Regional Integration and Welfare: Framing and Advocating Pro-Poor Norms through Southern Regionalisms

ABSTRACT

Regional organisations are moving away from traditional market-based goals to embrace issues of welfare, yet the role they play in social policy formation, and their contribution to the embedding of alternative approaches to development, is poorly understood. This article explores whether and how the Union of South American Nations (UNASUR) and the Southern African Development Community (SADC) advance pro-poor norms and policies in national and global governance. Whilst not coherent citizenship-centred projects of regionalism, SADC and UNASUR have developed institutional competences to address the health–poverty nexus, though their policy development practices and methods take quite different forms. Theoretically, the paper develops a framework addressing three key claims: (i) poverty and welfare need to be brought in to the study of regional governance; (ii) the agency of Southern regional organisations in the generation and diffusion of norms needs to be taken more seriously in the literature and in practice; and (iii) context matters for whether and how regional organisations provide normative leadership; act as brokers in a (re)distributive way; or as advocacy actors in a political way, enabling claims at different levels of governance.

KEYWORDS:

• Regionalism
• poverty reduction
• regional health diplomacy
• normative framing
• UNASUR
• SADC

Introduction

The last fifteen years have witnessed changing dynamics within the global political economy of international integration and development as a consequence of the emergence of Southern regional and inter-regional groupings and alliances. Although not without tensions, complexities, and fractures, the ambitions and initiatives of Southern regional organisations are expanding in ways that invite a closer examination of regional governance. Specifically, since the late 1990s, regional organisations in South America and Southern Africa have widened their mandates to incorporate elements of social policies embracing new agendas and developing plans of action to achieve social goals, including mandates on poverty reduction. Despite the growing research field of regionalism, expectations of what regional governance can deliver have been evaluated primarily in terms of economic and security governance, whilst a discussion of the significance of other policy areas in the process of region-building and regional governance has lagged behind.

The article takes up this topic by examining the Southern African Development Community (SADC) and the Union of South American Nations (UNASUR) as examples of regional organisations that, for normative and political reasons, have increasingly included new pro-poor commitments into their normative frameworks, forms of cooperation, and governance structure. Within these commitments, both SADC and UNASUR have made great strides in setting frameworks recognising health as an important dimension of social development and poverty reduction, seeking opportunities to diffuse and embed pro-poor health policies at different scales of governance. A key question that emerges in this context is: what are the possibilities for Southern regional organisations to provide leadership and direction in support of pro-poor norms and practices of regional and global governance? This links to a second topic of analytical interest; that is, the agency of Southern regional organisations in the generation and diffusion of norms supporting poverty-reduction strategies. SADC and UNASUR have emerged as significant sites for the creation, production and diffusion of norms addressing the poverty–health relationship. However, their ambitions, strategies, and successes in the framing and advocacy of rules and actions in national and global policy-making differ.

From this perspective, it is argued that the context in which regional organisations unfold, as well as their normative, institutional, and financial resources support different modalities of, and opportunities for, embedding (pro-poor) approaches to social development into national and international strategies. To account for these differences, we look at strategies by which this embedding might take place; namely (i) by creating normative frameworks in support of pro-poor practices; (ii) by facilitating the re-allocation of material and knowledge resources in support of policy formulation and implementation; and (iii) by mobilising (norms within and outside) the region. These roles are significant because they direct the attention to whether, how and to what effect, regional organisations act as a forum providing a normative vector and harmonised policy frameworks; as brokers in a (re)distributive way; or as advocacy actors in a political way, enabling action and contestatory strategies in the global arena.

Analytically, this study aims to bridge the continuing gulf between research in regional integration and global governance, which pays little attention to the ‘low’ politics of poverty and welfare, and research in social policy and health, which neglects regional governance. Theoretically, the article seeks to unveil what Acharya and Buzan (2007) recognised as ‘hidden’ dynamics in the thinking and practice of international relations (IR) by opening up to debate the normative purposes and functionality of regional organisations in regional and global political economy. The assumption of the South being neglected and hidden is not surprising since often what is visible and urgent, what shapes ideas in global governance and beliefs about international behaviour, and ultimately what is a matter of high politics, has often been associated with dominance of Northern-based states and non-governmental organisations. While this assumption holds on many counts, it also deserves a closer examination. We propose here that Southern regional organisations may play a role in supporting pro-poor approaches and advancing pro-poor programmes. Yet whether and how they do so could be better understood.

To unfold the argument, the analysis proceeds in four parts. The first part evaluates how the links between regionalism and social welfare have been addressed in the fields of regional and international studies, and social policy. It is argued that an over-emphasis on trade and financial arrangements mainstreamed analysis of regional impact on poverty reduction as a by-product of economic growth. Similarly, approaches to regional social policy are still highly normative and strongly Eurocentric. More needs to be scrutinised about the significance of regional organisations’ ambitions and initiatives for welfare systems, citizenship rights, and global governance. The second part develops a framework to analyse ambitions and modalities of advancing pro-poor norms in SADC and UNASUR and opportunities to embed pro-poor norms in the practice of (national and global) governance. The article closes with a reflection on the significance, in both practice and study, of Southern regional organisations re-enacting norms and practices regarding social welfare and poverty reduction.

