South-South cooperation and the re-politicization of development in health
Introduction
Emerging states’ engagement with South-South cooperation (SSC) for development in the 2000s and beyond has been largely legitimized by a politicized discourse. While the Northern development apparatus was accused of rendering development technical and economistic, translating the political roots of poverty into technical problems whose solutions only the expert agencies from the North could offer (Ferguson, 1994), new development providers such as Brazil, India and China have tried to expose, at least rhetorically, the unequal relationships between the North and the South that have long contributed to the latter’s ‘underdevelopment’. South-South cooperation principles of ‘horizontality’, ‘solidarity’, ‘self-reliance’ and ‘sovereignty’ were constructed in opposition to the verticality, self-interest and dependence promoted by foreign aid.
But if on the one hand the official discourse on SSC has re-politicized development by exposing power asymmetries that are at the very root of the problem of development, on the other hand several studies have shown how this same discourse can de-politicize development, particularly when it hides different local realities and uneven power relations by presenting “a natural congruity between very different southern states” (McEwan & Mawdsley, 2012, p. 1887). Although applied by emerging countries such as India and China, this [false] congruity has been most prominently constitutive of Brazil’s ‘culturalist discourse’, according to which Brazil and Africa are united by a common culture, biology, and historical heritage (Saraiva, 1993, Saraiva, 1995), especially in relation to Lusophone Africa. Several studies have shown how Brazilian agricultural expansion in Africa, more particularly in Mozambique1, was largely based not only on the culturalist discourse, but also on claims of similarity of context, climate, and even landscape (Funada-Classen, 2013, Abdenur, 2015, Shankland and Gonçalves, 2016). Such is the case of Brazil’s flagship large-scale agricultural cooperation project, the ProSavannah, which was initially inspired by Brazil’s transformation of its cerrado into a global producer of agricultural commodities. By claiming similarities between Brazil’s ‘vast unused and unproductive lands’ of the cerrado and Mozambique’s savannah, Prosavannah proponents were accused of ignoring Mozambique’s indigenous populations and their relationship with land (Funada-Classen, 2013) in order to advance a neoliberal model of development based on private gains and social losses (Nogueira et al., 2017, Nogueira and Ollinaho, 2013). Perhaps most notoriously the ProSavannah was accused of promoting an agricultural model based on a supposedly conflict-free relationship between peasants (or smallholders) and agribusiness as if they could coexist harmoniously (Cabral et al., 2013). It was alleged that Brazil was exporting its internal contradictions (Mello, 2013, Cabral, 2015) characterized by “opposing political forces and contradictory agricultural policy agendas [of agribusiness and family-farming]” (Zanella and Milhorance, 2016, p. 73). With more or less nuanced views, these studies have contributed to understanding how power relations are played – and masked – through discourse. Overall, their conclusions help problematize and challenge Brazil’s SSC official narrative of horizontality, similarity and solidarity and the category of the ‘South’ as a homogeneous group of countries.
This article focuses on a question that has been largely neglected: whether and how Brazilian SSC can in fact re-politicize development, by investigating Brazil’s flagship project in health cooperation: the project for the implementation of an antiretroviral (ARV) factory in Mozambique, the Sociedade Moçambicana de Medicamentos (Mozambican Pharmaceutical Ltd. – henceforth SMM). Together with the ProSavannah, the SMM was Brazil’s longest and most expensive programme, and received a lot of (negative and positive) attention worldwide2 particularly as it triggered a conflict between the governments of Brazil (henceforth GoB) and Mozambique (GoM) over the principles that should shape the SMM. As such, these projects have a higher degree of symbolic power as they can define more effectively than other projects what SSC is.
However, little has been written about the politics and discursive dynamics that have shaped the implementation of the SMM3. Esteves and Assunção (2017) argued that also in the case of the SMM the use of SSC principles such as ‘horizontality’ concealed structural differences and power asymmetries between partners. I argue that while this is true, it is precisely this same SSC language that represented the discursive limits of the conflict that unfolded between Mozambique and Brazil, promoting, to some extent, the re-politicization of the project. Based on a post-structuralist approach, I propose an ontological definition of ‘re-politicization’ which is linked to (some degree of) transformative political action that challenges Northern hegemonic norms of development. While Ferguson’s study is still useful to think about de-politicization (and re-politicization) as the masking (and unmasking) of power relations, the definition proposed here allows me to see change and political transformation as the ultimate goal of re-politicization.
Signed in 2003, the SMM’s initial objectives were to expand the population’s access to ARV medicine4 and other essential medications, and to build local capacity and production of generic pharmaceuticals in Mozambique thus reducing the country’s dependence on imports and donations (Russo & Banda, 2015). Importantly, the SMM was conceived by Brazil’s main public health institution, the Oswaldo Cruz Foundation (Fiocruz),5 as an expression of a ‘structuring cooperation’ project, a concept elaborated by Fiocruz which meant to promote capacity building and organizational strengthening based on a development agenda that would encourage local autonomy as opposed to the verticality promoted by Northern aid (Almeida et al., 2010). Structuring cooperation meant to strengthen public health systems rather than target specific diseases (Ferreira & Fonseca, 2017). Within this logic, the role of the state would be central to the implementation and development of the SMM. As initially agreed by both governments, the SMM should be the materialization of SSC principles of self-reliance and sovereignty.
