Collective health and regional integration in Latin America: An opportunity for building a new international health agenda

ABSTRACT

From its origins, the Latin American Social Medicine and the Collective Health (LASM/CH) movements have focused on thinking about health from and for the region. After the implementation of neoliberal policies, social improvements and the geopolitical strengthening of the region became the roots of new regional integration projects in South America. The objective of this article is twofold. First, we explore the legacy of long-standing efforts in the region that address the social and political dimensions of health, associated with the LASM/CH movements and their influence on the contemporary regional health agenda. Second, we analyze the UNASUR Health policy, its role in the construction of a regional health agenda, and the principles of South-South cooperation it supports. In order to accomplish this, a qualitative analysis was conducted, involving primary and secondary data. Through UNASUR, a new framework of regional health integration and regional health diplomacy emerged in South America and a ‘window of opportunity’ opened for the ideas of Social Medicine and Collective Health to occupy a dominant place on the regional health agenda. It is possible to observe a confluence between the principles and values of these movements and those of the main constituent bases of UNASUR Health.

KEYWORDS:

• Collective health
• regional integration
• UNASUR
• South-South cooperation
• social determinants of health

Introduction

The implementation of neoliberal policies increased social inequalities, inequities in health, and social exclusion in Latin America. Inadequate access to medical care and drugs remains a problem, particularly among the most vulnerable population groups in this region. Both access to medical care and access to medicines are recognised as social determinants of poor health outcomes and living conditions. To face this, a decade later, with the coming to power of leftist and progressive governments in most South American countries social policy has gained ground as a central principle for Latin American governments (Riggirozzi & Tussie, 2012). Furthermore, a more horizontal and solidary international cooperation between these countries has emerged as a strategy to increase power so that these countries may stop being mere receivers of the most traditional international cooperation and become cooperators in order to meet local social needs (Vance, Mafla, & Bermudez, 2016).

Social improvements and the geopolitical strengthening of the region became the roots of this new project in the region (Sanahuja, 2011). Good health improves living conditions, while better living conditions contribute to good health. Thus, social policies, and particularly health policies, have become essential strategies for the fight against poverty and for reducing inequalities on a regional scale in Latin America (Herrero, 2017). Likewise, health has acquired an important place in international relations and has come to play a key role in a regional policy agenda over the last decade. A key expression of this process was the founding of the South American United Nations (UNASUR 2008) in 2008 and particularly the creation of its Health Council. A special feature of the UNASUR Health Council is the fact that regional identity is based on health sovereignty and does not require that the member countries delegate any degree of national sovereignty. However, through the Health Council, UNASUR has incorporated the issue of social determinants, the right to health, and universal access to health systems into the debate on regional health policies.

In this paper we show that the approach of the Latin American Social Medicine and the Collective Health (LASM/CH) movements had considerable influence on many of UNASUR Health’s principles and values. Both intellectual traditions address the problems of disease, health and medical care of populations. These traditions are considered not only a field of scientific knowledge but also of political action. From this perspective, health is examined through different disciplines such as medicine, epidemiology, anthropology, sociology, history and political science (Paim & de Almeida Filho, 1998). From its origins, LASM/CH has focused on thinking about health from the region and for the region (Galeano, Trotta, & Spinelli, 2011). It is a field of knowledge and practice that claims the collective realisation of the right to health and universal and public health systems (Iriart, Waitzkin, Breilh, Estrada, & Merhy, 2002). It also focuses on the social determination of health, inequities and inequalities in health, and the social production of the health and disease process (Breilh, 2013).

Indeed, it is possible to observe a confluence between the principles and values of these trajectories and the main constituent bases of UNASUR Health (evident in its structure and explicit in its constitutive treaty). We argue that a window of opportunity was opened in the region that allowed LASM/CH to influence the principles and values of the new projects of regional integration. And, at the same time, this way of looking at the region and understanding regional integration contributed to strengthening new ways of South-South Cooperation (SSC) in Latin America. Importantly, the creation of this new project of regional integration in 2008 – UNASUR with its ministerial sectoral councils – is one of the most significant recent experiences of SSC in the region (Vance et al., 2016).