Poverty of regional studies

Multilateral regional organisations are of substantial and growing significance in the processes of international integration and international development cooperation. Regional policy cooperation is extending beyond the regionalisation of labour and commercial markets to address opportunities to strengthen actions on poverty reduction and equity (Yeates 2014a). One should not assume that this is new. There is a wealth of literature attesting the distinct question of ‘is regionalism good or bad for world welfare?’ that could be traced back to the early assessments of European integration (for instance, Viner 1950, Baldwin 2008). However, this literature has considered both welfare and regionalism in an economic rather than a social policy sense (e.g. state interventions), where poverty reduction was simply an unstated knock-on effect of economic efficiency and trade-led growth. In the developing world, notions of ‘developmental regionalism’ espoused claims of regional integration as a development tool, and often as a tool of industrial policy (see Sloan 1971, Asante 1997, also Hettne 2001, Dent 2008). Although this literature opened a stimulating debate about regional integration and the effects of increased economic output on development, it was not until recently that research on poverty was explored more systematically. Schiff and Winters (2003) and te Velde et al. (2006) looked at poverty reduction through economic and market generation, recognising the effects of regional integration on intra-regional trade and investment on employment. Much in line with these arguments, Tekere (2012) published a compelling edited volume, Regional Trade Integration, Economic Growth and Poverty Reduction in Southern Africa, in which contributors explore the effectiveness of regional organisations in the delivery of poverty-reduction strategies. But these arguments have not gone any further. Strictly speaking, the expectation has been that regional integration facilitates trade in goods and services, and movement of people and capital, as pathways to growth and poverty reduction through effects on prices, jobs, investment, and economic output. Left unexplored is whether and how poverty-reduction agendas are being advanced in practice through regional cooperation, as well as the scope and depth of cooperation for leveraging regional approaches in dimensions important for human development, such as health, education, and the environment.

In the field of social policy, normative arguments have been offered and calls for a stronger social policy focus in the analysis of transnational cooperation in the Global North and South alike are now well established (Threlfall 2003, Deacon et al. 2006, 2010, Yeates 2014a, 2014b). These arguments have revolved around effective ways of securing cross-border coordination and implementing specific projects (e.g. cross-border employment projects, disaster mitigation funds, vaccination campaigns, food programmes) within and beyond the EU. In the case of the EU, some issues related to regulatory frameworks for harmonisation of migration and health policies, services and potentially rights in the social fields have also been explored (Threlfall 2003, Deacon et al. 2010, Yeates 2014a, Hoffman and Bianculli 2016). Outside the EU, coordinating initiatives in regional spaces have been addressed as a means for breaking with traditional models of unilateral transfer of ‘ready-made packages’ conveyed in global development aid (Buss and do Carmo Leal 2009). Despite these conceptualisations, there is little actual empirical research on regional social policy outside the EU context; specifically, on how regional organisations address social needs and advance policies to promote social development. Not enough is yet known about the significance of regional organisations’ ambitions and initiatives addressing social development, welfare and rights; and we do not yet know enough about how regional groupings operate in practice within (and beyond) their territories in support of those ambitions and goals.

This is not academic neglect but rather the result of how regional integration, particularly in the South, has evolved: essentially, in response to economic and security dilemmas (Buzan 2003, Acharya and Johnston 2007, Mansfield and Solingen 2010, Acharya 2011). The intellectual imagination of scholars concerned with regionalism beyond EU studies was mainly captured by regional integration and regional responses to global economic pressures and geopolitical and security considerations (Gamble and Payne 1996, Hettne and Söderbaum 2000, Devlin and Estevadeordeal 2001, Phillips 2004, Gomez Mera 2008, Nel and Nolte 2010). In Africa, regional or continental integration agreements were meant to enhance domestic standing and to cement state sovereignty as much as to increase the size of markets; while in the Middle East, region-building has been driven by increasing economic globalisation and security (Solingen 2008). In Latin America, regionalism was seen as a political project leading away from dependence to autonomous development (Fawcett and Hurrell 1995, Serrano 2005).

The fact that, in the end, regionalism played a much smaller role than had been imagined in the political economy of world regions, in turn, means that there is now something of a credibility gap. Furthermore, recent controversies about the EU in the aftermath of the Eurozone financial crisis, including the strong showing of Eurosceptic parties in the 2014 European parliamentary elections and crucially the decision of the United Kingdom to opt-out of the EU, revitalised a conventional argument that regional integration is only sustainable as long as it does not affect state autonomy; that is, states’ capacity to manage their sovereign decisions over economic policies, including flows of workers and immigrants. In the developing world, these arguments are often amplified in developing countries under conditions of austerity (Fioramonti 2012). However, Southern regionalisms have developed sui generis forms of regional cooperation and modes of delivering policies in relation to the health–poverty nexus that are worth scrutinising.

