential countries in the construction of UNASUR and its plan of action on health. It is not coincidence that UNASUR headquarters are based in Quito, Ecuador, while UNASUR's health think tank, the South American Institute for Health Governance (Instituto Sudamericano de Gobernanza en Salud, ISAGS) is in Rio de Janeiro, Brazil. The UNASUR Constitutive Treaty, signed in Brasilia in May 2008, explicitly declared human rights as a core value of integration, expressing the need to foster an integrative process in support of social inclusion and poverty eradication. Within this framework, it is also specifically declared the ‘right to health as the energetic force of the people in the process for South American integration’.Footnote 68 In short, the experience of previous regional formations such as MERCOSUR and the Andean Community in addressing regional health governance issues was determined by a political economic environment marked by financial dependency, austerity, and reduced social spending. In contrast, UNASUR embraced health in a different political and economic environment. As a consequence, health took centrality in regional politics not only to address sanitary problems of transborder relations but fundamentally to redress equity and wellbeing as a right to be sought in intraregional relations and in global governance diplomacy.
Institutionally, UNASUR set up a Health Council that works at the ministerial level to consolidate South American integration in the health field through policies and an agenda proposed by members in combination with thematic Technical Groups and thematic networks. In 2009, UNASUR Health Council approved a Five Year Plan (Plan Quinquenal) outlining actions towards the implementation of projects and regulatory frameworks, allocation of financial resources, and capacity building on five programmes:
(1) Coordination of surveillance, immunisation, and networks for prevention and control of noninfectious diseases and dengue fever;
(2) Creation of Universal Health Systems in South American countries;
(3) Generation and coordination of information for implementation and monitoring of health policies;
(4) Coordination of strategies to increase access to medicines and foster production and commercialisation of generic drugs, including harmonisation of medicines' surveillance and registries for members; coordinated policy for pricing of medicines for the purchase from, and external negotiations;
(5) Development of mechanisms for capacity building and human resources management directed at health practitioners and policymakers for the formulation, management, and negotiation of health policies at domestic and international levels.Footnote 69
Based on these areas, UNASUR engaged in a new type of diplomacy in a twofold strategy: (i) intraregional diplomacy, focusing on intraregional cooperation; and (ii) transversal or extraregional diplomacy seeking to redefine North/South divide in health negotiations and strategies. These forms of diplomacy are not mutually exclusive but rather reinforce the role of UNASUR in health governance. While horizontal diplomacy reflects the formation of a new consensus in the region about social inclusion and rights, framing new terms of cooperation and mobilisation of human and financial resources; extraregional diplomacy concerns interventions of UNASUR as a bloc in the WHO and World Health Assembly (WHA), and vis-à-vis international pharmaceuticals.
Intraregional diplomacy is led by Technical Groups, which are responsible for analysing, preparing and developing proposals, plans, and projects according to the Five Year Plan. The Technical Groups report to the South American Health Council and are directed by two member countries in charge of setting up and observing projects on the ground. In addition, networks of national health institutions and public health schools promote technical education, research, and exchange for the development of public health workforce across the region. Particularly relevant in this regard has been the Network of Public Health Schools, which aims to create educational infrastructure for health workers and decision-makers; and the Network of National Institutions of Cancer (RINC), which coordinates cooperation among national public institutions across UNASUR member countries to develop and/or implement cancer control policies and programmes and research in South America. Supporting these developments, the South American Institute of Health Governance is an innovative regional institution, under the umbrella of UNASUR, which provides policy-oriented and informative research, training and capacity building.Footnote 70 ISAGS capitalised on the international role of Brazil, which over the past decade has taken an increasingly protagonist position contesting global norms regarding access to medicines and right to health in various United Nations bodies and South-South cooperation.Footnote 71 This activism turned to the region and was articulated by a leading Brazilian research institution, the Oswaldo Cruz Foundation, which proposed, in the first instance, the creation of ISAGS to UNASUR health ministers. ISAGS philosophy is that health not simply an issue of public policy but also a problem of governance. From this perspective, it was proposed that a new institution helped improving the quality of policymaking and management within the Ministries of Health in UNASUR members through regional networking activities, policy training and capacity building.Footnote 72 For instance, echoing the Five Year Plan, ISAGS plays a key role as ‘knowledge broker’ gathering, assessing and disseminating data on health policies of countries; benchmarking health policy and targets; and establishing effective mechanisms of diffusion through seminars, workshops, capacity building, and special meetings in support of policy reform by demand of member states.Footnote 73 For instance, UNASUR's Technical Group on Human Resources Development and Management, in collaboration with ISAGS, have offered technical support and capacity building activities for the creation of new institutions such as Public Health Schools in Peru, Uruguay, Bolivia, and Guyana.Footnote 74