The objectives of this article are twofold. First, we explore the legacy of long-standing efforts in the region that address the social and political dimensions of health, those associated with the LASM/CH movements and their influence on the health agenda of some states, as well as at the regional level. Second, we analyze regional-level politics and the UNASUR Health policy, its role in the construction of a regional health agenda and the principles of SSC it supports. In order to accomplish this analysis, a qualitative study was conducted, including primary and secondary data. Secondary data was based on a review of bibliography and was systematized in relation to the history and main principles of these health traditions in the region. Primary data was collected through semi-structured interviews among key actors related directly to UNASUR and others working in public health in Argentina, Bolivia, Brazil, Ecuador, Uruguay and Paraguay. Fieldwork was carried out during 2014 and 2015, including more than 35 interviews with Health Ministers, former officials in charge of health public policies and representatives of regional and national organisations. In this article, the identity of the interviewees remains anonymous.

The paper explores how the participation of the South American Health Council in the international arena has thus far tangibly contributed to building a shared agenda, and the contribution that these trajectories of thought can make in a new regional context that seems to be taking a new direction. Our goal here is to contribute to the understanding of the principles on which international health cooperation has been built in Latin America, the role that regional organisations such as UNASUR have played in laying the foundations for health and the contribution of this organism to the promotion of a renewed form of south-south cooperation.

Latin American social medicine and collective health movements and their contributions in the field of health

A variety of theoretical and methodological perspectives have converged in a specific intellectual tradition called Latin American Social Medicine, or Collective Health, as Brazilians have called it. This intellectual tradition emerged in the 1970s from academics, researchers and social movements concerned about the economic, social and political consequences of military dictatorships. That decade was also characterised in several regions by a strong tension in the medical field because the medical profession was going through a deep crisis of confidence. For example, the governments of the United States and Great Britain began to question the enormous expenditures on medical technologies that did not seem to produce a substantial improvement in the quality of life of the population – or at least that was the argument for the adjustment of the public health expenditure. The strong reaction was against not only the increasingly obvious inequity in health and differential access to health services but, fundamentally, to hegemonic thinking that was more concerned with cure than prevention. At the time, interventions were focused exclusively on medical care, underestimating the powerful role of social factors (apart from medical care) in shaping health.

The LASM/CH tradition has had varying degrees of influence on health policy agendas according to the particular historical moment in question. Latin America has long been a place in which trade unions and social and political movements have played a central role in national politics. In the last decades of the twentieth century, social movements in the region struggled especially for the fulfilment of basic social rights, including the right to health, equity in access to health services and improvement of living conditions. This long history of struggle in the region coupled with political reform processes in the 1990s in health (as in other spheres) facilitated the transnationalization of social movement action across the region. This led to a growing visibility of experiences of transnational collective action.

Latin American Social Medicine has two basic principles. First, it recognises the social nature of disease, the historical and political character of the disease/health process, and the impact of inequities and social differences. This political-intellectual trajectory gives particular importance to the social determinants¹ of health and health as a human right. Second, it recovers the primary responsibility of the state in the solution of health-disease problems. From the LASM/CH perspective, it is assumed that health issues are linked to political issues, that is, to collective and individual decisions. In this way, the social determinants of health perspective, as understood by LASM/CH becomes a useful tool to make visible the structural aspects of health. It brings greater political content to discourse on the right to health (as part of the whole of economic, social, cultural and environmental rights), making clear that its guarantee requires structural changes to the way societies are organised for an equitable distribution of economic resources, power, and knowledge. The LASM/CH approach encourages the values of solidarity and cooperation in the agendas of the struggles of social and cultural movements and in the public action of progressive local and national governments. In this sense, it focuses on strengthening a continental and global movement for equity in health, inscribed within the broad framework of regional and global struggles for the right to health (Granda, 2003; López Arellano, Escudero, & Carmona, 2008).

Over time, there has been significant growth in this arena of thought, which insists on overcoming the matrix exported from developed countries. This exported matrix observes public health problems from the perspective of developed countries, their own interests, and their own recipes – what Anibal Quijano (2005) called the ‘coloniality of power and knowledge’ that extends through economic and geopolitical interests.