Undeniably, regional economic frameworks (Fawcett and Hurrell 1995, Acharya and Johnston 2007), security complexes (Adler and Barnett 1998, Buzan 2003), supranationality and sovereignty (Mattli 1999, Malamud 2003) are fundamental dimensions for the analysis of regional governance. Nonetheless, a fresh line of enquiry into the ‘social’ dimensions of regionalism needs more exciting and challenging questions about how Southern regional organisations engage with issues and practices regarding social welfare and poverty reduction. As a first approximation of the social dimension of regionalism, this study examines the regional integration–poverty nexus in relation to health policies for two principal reasons. First, poor health and poverty coincide, are mutually reinforcing, and are structured by socio-economic development within and across societies (Haines et al. 2000, Marmot 2005, CSDH 2008). Second, health is emerging as a distinctive focus of attention for global commitments and regional pro-poor policy-making. In this context, SADC and UNASUR have developed institutional competences in health policy and poverty reduction, although their policy development practices and methods of advocacy have taken quite different forms.

Framing and advocating norms through regional organisations

The responsibility of the state in delivering social protection, development, and welfare in developing countries is determined by sovereign domestic spending choices, albeit often constrained by systematic market pressures and by the need to secure domestic political support. In the absence of state capacity or a willingness to respond to social needs, global private non-governmental organisations and multilateral development agencies have commonly influenced national policies of (re)distribution, regulations, and pro-poor interventions through technical advice and conditional aid (Deacon et al. 2007: 8). However, international efforts to advance values, norms and rules through human development and poverty-reduction programmes are not free of conflict, resistance or politics (Börzel and Risse 2016). When it comes to responding to norms and ideas, key actors may mediate to ensure that those ideas are taken up, adjusted or rejected in ways that respond to, and support, prevailing forms of local governance and needs (Acharya 2004: 269).

So the question here is less what regionalism is (in terms of its philosophical, legal, or institutional bases) and more one of how regionalism acts, the roles and purposes to which the practice of regionalism gives expression. It has been argued, for example, that regional organisations can actively promote democracy and the achievement of democratically mandated goals, through ‘locking in’ normative, regulatory and constitutional reforms amongst members (Pevehouse 2005). They can do so through negative action – excluding states that contravene established democratic standards – and in positive ways, by embedding democratic or human rights-based legislation, supporting capacity building, or the provision of norms and standard-setting in support of policies which promote deeper democracy, enhance or extend human rights, well-being and welfare (Risse 2015). From this perspective, it could also be argued that regional organisations can steer collective efforts by (i) creating normative frameworks in support of pro-poor practices; (ii) facilitating the re-allocation of material and knowledge resources in support of policy formulation and implementation; and (iii) enabling representation and claims-making of actors in global governance (also Riggirozzi 2015: 414).

Creating normative frameworks: Regional organisations may take up or create a norm that brings particular issues to the fore, and supports particular forms of political practice and modes of action. Framing debates and getting issues onto the political agenda is an important mechanism for policy diffusion, drawing attention to issues and to affect the awareness, attitudes or perceptions of key stakeholders within regional member states and their societies, promoting, for example, recognition of specific groups or endorsements of international declarations. Who frames what and why depends on how actors in global governance, including government officials, non-governmental organisations, multilateral institutions, and public–private partnerships, define their goals and objectives, and exercise use of material and knowledge resources to support actions accordingly. In this process of regional organisations, often neglected partners in global governance – of development but not only – may become significant agents in the harmonisation of norms, defining ‘common problems’ and policy guidance for action on solutions (also Risse 2015). Following Acharya (2004: 244), framing may involve a process by which regional organisations ‘interpret’ external norms, including processes of revision to make outside norms ‘congruent’ with pre-existing local normative orders. In this case, norms may not be conceived within a specific regional geographical context, but what matters is how regional organisations facilitate the mainstreaming of frameworks, guidance and protocols that respond to, and are congruent with, national needs of members and societies.

That regional organisations can affect how policy is thought and practiced adds nuance to conventional analysis, particularly within comparative regionalism, that has centred almost exclusively on scrutinising ‘tangibles’ as measures of meaningful and effective regionalism (de Lombaerde et al. 2010, Börzel 2011). Little attention has been paid to how regional organisations contribute to creating ‘normative congruence’ (Acharya 2004: 241, 2011) or the capacity of regional organisations to ‘translate’ international norms into local settings, sometimes amalgamating and compromising with already rooted systems of belief and prevailing norms in the region and in domestic arenas. The underpinning notion is that regional organisations and subsidiary mechanisms can provide a space above the state for the articulation and promotion of norms and methods of regional policy formation and practices.

Of course, the capacity of regional organisations to translate normative frameworks into legislative change or binding regulations may vary across members and between regions. Translating normative principles into politics of compliance and practice for policy implementation remains suboptimal, inefficient, and uneven, particularly in the absence of binding regulatory and enforcement mechanisms. Nonetheless, we agree with Börzel and Risse (2016: 54) as they claim that there are important mechanisms of ‘soft power’ by which regional organisations may ‘promote’, ‘socialise and persuade’, or ‘seek to advance’ norms and ideas. While norm framing defines the object to be diffused, regional organisation can also actively promote diffusion and uptake of norms through the mobilisation of resources. In effect, regional organisations may act as key brokers facilitating the (re)allocation of (regional or external) human, knowledge, and financial resources, in support of formulation of (better) policy-making and implementation. The presence of intermediary actors, such as regional think tanks or networks, linking regional-national corridors of policy is likely to facilitate knowledge and policy exchange activities and capacity building in support of (alternative) modalities of governance.

