The Health Ministers of the BRICS countries are convening in Brasil this week (5 December) for their fourth meeting – with BRICS cooperation on the Ebola crisis high on the agenda. These Ministers will no doubt be buoyed by the International Monetary Fund’s recent assessment of the world economy, an assessment that puts the collective economic strength of the BRICs and three MINT economies – Mexico, Indonesia and Turkey – ahead of the G7. This will also be welcome news to some prominent global health commentators who, earlier this year, drew attention to what they perceived to be US “hegemony” in global health, and called for that hegemonic dominance to be “challenged”. If justification for such a ‘call to arms’ were required, one need look no further than the Oslo Commission on Global Governance for Health. The Commission’s lead article has had its fair share of criticism (as reported in previous issues of this Newsletter), but its authors were surely right to assert that “power asymmetry” limits choice and constrains action on health inequity, requiring “vigilance across all policy arenas”.
On the face of it, US domination of global health – defined in terms of material contributions, institutional influence, but also authorship of the defining ideas shaping policy – would appear self-evident: The US provides the lion’s share of development assistance for health (DAH) – the US treasury and the Bill and Melinda Gates Foundation account for over 42% alone; the US exercises significant leadership over the key institutions which drive global public health spending (the IMF, World Bank, Global Fund, GAVI Alliance, etc); and, to take one ideational driver of global health – the Washington Consensus – US-led neoliberalism has had a profound impact on the development of health systems worldwide (see the forthcoming Global Health Watch 4 for further insight into the precise details of that impact).
But pace critics. Despite US largesse, DAH must be seen in relation to out-of-pocket spending and domestic resources invested in health. Total spending on health was estimated at USD 6.5 trillion in 2010. By this metric, US DAH of around USD15 billion, while important, is relatively modest and cannot justify the claim to US dominance of global health (even in Africa, donors only meet 11% of health expenditure). Yet discussion of leadership should not boil down to how much each stakeholder puts in the pot; it concerns the fundamental principle of equitable representation and participation as well as principles of shared responsibility and global solidarity.
Where might the challenge come from? In his Offline Comment, Editor of the Lancet Richard Horton champions France as a country that makes a sizeable contribution yet “sits on the margins of global health leadership.” The G8 summit, which France co-founded in 1975 and hosted in 2011, stopped seriously addressing global health after 2010 and the G20, which France co-founded in 2008 and hosted in 2011, never took up health in a serious way (although Ebola might be re-orienting this grouping’s perspective). Whilst not wishing to understate France’s commitment, French leadership would do little to redress the “power asymmetry” identified by the Oslo Commission. The Foreign Policy and Global Health initiative has been welcome by many as an important initiative – yet its informality and ad hoc engagement limits its influence. And what about the African Union? It has been active in health over the past decade with a series of ambitions commitments and roadmaps – and thereby makes an important regional contribution to global health governance.
Yet, in the midst of the transformative shift from MDGs to SDGs, we see evidence of a more discrete challenge to US hegemony, quietly, in the wings, by a group of emerging economies known collectively as the BRICS (Brazil, Russia, India, China, South Africa). Whether as a distinct bloc or as a collection of loosely aligned countries, the BRICS may be on the cusp of a silent revolution in global health.
While pundits have noted increasing DAH from the BRICS, it remains limited. Of greater significance is the potential of the BRICS to exert influence as a political bloc by leveraging their material contributions, engaging in or establishing rival institutions, and articulating fresh ideas about the underlying ethos and praxis of global health.
While some have been skeptical of the BRICS’ potential to evolve into a coherent political unit, its plurilateral summitry around global health, which commenced in 2009 and was further institutionalized by the BRICS health ministers’ forum meetings, represents a noteworthy evolution in the landscape of global health governance. BRICS have made and met specific health and health-related commitments: since 2010 its members have complied completely with their commitments on health and on the health-related Millennium Development Goals (MDGs), whereas the G8’s health compliance has averaged only 57% and the G20’s compliance with its development commitments (which embrace health) since 2008 has been only 68%.
Moreover the BRICS are setting out an embryonic counter-hegemonic agenda in three areas as articulated in their health ministerial forum communiqués. First, while they acknowledge the importance of the health-related MDGs, they place far greater emphasis on non-communicable diseases. Second, they voice strong support for progressive Intellectual Property regimes (e.g., TRIPS flexibilities). Third, they prioritize a discourse on south-south cooperation, including in relation to strengthening domestic pharmaceutical manufacturing in Africa, which is often lacking elsewhere.
Seen through the prism of International Relations, some have queried whether the ‘new world order’ that the BRICS are allegedly championing is not so new after all: focusing on the BRICS offers a narrow, state-centric, perspective at a time when powerful non-state actors, notably those within the financial sector, are becoming increasingly influential; at a population level, inequalities within the individual BRICS are beginning to mirror a familiar trend amongst so-called ‘developed’ countries; and while some of the BRICS are investing significantly in environmental mitigation policy, the bloc’s carbon output continues unabated. For these commentators, it is more plus ca change, plus la meme chose.
Whilst recognizing the importance of such criticism, we also see some evidence of the BRICS aligning their interests and assets to amplify their voice in global health. Yet the extent to which their commitments will be effective in improving global health will depend on the bloc making greater use of institutions and further deploying its material capabilities in a way that is sustainable and equitable – no small challenge. Moreover, while it is encouraging to see BRICS reinforce global health governance, it is not a substitute for the further democratization of global health leadership.
Kent Buse, PhD*
Chief, UNAIDS – the author’s views don’t necessarily reflect those of UNAIDS.
University of Edinburgh
* Corresponding author