Globalisation and health in the international agenda

Global health governance solidified and diversified after World War II and new concepts appeared with the 1948 establishment of the World Health Organization (WHO) (Fidler, 2010). During the period of the Cold War the field of international health suffered tensions of political and ideological rivalries of the two most important blocks of that time: the one that represented capitalism and the other that represented communism; and health was not immune to this dispute. When the Soviet Union and the communist countries decided to withdraw in 1949 from the UN and, therefore, from the WHO, this body was clearly controlled by the interests of the Western block, particularly the United States, stimulating professionalism and bureaucratic growth, and carrying out global campaigns and technically oriented to the control or elimination of specific diseases in vertical programmes, operating with an approach similar to that of the Rockefeller Foundation imposed as a model since the beginning of the century (Brown, Cueto, & Fee, 2006). Two health approaches in permanent tension characterised this stage: one based on social and economic approaches that determine the health of the population and the other more focused on technologies and diseases. Both approaches remained over time with different emphases, increasing or decreasing (Brown et al, 2006) depending on the strong relationships of the countries and the interests of international actors. The 1960s and 1970s were marked by the emergence of decolonised African nations, the expansion of socialist and nationalist movements and new theories of development with an emphasis on economic and social growth. A milestone was the Alma Ata Declaration in 1978 which posits health as a fundamental human right that must be achieved by integrated social and health policies. Behind the movement for primary health care was a series of successful experiences of non-governmental organisations in Latin America, Africa and Asia that acted together with local populations. The response to Alma-Ata was the Bellagio Conference (Italy) influenced by the United States, funded by the Rockefeller Foundation, and supported by the World Bank. The meeting launched the concept of ‘selective primary health care’. That is, the implementation of technical interventions, low cost and small scale, with UNICEF leading the initiative in the 1980s. However, retrenchment and neoliberal policies were strongly felt in the WHO, which began to rely increasingly on contributions. In the 1990s, World Bank loans for the health sector surpassed the total budget of the WHO (Brown et al., 2006). The WHO subsequently lost credibility and in order to strengthen its global image began to employ the concept of ‘global funds’ and ‘global partnerships’. Its agenda was reduced to specific goals such as fighting Malaria or Tuberculosis (Stop TB) or improving access to new and underused vaccines for children living in the world’s poorest countries (GAVI). These programmes are public-private partnerships, the Bill and Melinda Gates Foundation being one of the largest funders. Partnerships with the commercial sector clearly limit the objectives of the universal right to health, through a limited approach focusing on ‘priority diseases’ (Buse & Waxman, 2001).

The so-called process of globalisation has generated an unprecedented hike in funding while also growing the influence of policymakers, activists, and philanthropists who claim health as a foreign policy issue of first-order importance. Likewise, this increasing role of health in the foreign policy agenda gave rise to the emergence of new actors with renewed flags and perspectives.

Amidst market globalisation, health emerged during the twenty-first century on the global political agenda as an issue that could only be effectively addressed through cooperative efforts. In this context, health has acquired an important place in international relations and has come to play a key role in foreign policy agendas in the last decade. The fields of international health and health diplomacy owe much of their growth and development, during the twentieth century, to the processes of economic expansion (Gómez-Dantés & Khoshnood, 1991). The Declaration of the Millennium Development Goals in the year 2000 also revealed the central role of health in the international debate on social policy. The WHO Commission on Social Determinants of Health, formed in 2005, injected further momentum. Fidler (2010) has called this moment the global health ‘revolution’ to denote the increasing role of health in foreign policy (Fidler, 2010; Labonté y Gagnon, 2010). That ‘revolution’ generated an unprecedented increase in funding and a rise in the influence of policymakers, activists, and philanthropists who claim health as a foreign policy issue of first-order importance. As a result, global health became an essential part of the equation of international relations (Fidler, 2001; 2010).

While in the past globalisation has often been seen as a more or less an economic process, it is increasingly understood as a more comprehensive phenomenon, fashioned by a multitude of factors and events that are reshaping our society as well (Huymen, Martens, & Hilderink, 2005). Through migration, war, and epidemics, health has transcended national boundaries, causing political and economic impacts on a global scale. Better life and good health are both essential elements towards the quality of civic life, peace, security, and governance. In this way, health has become a multi-dimensional topic that could be linked to global action. Accordingly, in the field of international relations there is now greater awareness of the scope of health issues and about the consequences of the rapid pace of scientific and technological development. Despite this and while there have been major advances in life expectancy over the past century, health inequalities, lack of access to health systems and social exclusion persist within and between countries. In this scenario, we argue that future prospects for health improvements depend increasingly on the relative new directions of the globalisation processes, international cooperation, and regional integration.