Finally, regional organisations may enable representation and claims-making, creating spaces for collective action in the advocacy of (alternative) norms and acting as policy champions attempting to establish themselves as a broker between national needs and global norms. This political pathway may support new modalities of regional activism in support of common positions in, and to affect, global governance through regional diplomacy. This is an important aspect of the purpose of regionalism in the South as it refers to opportunities of regional organisations to engage as a bloc in political action and advocacy of practices of governance with the capacity to promote the realisation of collective goods.

As the subsequent analysis of SADC and UNASUR indicates, different regional institutional and governance mandates, including prior ideological consensus and sense of regional mission of identity, support different normative claims to be made, framed, and different kinds of collective action (also Sikkink 2014: 389). Likewise, institutional and financial resources will support different opportunities for regional organisations to act as a forum providing normative vectors; as brokers in a (re)distributive way; or as advocacy actors in a political way, including regional autonomy as a bloc to advance claims through regional collective action. SADC and UNASUR are indicative of these differences.

Addressing the poverty–health nexus in SADC and UNASUR

Since achieving independence from colonial powers – most of Latin America after 1820 and most of Africa after 1960 – fostering economic development and political stability have been major objectives of South American and African governments. In both regions, regional cooperation was seen as a way of achieving those goals while enhancing resources and forces against imperialist external rule. These visions evolved into modern manifestations of, sometimes contrasting and competing, models of economic and political governance, inspiring regionalism throughout the twentieth and twenty-first centuries (Schoeman 2002, Pallotti 2004, Söderbaum 2015).

One of the most salient characteristics of recent regional governance in Southern Africa and South American regionalism has been the identification of health as a distinctive policy area that affects economic development and autonomy. While not coherent citizenship-centred projects of regionalism, both SADC and UNASUR have adopted policy mandates and programmes to address the poverty–health nexus: as imperatives for economic and social development, in the case of SADC; and as part of a broader agenda of social rights and inclusion, in the case of UNASUR. Poverty and lack of access to healthcare and medicines remain the driving forces behind ill health, consistent underdevelopment, and marginalisation in both Southern Africa and Southern America (Haines et al. 2000, Marmot 2005). In this context, trans-border and regional social policy in health make sense not only to facilitate border activities and market policies but also because some social harms are inherently cross-border, exacerbated or facilitated by regional developments. For many poor people, the health-damaging effects of poverty are compounded by inequality related to sex, racial or ethnic group, disability, HIV infection, or other factors associated with social position. Of course, health also has market traces - more than other social welfare policy areas – through the production, commercialisation and consumption of medicines and healthcare. So for normative, political and economic reasons, health offers a particularly significant window onto analysing the regional responses to social development and poverty in SADC and UNASUR.

In SADC communicable diseases such as HIV/AIDS, tuberculosis, and malaria have become a priority for approaching the health–poverty nexus. In particular, the total burden of HIV and the need to respond to its socio-economic consequences have been recognised as a ‘prerequisite for sustainable development and productivity in member states’ (SADC Health Protocol, article 1; also Fourie and Penfold 2015). The sense of immediateness in SADC posed by communicable diseases has bared value as ‘response to risk’, ‘response to pandemic’ and ‘response to vulnerability’ for those who qualify. This is not surprising in a region that has been particularly stricken by HIV/AIDS since the 1980s and still remains the region hardest hit by the epidemic globally. According to the UNAIDS 2014 Global Report, out of the 35 million people living with HIV, 24.7 million are living in sub-Saharan Africa, (UNAIDS 2014: 18).

The relationship between HIV, poverty, and socio-economic vulnerability in Southern Africa was first made by social activists led by civil society organisations, NGOs, and trade unions in the mid-1990s, as they turned to SADC to demand the adoption of a regional code to avoid vulnerability and discrimination of people affected with HIV in the job market. This code was discussed within the SADC Tripartite Employment and Labour Committee, which subsequently adopted the SADC Code on HIV/AIDS and Employment (Armstrong et al. 2011: 159, Van der Vleuten and Hulse 2013: 26). The SADC Code is a referential document that framed regional standards regarding HIV, employment and human rights in business practice and the workplace. Recognising poverty reduction as a global responsibility, or ‘moral cosmopolitanism’ in Acharya’s words (2004: 242), the UN Millennium Summit in September 2000 accepted the challenge to halve poverty by 2015. Meanwhile World Bank-sponsored Poverty Reduction Strategy Papers in developing countries became an important framework for addressing HIV and poverty within development planning (Bonnel et al. 2004). Similarly, in 1999 the SADC Protocol on Health codified health as prerequisite for sustainable development. In this context, SADC institutionalised legal guidance and policy recommendations for surveillance and other measures in support of HIV/AIDS policies across the region. These commitments were framed in 2003 as SADC member states adopted the Maseru Declaration on HIV/AIDS. The Maseru Declaration laid the cornerstone of regional health policy identifying targeted, vulnerable populations at increased risk of HIV and higher-risk behaviours, such as adolescent girls, street children, people with disabilities, migrants and mobile workers, and sex workers (SADC 2015). In practice, it prioritised prevention and care; access to treatment and support; combating stigma; and strengthening institutional mechanisms to combat HIV in a coordinated manner (SADC 2015, Fourie and Penfold 2015).