Similarly, as a ‘training hub’ ISAGS engages policymakers that fill in ministerial positions, negotiators that sit in the international fora, and practitioners that liaise with the general public, providing technical assistance and capacity building, strengthening skills and institutional capacity through a range of activities in support of professionalisation and leadership.Footnote 75 For instance, ISAGS supported Ministry of Health officials in Paraguay and Guyana for the implementation of national policies regarding primary attention and preparation of clinical protocols in these poor countries, and more recently echoing the challenges of creating universal health systems, ISAGS supported reforms towards the universalisation of the health sector in Colombia, Peru, and Bolivia.Footnote 76 The politico-institutional framework fostered by UNASUR is also manifested in its support of theme-specific networks of country-based institutions to implement projects on noncommunicable diseases, such as cancer and obesity; to combat the propagation of HIV/AIDS, and to undertake extensive vaccination programs against H1N1 influenza and Dengue Fever across the region, and addressing counter-cholera efforts in Haiti after the earthquake in 2010.Footnote 77 ISAGS also leads theme-specific networks of country-based institutions to implement projects on noncommunicable diseases, such as cancer and obesity, and to combat the propagation of HIV/AIDS, malaria, dengue, tuberculosis, chagas, and other serious communicable diseases through health surveillance, access to vaccinations and medicines.Footnote 78
More recently, UNASUR has been instrumental, as ‘industrial coordinator’, in the establishment of two projects to promote harmonisation of data for public health decision-making across the region: a ‘Map of Regional Capacities in Medicine Production’ approved by the Health Council in 2012, where ISAGS, is identifying existing industrial capacities in the region to coordinate common policies for production of medicines; and a ‘Bank of Medicine Prices’, a computerised data set revealing prices paid by UNASUR countries for drug purchases, and thus providing policymakers and health authorities a common background and information to strengthen the position of member states in purchases of medicines vis-à-vis pharmaceuticals. Based on this, joint negotiation strategies, as a purchase cartel, are also in place to enhance the leverage vis-à-vis pharmaceutical companies. UNASUR Health Council is also seeking new ways of coordinating industrial capacity for the production of generic medicines, potentially in coordination with the Defence Council. This was confirmed in a seminar organised by UNASUR and the Ministry of Defence in Argentina, in April 2013, where a proposal for the creation of a South American Program of Medicine Production in the field of Defence, was discussed.Footnote 79
These practices are not only oriented to generate conditions for better access to health and efficient use of public resources within the regional space but are also reaching outside the region through South-South cooperation and UNASUR leadership in health diplomacy. In terms of extraregional diplomacy, UNASUR is establishing as a legitimate and proactive actor advancing a new regional diplomacy to change policies regarding representation of developing countries in the executive boards of the WHO and its regional branch the Pan-American Health Organisation (PAHO). The leadership of Brazil in the region is undoubtedly critical for these developments as it has been instrumental in promoting an international presence of UNASUR, yet policy positions for international discussions concerning the impact intellectual property rights on access to medicines or the monopolist position of pharmaceutical companies on price setting and generics have been particularly driven by Ecuador and Argentina, echoing new regional motivations for redistribution and rights.Footnote 80 UNASUR also led successful discussions on the role of the WHO in combating counterfeit medical products in partnership with the International Medical Products Anti-Counterfeiting Taskforce (IMPACT), an agency led by Big Pharma and the International Criminal Police Organisation (Interpol) and funded by developed countries engaged in intellectual property rights enforcement. Controversies focused on the legitimacy of IMPACT and its actions seen as led by technical rather than sanitary interests, unfairly restricting the marketing of generic products in the developing world.Footnote 81 At the 63rd World Health Assembly in 2010, UNASUR proposed that an intergovernmental group replaced IMPACT to act on, and prevent, counterfeiting of medical products. This resolution was approved at the 65th World Health Assembly in May 2012. The first meeting of the intergovernmental group was held in Buenos Aires, Argentina, in November 2012. In the course of this meeting, UNASUR also lobbied for opening negotiations for a binding agreement on financial support and research enhancing opportunities in innovation and access to medicines to meet the needs of developing countries. More recently, led by Ecuador, UNASUR presented for discussion an action plan for greater recognition of rights of disabled people within the normative of the WHO, a normative that was successfully taken up in the WHA Assembly in May 2013.Footnote 82 Finally, UNASUR entered into capacity building partnerships with other regional organisations, such as the Pan-American Health Organisation, and is seeking recognition to act through regional, rather than national, delegates at the World Health Assembly, just as the EU negotiates as a bloc across a wide range of agenda items.Footnote 83
The presence of UNASUR in this type of health diplomacy, and its coordinated efforts to redefine rules of participation and representation in the governing of global and regional health, and production and access to medicine vis-à-vis international negotiations, are indicative of a new rationale in regional integration in Latin America based on international leadership and policymaking. These actions create new spaces for policy coordination and collective action where regional institutions become an opportunity for practitioners, academics, and policymakers to collaborate and network in support of better access to healthcare, services, and policymaking. For negotiators, UNASUR structures practices to enhance leverage in international negotiations for better access to medicines and research and development funding, as well as better representation of developing countries in international health governance. For advocacy actors, UNASUR represents a new normative platform for claiming and advancing the right to health within the region while at the same time attempting to establish itself as a broker between national needs and global norms, a political pathway that differs from the position held by Latin America in the past.
