The BRICS countries: a new force in global health?
Diverse in profile, but unified in purpose. Andrew Harmer tells Fiona Fleck why the BRICS countries’ approach to health is different.
Andrew Harmer is one of the first researchers to study the role of the BRICS countries in health – both in their own countries and globally. He is a lecturer in global health policy at the University of Edinburgh, Scotland, and the programme director of the Global Public Health Unit’s post-graduate certificate Global Health Policy by distance learning. He received a PhD in International Relations in 2006 from the University of Southampton, and since then has specialized in the study of global health partnerships, health systems strengthening in low and low-middle income countries, the role of emerging economies in global health, and the health effects of climate change. Harmer is also an Honorary Research Fellow in the Department of Global Health & Development of the London School of Hygiene & Tropical Medicine.
Bulletin of the World Health Organization 2014;92:394-395. doi: http://dx.doi.org/10.2471/BLT.14.030614
Q: The term “BRIC” was coined by a Goldman Sachs analyst for four big emerging economies, Brazil, the Russian Federation, India and China, in 2001. Why has the group – with South Africa added in 2010 – embraced the term?
A: Goldman Sachs was not the only one to realize that these four economies were way ahead of the others, but they didn’t meet as a group until 2006 and only held their first formal summit in 2009 in the Russian Federation to discuss the global economy and reform of global financial institutions, their primary concerns. Academics started looking at these countries as a group from early on, so in some ways there may be a sense of self-fulfilling prophecy in their formation. They now meet regularly and, although they have never actually signed a document saying “we are the BRICS”, they seem quite happy with the term.
Q: When did the BRICS countries start discussing health?
A: Health appears for the first time as a discussion point in the Sanya Declaration at the 3rd BRICS Summit in 2011 in China, with regard to HIV/AIDS. Since then the group has held annual meetings devoted to health, with the first meeting of the BRICS health ministers hosted by the Chinese in Beijing in July that year. In 2012, the BRICS health ministers also decided to meet every year on the side-lines of the World Health Assembly.
Q: How did you become interested in researching this area?
A: The BRICS countries were being discussed, but there was very little published on their role in health. It was an obvious area to explore. What interested me most was the extent to which they were acting as a unified bloc: looking at what they were doing, compared with the rhetoric, was fascinating. It’s fascinating to see a new centre of power emerging in global health with a new set of priorities that contrast with the dominant western health development paradigm. This is seen in their efforts to promote multilateralism in health, in contrast to the United States, for example, that is keen to pursue bilateral relations. In 2012, the BRICS countries announced they would create a new development bank with a start-up capital of US$ 50 billion, eventually increasing to US$ 100 billion, and a BRICS Contingency Reserve Arrangement, which would be a US$ 100 billion fund to steady currency markets. These two projects are expected to be finalized at their next summit in Brazil in July this year.
Q: On which health areas do these five countries work together most?
A: They have committed themselves to promoting certain health issues above others. In some ways their priorities are different to the priorities of the Organisation of Economic Co-operation and Development (OECD) countries. At their first meeting of health ministers, they discussed four priorities: strengthening their domestic health systems, primarily by developing and ensuring access to health technologies, the double burden of infectious and noncommunicable diseases, support for international organizations, such as WHO and UNAIDS as well as global health partnerships, and promoting technology transfer to developing countries. There is a lot of interest in intra-BRICS health cooperation. The health ministers referred to this last year at the 3rd health ministers’ meeting in Cape Town. Soon, we may have a new development bank doing development differently to the World Bank. Other than that and supporting international organizations and health partnerships, there are few tangible examples of the BRICS countries working together on health.
Q: How are the BRICS countries facing up to the problem of NCDs?
A: With the exception of South Africa, NCDs are the biggest problem facing these countries and the incidence of NCDs is increasing, even as infectious diseases are being brought under control. The Russian Federation has one of the world’s highest rates of cardiovascular disease. China and India have two of the highest diabetes burdens. The Chinese Health Minister Chen Zhu recently went so far as to call NCDs “the number one threat”. NCDs have been a priority at every BRICS health ministers’ meeting and you can see what these countries have been doing. Brazil was very influential in the Framework Convention on Tobacco Control negotiations and is now the world’s largest smoke-free country, given its tough legislation on smoking in public places. The Russian Federation hosted the first international NCDs conference in 2011 and committed US$ 36 million to the global NCD response. India issued its first compulsory licence for cancer drug imatinib (Glivec) in 2012, sharply reducing the price, which was not an easy thing to do given the pressure. Meanwhile, China is investing US$ 1.3 billion in drug research and development, infectious disease control and prevention. In addition, both India and Brazil are leading manufacturers of generic medicines. India’s generics industry has supplied about 80% of all donor-funded therapies in the developing world. About 60–80% of all United Nations-procured vaccines come from India. The BRICS countries see technology transfer as a way of empowering developing countries keen to produce generic medicines.