The Maseru Declaration provided the normative umbrella for the Global Fund five-year grant to implement the ‘SADC HIV and AIDS Cross Border Initiative’.¹ The Initiative was awarded to the SADC HIV/AIDS Unit in 2010 to mitigate the impacts of HIV and AIDS on mobile populations and affected communities across SADC member states. The programme was initiated as it was found that increased cross-border movement in the region increases the risk of HIV infection – not just among high risk groups such as commercial sex workers and long-distance truck drivers, but also among migrant populations, communities close to border sites, and communities with high levels of in- and out-migration. Young working age adults are at particular risk, given that they make up the largest portion of mobile populations.

Part of the Cross Border Initiative and one of the conditions for the Global Fund grant was for SADC to sign Memoranda of Understanding (MoUs) with all 12 SADC member states participating in the Cross Border Initiative. The MoUs describe the commitments between SADC, its sub-recipients, and member states, and delineate the member states’ provision of pharmaceuticals, medical supplies, work permits, and exemption from customs duties. Signing of the MoUs entailed individual country visits to 12 member states to introduce the project, agree on location of mobile wellness clinics at border posts, and negotiate and obtain commitments from each member state to support the resourcing and effective functioning of these centres. In other words, member states and the SADC HIV/AIDS Unit agree on the normative terms for implementation, or ‘domestication’ in the words of policy makers in the region,² and the process of implementation itself is supported financially by ‘partner agencies’ (i.e. donors). To date, the project has established and is creating a sustainable system for 29 vehicle-based mobile clinics that employ medical staff across countries (Fourie and Penfold 2015). Another important normative framework developed by the SADC Secretariat is the ‘Cross Border Road Transport Regulations and Standards’ and the ‘Regional Minimum Standards for HIV’, which set out plans and strategies regarding roadside mobile populations and sex workers and the creation of wellness centres in region’s transport corridors.³

What this suggests is that the SADC Secretariat is an important forum for the articulation of normative and policy frameworks, supporting action amongst actors with a disparity of policy capacities and resources. The need for regulatory uniformity has been a recognised demand by member states. SADC is seen as a custodian of normative frameworks, articulating some sense of ‘common’ – not an easy task in a region where ethnic differences and legacy of intra- and inter-state conflict in the SADC region affects not only politics and welfare in the national space, but also the capacity to work together toward common goals (Pallotti 2004). Likewise, significant national actors, from health ministries to residential officers and practitioners, may organise around fulfilling international criteria attached to specific aid programmes undermining regional approaches, or country specificity by the same token.

While SADC is a recognised forum providing normative direction, its capacity to facilitate the re-allocation of resources is subsidiary. SADC plays an intermediary role promoting and encouraging the involvement of agencies outside SADC, mainly donors. It facilitates the allocation of resources through donors’ programmes and agendas. There is indeed a strong dependency on external funding and SADC acts as conduit for donors’ interventions where recourse of national solutions and resources fall short. More than half of SADC’s US$79 million annual budget in 2014 came from donors (ENCA 2015) supporting regional programmes that might well reflect donors’ priorities – who are often driven by evidence-based outputs and who need to justify to their national constituencies the rationale of intervention and foreign aid. This is not to say that SADC normative frameworks, particularly those for HIV and communicable diseases, are not mainstreamed or grounded in national programmes but rather that often norms are realised through a political battle. Facing the pressures of HIV/AIDS and other communicable diseases SADC and SADC countries are particularly susceptible to advance national programmes that donors are willing and able to support, and those programmes may come with specific approaches, if not conditions, attached to them (Harman 2015: 468, Mooketsane and Phirinyane 2015: 346). Effectively, the last fifteen years have seen a marked emphasis on lifestyle and behaviour change as a strategy to tackle social urgencies and development, which while important brushes aside more integrated, long-term and comprehensive approaches to social determinants of health and poverty. The risk is that what is visible and urgent is defined by external agencies and takes priority over regionally defined actions on poverty.

Given that the financial resources supporting implementation of programmes in the SADC region depend on donors’ agendas, it is not surprising that the majority of the efforts required to reduce poverty have been associated with programmes that target the poor, rather than institutional or policy reforms addressing determinants of poverty more broadly. These are certainly politically sensitive and more difficult for donors to justify to their constituencies. The fact that SADC depends financially on external donors consequently reduces opportunities for, and leverage of, ‘regional diplomacy’ contesting or reworking norms in global (health) governance (see Brown and Harman 2014).

But SADC provides ‘regional frontiers’, harmonising policy frameworks and exhortative declarations that encourage national policy-making and collaboration between donors, aid agencies and region’s member states for the implementation of health campaigns, treatment centres, vaccinations, and other programmes on the ground. This is an important role in highly fragmented and underfunded national systems throughout Southern Africa. Furthermore, despite differences in the levels of national responses to frameworks and guidelines, SADC members have endorsed resolutions, including commitments on surveillance and reporting on SADC HIV targets to the Secretariat, and made significant progress in integrating national frameworks and regional codes of conduct, such as those for Employment, HIV in cross-border areas, migrant and mobile populations, HIV/TB in the mining sector, respond to the needs of the region. Countries like Botswana, Lesotho, Malawi, Namibia, Swaziland, Zambia, and Zimbabwe have taken concrete steps towards integrating HIV into their national health and development planning, and increased uptake of HIV testing, counselling, and anti-retroviral treatment (SADC 2015, 2016).