Regional activism and rights
The regional experience of UNASUR opens an unprecedented opportunity to evaluate and compare the ways and extent to which regional organisations address rights-based concerns affecting ordinary people. It was argued here that regional organisations should be seen as both a space redefining cooperation on social policies within a geographical space, as well as transborder practices reworking and contesting norms. In the first, place, the evidence in the preceding sections highlights the importance of political and economic contexts driving new forms of regional cooperation. The regional space facilitates new corridors of knowledge exchange, reallocating resources in support of not only claims making and advocacy of actors but also of better policymaking. Regional organisations, such as UNASUR, can enable the exchange and networking of actors and epistemic communities for addressing neglected issues and for research and development of medicines. Unlike previous regional integration experiences in Latin America where building fixed and effective social regional institutions remained a rhetorical aspiration, UNASUR Health facilitates opportunities for policy change through training and capacity building activities directed at the professionalisation of policymakers and international health negotiators, enhancing leadership for national policymaking. Likewise, it provides technical and policy support fostering approximation of laws conducive to similar legal provisions in primary health, and the universalisation of health systems. The article illustrates this interplay between regional institutions/regulations and implementation of health policies at the national level in Paraguay and Guyana where UNASUR's think tank was key supporting the implementation of national policies regarding primary attention and preparation of clinical protocols, as well as reforms towards the universalisation of health sector in Colombia, Peru, and Bolivia. The creation of new institutions such as Public Health Schools across UNASUR members is a manifestation of positive regional/national synergies in health.
Yet regionalism should also be seen as more than an instrumental mechanism aiming at the maximisation of regulatory capacity in different policy domains. Regional organisations can become sites for collective action and pivotal actors in contending (global) politics by means of providing an alternative normative framework and rescaling practices in support of rights-based and social development governance. Undoubtedly, the most innovative aspect of UNASUR is its global activism. Playing global politics under a unified umbrella, UNASUR means that representation of less powerful and resourced countries in the region enhance their visibility, voice, and claims-making capacity in global governance. UNASUR's regional logic is not reduced to an institutional expression of market liberalisation, as previous regional formations in South America anticipated, and many scholars claimed,Footnote 84 but to new symbolic and practical aspects of social rights. In other words, health, as a social component of the regional normative and institutional structure, downplays the excessive emphasis on trade in the study and practice of regionalism in the South, suggesting also that there are new opportunities for linking leadership and regional governance to advocacy and claims-making. As the previous section demonstrated, national governments and policy makers turned to UNASUR to set up new institutions; support new policies and policymaking; advocate access to health and medicines, rights of disabled people; broaden representation of developing countries in the institutions of global health governance; and contest the power of pharmaceuticals. Likewise, the relevance of UNASUR must be seen in the opportunities it opens to redefine the terms of engagement of developing countries in South America in relation to sensitive issues of rights and representation global health governance.
Based on this, it can be claimed that regional organisations can become sites for collective action and pivotal actors in the advocacy of rights (to health) enabling diplomatic and strategic options to member state and nonstate actors. At the same time, regional organisations can play a role as deal-broker in the international arena by engaging in new forms of regional diplomacy. This is not a minor issue given that international frameworks pushing for universal human rights in relation to social and economic development have significantly filtered the normative discourse of the UN System, yet international agencies have been quite conservative in turning the rhetoric into practice, acknowledging and affecting bearers of rights in different ways. In the case of UNASUR diplomacy, advancing goals of social justice entails acting as a corrective to the sidelining of rights on account of security concerns in international health politics.
The presence of regional organisations in public policymaking is an increasing subject of North-South and South-South development agendas, and an intriguing entry-point for research into the benefits of regional integration for public goods provision and combating the sources and effects of poverty. There is growing recognition that regional integration ambitions and initiatives extend beyond commercial trade and investment to embrace health and welfare policy, but little is known about whether and how regional organisations' commitments are being implemented in these domains or about the ways in which regional policy processes can be conducive to broadening rights (to health, but not only health) in national and international spheres. To repair this epistemic lacuna, this article investigated regional health policy and diplomacy by undertaking an analysis of UNASUR's regional health agenda and global ambitions. It was argued that regional organisations such as UNASUR can provide frameworks structuring practices and shaping, normatively and institutionally, national health regimes projecting, at the same time, goals through regional health diplomacy.