Q: To what extent have the BRICS countries attained universal health coverage (UHC)?
A: Whether UHC has been achieved depends on how you define it. China recently revised its understanding of UHC to mean coverage of health services and since 2009, started a series of reforms to achieve this by 2010. Brazil has extended health-care coverage particularly to the poor and reached 100 million people through its tax-financed Unified Health System, as well as its conditional cash transfer programme, the Bolsa Familia, and its flagship Family Health Strategy, but while access to services may be universal, the quality is uneven. Russians face uneven access to drugs and care – the best services are nearly always found in the cities. The BRICS countries are no different to most other developing countries in this regard. Russian health-care – particularly access to prescription medicines – is apparently a top priority for the president, who has committed substantial funding to this and to improving the quality of health services. India has a national health insurance programme that has helped to expand coverage to more than 140 million people since its launch in 2008. Some quite innovative technology underpins its success, such as individual smartcards that allow immediate enrolment. Quite a few other countries have started to adopt this innovation. Still, India’s health system is fragmented – with a myriad of private providers and a weak system of quality control. The health sector is not well funded and out-of-pocket spending is high. For UHC watchers in South Africa, all eyes are on the government’s universal health financing system, the National Health Insurance programme, which is being rolled out over the next few years. Its antiretroviral therapy scheme is something of a success story, with more than two million people accessing treatment.
Q: What other important health areas are there for these countries?
A: One important area, when you talk about the influence of BRICS on global health, is their contribution to the climate change debate. The Russian Federation, China and India own three of the largest carbon reserves: a quarter of the global total 823 gigatons of carbon, and, in addition, China also has plans to build some 70 new airports. At the same time China is investing heavily in clean energy. In 2012, it invested US$ 65 billion – a third of the entire G20 investment. Four of the BRICS countries established a coordinating group (without the Russian Federation), called BASIC, to represent their unified position on climate change. How China and the others manage climate change will be very important for health.
Q: Are there any BRICS’ successes in health as a group?
A: The broad success, so far, is that these countries have come together to talk about global health and present a new agenda, which is different from the traditional western global health agenda. We have yet to see whether they launch a development bank. It must be immensely empowering for poorer countries to see these countries as role models – reshaping the global health agenda and global health architecture.
Q: Why are these countries sometimes described as “non-traditional donors”?
A: “Non-traditional” because they don’t always accept the language and ethos of traditional OECD development. They talk about “development assistance” or “cooperation” – not “aid’. They don’t describe themselves as “donors” or “recipients of aid”, but see themselves as “partners” with other countries and are interested in what is known as “south–south cooperation”, that is, between low- and middle-income countries. In some ways this has its history in the non-aligned movement that started at the Bandung conference in Indonesia in the 1950s; there has been a long tradition with countries not aligned with superpowers keen to do things differently and independently. The BRICS countries are non-traditional in the development models they promote, to an extent. But, as with traditional donors, you can also find examples of tied aid.
Q: What impact have BRICS had in their development policies and activities to date, and in which countries?
A: In all five countries there are insufficient data on the level of support for development projects, so their impact is difficult to gauge. China has a development department within the Ministry of Commerce, while South Africa and India are still developing their agencies. The Russian Federation and Brazil provide assistance through dedicated development agencies, Brazil has done so since the late 1980s and there are examples, such as Brazil’s financial and technical assistance in building a factory in Mozambique to produce antiretroviral medicines for that country. The Russian Federation provides development assistance to health projects by supporting global health initiatives and partnerships such as the Global Fund to fight AIDS, Tuberculosis and Malaria. China is keen on mutually beneficial development projects and capacity building, as well as sending medical teams abroad to help with medical assistance following disasters, such as the 2004 tsunami. India quadrupled its foreign assistance over the last decade, setting aside US$ 1.3 billion for 2013–14. Most of this goes to its neighbours, but one example of India’s assistance to Africa is the US$ 125 million Pan-African e-Network: Africa’s largest tele-education and tele-medicine initiative which connects African countries with top schools and hospitals in India through satellite and fibre-optic links. South Africa is an interesting case. In terms of global influence its civil society organizations have contributed significantly, such as the Treatment Action Campaign that fought “big Pharma” in the early 2000s for access to antiretrovirals.
Q: How do you see the future role of the BRICS countries in global health?
A: Coalitions don't always stand the test of time. Given the challenge of climate change, the BRICS countries’ energy may shift towards BASIC priorities. If the group endures, it is likely to promote a global health development discourse informed by its members’ experience of cooperation based on partnership and equity. We’ll see next month at the BRICS Summit in Brazil to what extent these principles and values are put in practice.