Much more needs to be done in terms of changing regulatory regimes to directly address struggles for access to healthcare and equity in Southern Africa, but it is precisely the normative vision of its role that makes SADC so interesting, providing as it does a normative vector and a set of common policies and targets backing cross-border strategies and internationally financed programmes.

Similar dilemmas, different opportunities to enable change through regional diplomacy in South America

Unlike SADC in Southern Africa, UNASUR is a new experience for South America which can be traced back to early 2000s, despite crystallising institutionally in 2008. This is a regional governance project based not on economic integration but is a fundamentally political project of cooperation in the distinctive political economic context of South America.

UNASUR is the most recent attempt at regional governance in South America and it follows on from two quite intense decades of sometimes controversial region-building, based chiefly on the principles of increasing inter-regional trade and market opening, alongside increased poverty and inequality as a consequence of economic crisis and austerity during the 1980s and 1990s. The idea of political and social cooperation as advanced by UNASUR was shaped by changes to the forms of national democracy across the region. After two decades of neoliberal democracy and market-based governance, a new wave of Left governments took office across the region – in Venezuela (1998), Brazil (2002), Argentina (2003), Uruguay (2004), Bolivia (2005), Ecuador (2006), Paraguay (2008) and Peru (2011) – promising mixed economies and a generally pragmatic combination of welfare and populist policies which reasserted equity and sovereignty as distinctive national and regional identities in South America (Sanahuja 2012). In terms of region-building itself, UNASUR was established at the same time as the new governments decided to halt negotiations with the United States-led hemispheric regionalist project, the Free Trade Agreement of the Americas (FTAA). In fact, the defeat of the FTAA was an indication that the association between regionalism and the trade/investment agendas was now open for review; and that South America was the platform for the re-ignition of a ‘new’ regionalism at odds with both the neoliberal core and US tutelage (Riggirozzi and Tussie 2012).

UNASUR gathers the 12 South American countries, taking up an agenda to respond to the legacies of poverty and social debt. The Constitutive Treaty, signed in Brasilia in May 2008, explicitly declares commitments to improve regional development through the creation of physical infrastructure (e.g. roads, energy and communications), and the need to reduce asymmetries within and across societies. Unlike SADC, and in marked contrast to the MERCOSUR and Andean Community-led emphasis on trade and investment in earlier phases of region-building, UNASUR embraced notions of inclusion, equity and rights of citizens within its normative framework. The UNASUR Constitutional Treaty, for instance, specifically declared the ‘right to health as the energetic force of the people in the process for South American integration’ (UNASUR 2009a: 14).

Like in the SADC region, South America also faces high rates of communicable diseases such as tuberculosis, Chagas and Dengue, and more recently Zika – all of which are fuelled by poverty. However, regional governance in this case developed along an emphasis on the social determinants of health. In both regions there are disparities in health status and unequal distribution of resources for healthcare, magnified by inequalities. Yet, while the imperative in SADC has been defined in terms of disease, for UNASUR the focus has been on mobilising resources to develop better (health) policies in support of universal access to healthcare and social inclusion. The language of vulnerable populations has not permeated UNASUR as it has framed the approach to health and poverty in SADC. In UNASUR, addressing the most vulnerable invokes justice and equity in a normative sense as ‘right to development’ or ‘human right to health’, based on the recognition of legal obligations, often grounded in state legislation, to create opportunities and capabilities for citizens to enjoy those rights.⁴

This is not a minor issue in societies with high levels of poverty, exclusion, inequality, and which have, in addition, struggled to mobilise funding for social cohesion programmes. After years of sluggish growth and recession, a new cycle of economic growth saw the region’s population living in poverty fall from 45 to 25 per cent between 2000 and 2014 (CEPAL 2014). But despite these records, social development remained ambiguous, with around 168 million living in poverty, and 66 million in extreme poverty, earning less than one dollar per day (CEPAL 2014: 14). Amongst the most economically and socially vulnerable – that is indigenous, rural poor, slum residents, migrant workers, women – the incidence of endemic infectious diseases such as malaria, tuberculosis and dengue, and other communicable diseases such as HIV, became a significant and growing problem across the region. This bleak situation has been worsened by weak health systems, low levels of technical, scientific and institutional capacities, and limited access to (affordable) medicines (Holveck et al. 2007). Unlike SADC, these circumstances have, since the late 1990s, defined a policy-focused repertoire that echoed social protests demanding more inclusive models of democracy and development across South America (Szekely and Birdsall 2003). Furthermore, there is a long history of Latin American struggle for democratisation linked to claims about social entitlement and citizenship rights (Birn and Nervi 2015) – particularly as Latin America became heavily unionised and workers pressed for a range of social security benefits, including health as bastion of welfare state provisions. In Chile, working class and socialist claims for social justice were led by medical activist Salvador Allende since the 1940s. In Brazil, demands for social medicine and the right to health was embraced by the movimiento sanitarista (health movement), an activist movement that played a key role in the process of redemocratisation in Brazil and its Constitutional reform in 1988, leading to the adoption of the universal public health system (Cornwall and Shankland 2008). More recently, alternatives to traditional development philosophies were embraced by indigenous movements in Bolivia and Ecuador, and embedded in new constitutions (Gudynas 2011). UNASUR’s motivation came from these paradigms and the new opportunities to ground them regionally. UNASUR was formed as contestation to the ‘morality’ of neoliberal governance and hence regionalism has been about addressing political roots of the struggle for inclusive development and citizenship in the region.