However, shaped by decades of foreign aid, Mozambique’s health sector and ARV treatment (ART) more specifically had been mostly informed by the logics of Northern aid. These were characterized by a results-oriented approach according to which international non-governmental organizations (INGOs) would implement projects in line with donor-identified objectives rather than the state’s goals and health agenda. An approach to health in the form of international vertical funds that targeted specific diseases became a common practice, consequently contributing to the weakening of state institutions. Furthermore, with structural adjustment policies promoted by the World Bank in the 1980s, neoliberal principles of privatization were part of Mozambique’s restructuring of state institutions and experience of development. It is within this context of opposing discursive structures that the implementation of the SMM unfolded.
A discursive approach allows me to see these discursive structures such as norms of foreign aid or structuring cooperation not only as describing an underlying reality in these countries but also as resources that actors mobilize in order to construct policies and reinforce certain development practices. It is these discourses that the GoB and GoM mobilize to shape the SMM according to their view. If in the first stage of the project the SMM was framed as part of a Southern alliance based on a horizontal partnership, in the second stage it became the object of a political dispute. The two governments disagreed over fundamental principles and norms that should shape the SMM, with the GoM drawing on Northern principles such as ‘privatization’, while Fiocruz and Brazil’s Ministry of Health (henceforth MoH) promoted ‘state ownership’ based on the logics of structuring cooperation. In the third stage of the implementation, SSC principles of horizontality and sovereignty were mobilized to break down the antagonistic frontier between the two governments. This was fundamental in the construction of a compromise over the fate of the SMM. Rather than 100% state owned, a common decision was reached whereby 35% of the SMM’s shares were supposed to be listed in the country’s stock exchange – thus acknowledging Mozambique’s agency and sovereignty – while preserving majority state ownership in line with a structuring cooperation project.
This article first exposes structural asymmetries between Brazil and Mozambique in the health sector as a result of different historical trajectories of development. In doing so it contributes to the literature that questions and problematizes the South as a homogeneous group of countries and SSC as a narrative that claims affinity between so-called Southern countries (Mawdsley, 2012, Cabral et al., 2016, Shankland and Gonçalves, 2016, Cabral, 2019). If SSC principles such as ‘horizontality’ first concealed these asymmetries, the same language was later mobilized to acknowledge Mozambique’s context and to effect some degree of structural transformation in Mozambique’s health sector. What my analysis illustrates is that development principles or norms are not universal – a criticism long addressed at foreign aid – as they unfold differently in different contexts, nor do they have a single effect. The transformative potential development projects may have will depend not only on how they are initially framed, but also on the political and discursive interactions that unfold between stakeholders as a result of different views and underlying realities. This has broader implications for international development, particularly SSC projects that aim to promote structural transformation: applied to highly divergent contexts, SSC initiatives would have to rely on – and be shaped by – an intensive discursive labour where negotiation and accommodation take place.
Section snippets
The logics of critical explanation
The case of the SMM is not a story of a SSC project whose implementation was smooth, much like the official discourse of horizontality and similarity would make us believe. It is a story of conflict, contestation and adaptability of an enterprise that had been inspired by policies that emerged in a context and travelled to a completely different socio-political context. This calls for an approach that helps to characterize through a conceptual framework these different contexts (through the
The Social Logics of the Health Sector and ART in Mozambique
Mozambique and its health sector have been highly shaped by foreign donors and international agencies. With the end of a 15-year devastating civil war between the socialist government of Frelimo (Mozambique Liberation Front) and the rebel group Renamo (Mozambican National Resistance) in 1992, a liberal post-war programme of state building under the watch of European donors and international financial institutions (IFIs) intensified Mozambique’s political and economic liberalization (Sabaratnam,
The Social Logics of Healthcare and ART in Brazil
The decision by Lula da Silva’s government to implement an ARV drugs factory in Mozambique was inspired by the successful policies and initiatives of Brazil’s AIDS programme since the 1990s. Brazil’s response to HIV-AIDS was firmly rooted in the norms that shaped the new health system institutionalized in the 1988 Constitution, marking the re-democratization of Brazil. The main actor responsible for Brazil’s health reform was the ‘Sanitarist Movement’,12 a
The initial stage: a fragile political alignment
The idea of transferring technology from Brazil for the domestic production of ARV drugs in Mozambique can be traced back to the III Conference of Heads of State and Government of the CPLP (Community of Portuguese Language Countries) in Maputo in July 2000 (MRE, 2000). But it was only in 2003, after president Lula’s visit to Mozambique, that the ARV project started to materialize through a memorandum of understanding (MoU) between the two countries.
From the beginning, the MoU stated its general
Conclusion
The SMM had been originally articulated as part of a logic of structuring cooperation. Inspired by the Brazilian experience of healthcare and particularly of domestic drug production under the state, the SMM did not sit easily within the Mozambican context, highly shaped by the logics of foreign aid. I explored the political dynamics that shaped the implementation of the project, in an attempt to understand whether it has effected some degree of structural transformation. I argued that despite
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgement
This work was conducted under the Capes, Brazilian Ministry of Education, doctorate scholarship. I would like to acknowledge the valuable feedback received by Professor Francisco Panizza, from the London School of Economics (LSE).
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