Empirically, the analysis of synergies between regionalism and welfare through health contributes to studies rooted in the field of comparative regionalism, substantiating the claim that ‘regions other than Europe are thinking of regionalism as a way of addressing the most pressing challenges that these societies faced’.Footnote 85 In the case of UNASUR, this is exemplified by the expansion of regional cooperation and strategies of regionalism, and the new impetus it gives to the goal of tackling poverty through its focus on regional health policy processes and institutions. Likewise, a focus on Southern regional institutions as sites of policymaking and as international actors adds geographical nuance to scholarly work on the foreign policy dynamics of regional formations that have, to date, largely focused on the European Union. In keeping with the rapid growth of global (health) governance literatures, the present analysis brings new evidence about how social relations of welfare are being (re)made over larger integrative scales and how regional actors may initiate new norms to improve health rights in international arenas engaging in new forms of ‘regional’ diplomacy beyond traditional spheres of trade, finance, and investment.
Theoretically, the message is that, in the light of the new modalities of mobilisation, diplomatic and strategic options, regional organisations and identities must be considered important keywords in advocacy and contention politics, as well as in the academic analysis of who acts, who frames and who contests global (health) policies. In many ways the argument developed here points to the need to investigate the relations of the regional level of analysis between the state and the globe, and the processes that connect regional and national politics within the regional space if we are adequately to analyse contemporary forms of power, activism, and cooperation on health and other social issue areas. Accepting that states pool rather than cede sovereignty to play out externally pressing shared dilemmas the analysis settles on three variables specific to regional structures: (i) regional normative frameworks structuring practices in support of rights-based governance; (ii) regional norms and practices creating opportunities for (re)allocation of material and nonmaterial resources and thus for inclusion; and (iii) regional formations as unified representative actors in global political space enabling representation and claims-making, contesting, and reworking global governance in support of global justice goals.
For scholars concerned with the study of regionalism, this framework encourages new forms to assess, normatively, the capacity of regional institutions to diffuse regulations, norms, and practices for more inclusive and responsive national and global regimes, moving away from mere assessments of regions and regionalism on the basis of material indicators such as free trade or levels institutionalisation (that is, hard institutionalism) through the presence of – often supranational – institutions. Similarly, for those concerned with International Relations and health, the analysis of the role and opportunities for meso-level institutions mediating transnational norms through new forms of diplomacy sheds new light on what so far has been a theoretical ‘blind spot’. The way IR looks at health has been mainly rooted in theorisations of health as threat, and health as a matter of international cooperation. These approaches generated different conclusions about what (global) health entails, shaping the main ways in which health has featured in International Relations; namely, as realpolitik responses by states to transborder disease risks, and as collective humanitarian commitments and modalities of intervention by multilateral institutions and nongovernmental actors to reduce inequalities within and across societies.Footnote 86 It is only with the emergence of the alternative theorisation provided by new normative right-based approaches emphasising the right to health that the topic has acquired its contemporary salience. The last two decades have seen rapid advances in political economy and right-based approaches denouncing health inequities between different populations, within and between countries, and fostering debates about social determinant of health.Footnote 87 However, this rights-oriented scholarship has largely remained focused on the role of states and nonstate institutions in the making and shaping of global health politics, disregarding other formations such as regional organisations. This has been the consequence of theoretical idiosyncrasies rather than a problem of irrelevance of regional organisations affecting opportunities for social development and rights. Addressing these limitations, this study casts new light on the synergies between regionalism and social development, and between modalities of regional activism, health diplomacy, and rights, suggesting that regional organisations can provide opportunities and incentives for individuals or groups to undertake collective action in support of rights-based governance, and engage as ‘regional actors’ in support of rights-based global governance.
The present study should be taken as a starting point of this broader research agenda; it claims only to have established a prima facie case for the importance of this area of enquiry. It is, of course, the case that future difficulties faced by regional groupings in the South may affect the political and social foundations of regional activism, in health and other social areas. Latin America in particular has a long history of truncated regional aspirations. Nevertheless, the advancements in regional health, as an area of diplomacy in South America, not only marks an important difference, in symbolic, practical and institutional terms, in relation to experiments of the past, but also illustrates how policymaking can be made over larger policy scales. In this respect, the argument advanced here establishes at least the value of devoting more attention to the linkages between regionalism and poverty reduction through effective, context-specific, policy interventions, as well as for further analysis of the role regional organisations play as actors in global (health) politics.