In order to advance this agenda, in 2009 UNASUR framed a Five Year Plan (Plan Quinquenal) which outlined actions on five priority areas: (1) surveillance, prevention and control of diseases; (2) development of Universal Health Systems for South American countries; (3) information for implementation and monitoring health policies; (4) strategies to increase access to medicines and foster production and commercialisation of generic drugs; and (5) capacity building directed at health practitioners and policy makers for the formulation, management and negotiation of health policies at domestic and international levels (UNASUR 2009b, 2011).

One issue that quickly became apparent within UNASUR was that, in order to tackle health inequalities and embed the notion of rights and social determinants of health, more than cross-border cooperation and surveillance would be required from governments. This led to the creation of the UNASUR health think tank, the South American Institute of Health Governance (Instituto Sudamericano de Gobierno en Salud, ISAGS), under the auspices of the Health Council and reporting directly to it. ISAGS tasks are to provide policy-oriented and informative research, training and capacity building for member states. It supports ‘decision-making process and advocacy’ and ‘the formulation of UNASUR’s common external policies to back-up negotiations in international agendas’ (ISAGS 2014). Located in Rio de Janeiro, Brazil, ISAGS has capitalised on the leadership of Brazilian diplomats in previous international negotiations for the provision of medicines; as well as on the activism of the historic movimiento sanitarista; and experts of the prestigious FioCruz Foundation, who were part and parcel of the foundation of ISAGS and its operational plan (Buss and do Carmo Leal 2009). ISAGS gives UNASUR an aura not just of technical know-how and expertise, much in the way of the Washington-based Pan-American Health Organisation, but also conveys the message that health is a matter of politics, advocacy and policy-making. Furthermore, regional governance as advanced by UNASUR reinforced the ideologically based identification across the region and demands from previously mobilised actors.

Like SADC, UNASUR is about setting common parameters as much as creating a space for cooperation between member states. But while in SADC the presence of donors reinforces a disease-led agenda to address issues of (social) development, UNASUR took a political turn to make professionalisation and global negotiations key modalities for embedding principles of equity and rights in health governance. In line with this, UNASUR and its regionally funded think tank deliver programmes to support institutional reform and capacity building amongst member states. These programmes have been supported financially by contributions from member states, based on agreed annual quotas administered by UNASUR and ISAGS (ISAGS 2013). In practice, UNASUR/ISAGS has provided support directly to Ministries of Health in setting up UNASUR-sponsored Public Health Schools in Peru, Uruguay, Bolivia and Guyana and training in Paraguay and Guyana on primary care and preparation of clinical protocols. It has also supported reforms aimed to move towards universalisation of health provision in Colombia, Peru, and Bolivia (ISAGS 2014). ISAGS also acts as an active ‘knowledge broker’, gathering, assessing and disseminating data and experiences in the provision of healthcare and challenges of universalisation and regulation. In addition, it establishes effective mechanisms of exchange of best practices through regular seminars, workshops and special meetings (ISAGS 2014).⁵ ISAGS has also taken a distinctive role as an ‘industrial broker’, identifying existing industrial capacities across the region since 2012 and setting out plans for coordinated programmes for the production of generic medicines. The aim is to strengthen the position of member states in purchases of medicines vis-à-vis pharmaceuticals and allow joint negotiation and purchase strategies.

These practices are not only oriented to generate conditions for safeguarding and embedding rights-based and social development approaches within the region, but are also reaching out through ‘regional health diplomacy’. In effect, UNASUR took the view that ‘germs, norms and power’, as put by Fidler (2004), define an international structure where risks, regulatory frameworks and financial resources particularly affect developing countries and their populations. Consequently, since 2010 UNASUR took up the role as a ‘regional actor’, denouncing the side-lining of rights and social determinant of health on accounts of risk/security concerns in international health politics and aid assistance to the developing world. One of the first positions taken by UNASUR at the WHO concerned the impact of intellectual property rights on access to medicines and the monopolist position of pharmaceutical companies on price setting and generics (Riggirozzi 2015). Led by Ecuador and Argentina, UNASUR also successfully advanced 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, which unfairly restricted the marketing of generic products in the developing world. At the 2010 meeting of the World Health Assembly (WHA), UNASUR successfully proposed that an inter-governmental group replaced IMPACT to act on, and prevent, counterfeiting of medical products. This resolution was approved by the WHA in May 2012. More recently, UNASUR led discussions at the WHO to connect well-being of people with disabilities with broader frameworks of development and poverty-reduction plans. This recommendation was successfully taken up at the 67th session of the WHA, in May 2014, when the WHO approved its 2014–2021 Disability Action Plan. At the subsequent WHA annual meetings UNASUR has consistently voiced common positions on access to affordable and safe medicines and the inclusion of social determinants of health within the global post-2015 development agenda (see ISAGS 2016).

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 health, is indicative of a distinctive modality of regional policy-making and regional diplomacy in Latin America and within Southern regionalisms.

Conclusion

Although regional organisations are moving away from market-based goals to embrace issues of welfare and social development, little is known of the role they can play in the formation of policy conducive to embedding alternative approaches to development into national and international strategies. The analysis of SADC and UNASUR should be taken as prima facie cases for exploring the developmental dimension of Southern regionalism and the modalities of, and opportunities for, embedding approaches to social development and poverty at different levels of governance. The analysis of SADC and UNASUR developed here suggested that the context in which regional organisations are formed, as well as their normative, institutional and financial resources, support different opportunities for regional organisations to act as normative vectors; as brokers in a (re)distributive way; or as advocacy actors in a political way, enabling action and advancing claims at different levels of governance.

Both SADC and UNASUR are indicative of organisations that generate, harmonise and disseminate normative paradigms and/or policy proposals; and this is significant because (regional) normative frameworks make visible particular issues as central problems, and privilege particular forms of political practice that may help to embed those norms to governance settings. However, regional organisations in South America and Southern Africa differ in what they can do to support practices that embed pro-poor responses to poverty through health. SADC’s work on health has mainly been based on providing a normative vector, developing policy frameworks, regional templates for surveillance, and other measures to harmonise health policies across the SADC region, and engage member states to commit to HIV/AIDS policies. UNASUR also provides normative leadership, but has developed a distinctive modality of regional diplomacy and network activities to influence policy formulation and reform in national and global governance. As such, SADC’s role as a forum providing harmonised normative and policy frameworks reflects the ‘softer’ end of a spectrum⁶of Southern regionalist strategies compared to the pursuit of more overtly contestatory strategies by the better-resourced, more politically charged UNASUR which has taken a role of broker in the distribution of material and knowledge resources within the region and of advocacy actor in the global arena. This is not to say that UNASUR is a success story while SADC fails, but rather that different institutional arrangements enable certain possibilities (of political debate and practice) while constraining others.

The role of regional organisations in articulating policy frameworks that structure practices, co-ordinate responses to, and capacity building for, consequences of poverty and health crises, is still underdeveloped. The argument advanced here establishes the value of devoting more attention to how regional organisations contribute to processes of vernacularisation of norms, which is quite different from diffusion or adaptation of international norms; and to whether and how Southern regionalisms may affect policy horizons; policy capacities; and/or in policy regimes (at national and international levels). This also adds nuance to the analysis of what inter-governmental, non-binding, regional organisations can do and what they actually do, in at least in some fields, responding to prevailing scepticism in comparative regional studies and IR, and the quasi-academic campaign regarding what is seen as a proliferation of weak, unstable, and disappointing models of region-building (see Malamud 2013). The need to think more creatively about regionalism beyond realpolitik responses by states to international trade dependence and market pressures has been acknowledged. But few studies and even fewer theories support new thinking about the ‘social’ dimension of regionalism; the role of regional organisations shaping the course of socio-politically grounded projects; and the connection between the ‘intra-regional’ agendas and ‘external’ diplomacy in areas beyond trade and finance. The present article provides alternatives to conventional approaches; casting new light on synergies between regionalism and social development, modalities of, and opportunities for, embedding (pro-poor) approaches to development into national and international governance.

Acknowledgements

The author is most grateful for the careful reading and insightful comments on drafts of this paper from the anonymous reviewers for NPE.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes on contributor

Pía Riggirozzi is Associate Professor at the University of Southampton. Her research focuses on political economy of development and regionalism. Her publications include ‘Region, Regionness and Regionalism in Latin America: Towards a New Synthesis’ (New Political Economy, 17 (4), 2012), ‘The Rise of Post-Hegemonic Regionalism: The Case of Latin America’ (edited with D. Tussie, Springer, 2012); ‘Post-Neoliberalism in Latin America: Rebuilding and Reclaiming the State after Crisis’ (with J. Grugel, Development and Change, 43 (1), 2012); ‘Regionalism through Social Policy: Collective Action and Health Diplomacy in South America’ (Economy and Society, 43 (2), 2014); ‘Regionalism, Activism, and Rights: New Opportunities for Health Diplomacy in South America’ (Review of International Studies, 41 (2), 2015), and ‘Regional Governance and Legitimacy in South America’ (International Affairs, 91 (4), 2015). Pía Riggirozzi is currently engaged in a collaborative ESRC-DFID-funded project that explores regional integration processes and poverty reduction in the South.

Additional information

Funding

This work was carried out with support from the Economic and Social Research Council (ESRC), Grant Ref. ES/L005336/1, and does not necessarily reflect the opinions of the ESRC.

Notes

1 See Cross Border Initiative at http://www.comminit.com/africa/content/sadc-hiv-and-aids-cross-border-initiative

2 Informal exchange with SADC senior officials at workshop co-organised by the author, 2 June 2014.

3 For details of project, see http://www.fact.org.zw/index.php/programmes/health-and-hiv/road-wellness-project

4 Author’s interviews with ISAGS Chief of Cabinet, 10 November 2014; with former Officer at the Pan-American Health Organisation, 12 June 2012; and with Senior Officer at Ministry of Health in Ecuador, 9 October 2015.

5 Author’s interviews with ISAGS Chief of Staff, 29th August 2012; and with Officer from Ministry of Health in Argentina, 10 November 2014.

6 I thank an anonymous reviewer for emphasising this to me.