Latin America was a leading region in the promotion and practice of social medicine since 1970. It was swiftly reasserted when the process of re-democratization picked up in the early 1980s (Mariani, 2007), but along with the green shoots of democratisation, international financial institutions, and in particular the World Bank gained the upper hand in policy writ large. In the social sectors, reforms effectively removed the idea of equity and universalism as an organising principle for national social policy. Although these ideas were pushed aside during health reforms that were carried out in this period, they remained the organising principle of the overtly politically strategy of the Movimiento Sanitarista (Sanitation Movement). The Social Medicine and the Collective Health movements (especially in Brazil) continued to work to develop an approach linked to social epidemiology and to assert the ambitious goal of collective health and social determination of health to address the causes of ill health: social inequalities (Breilh, 2013).

Recovering the region: The influence of Latin-American social medicine on UNASUR

After the Washington Consensus, by the early 1990s neoliberalism had taken hold as a political and economic paradigm in Latin America. As a result of neoliberal policies the regional picture was becoming increasingly weak, challenging the notion of Latin America as an independent region given the influence of US-led liberal governance. The market orientation of neoliberal policies led to a selective focus in public policies, resulting in a series of simple and often low-quality benefits for the poor, which had a serious impact on the health sector and particularly on primary care (Giovanella, 2015). Access to more complex health care increasingly became associated with the ability to pay. Vertical programmes targeting populations or specific problems through the creation of targeted health insurance were strengthened, deepening the segmentation of health systems while poverty rates and income inequality increased region-wide (Soares, 2001).

In the 2000s, leftist and progressive governments gained power in most countries in the region and attempted to counteract the effects of neoliberal policies. The region itself also began to emerge as a territorial unit capable of intervening in struggles for power and symbolic resources. Subsequent attempts at the constitution of regional organisations under progressive and left-leaning governments (including UNASUR, The Community of Latin American and Caribbean States –CELAC-, The Bolivarian Alliance for the Peoples of Our America –ALBA-) have represented a conglomerate of commercial, political, and social projects that revolve around new principles of solidarity and regional autonomy and have provided the opportunity to synchronise policy at multiple scales.

The effort to recover South America’s potential for development was a clear manifestation of a historical change, a ‘change of era’ (rather than simply an era of change), in accordance with the statements by the President of Ecuador, Rafael Correa, in his inaugural speech in January 2007. This change of era was characterised by the formulation of political practices rooted in social development, community, and new practices of regional action.

Social and health policies were key axes of the Welfare State in many South American countries. After the results of neoliberal policies, in a context of increased social inequalities, lack of access to health systems and expansion of social exclusion, social policy rose to a high priority of countries. Thus, social policies, and particularly health policies, become essential strategies to combat poverty and reduce inequalities. Health is a prime example of an ongoing quiet revolution in the regional political economy of cooperation and diplomacy. New catalysts, at the national and international level, forged new opportunities to redefine objectives of regional political economy and forms of collective action.

Health is a paradigmatic example of regional cooperation, as a pos­sibility of expanding chains of public policy (Riggirozzi, 2014). As argued by Riggirozzi (2014, p. 434), the attention to health policies shows a ‘social turn’ in the life of Southern regional organisations and their mission to cooperate in order to meet high-profile social demands. An expression of that is the emergence of the South American Health Council of UNASUR. The appearance of UNASUR is a paradigmatic case that shows not only important changes in the form and content of regional governance and the structure of opportunities for social inclusion through health, but also on the principles and particular values that have permeated this agenda..

The member countries of UNASUR assumed the political commitment to give prominence to the health sector as never before. This commitment acquired different characteristics compared to the principles and actions carried out by traditional international organisations such as WHO and PAHO. Traditional international cooperation usually develops specific programmes for diseases, for example, against malaria, HIV / AIDS and tuberculosis through specific funds. These are ‘vertical’ programmes that do not take into account neither the specificities nor the participation of the population. In contrast, UNASUR has attempted to modify this traditional approach and has tried to understand health from a more political perspective and from an approach based on human rights. This paradigm shift has resulted in different actions such as the promotion of a joint work of public health schools, the strengthening of national health systems and the encouragement of regional studies of the social determinants of health (Herrero & Loza, 2018). All the interviewees argued that the UNASUR Health Council put on agenda the social determinants of health in regional health policies.

Our results show that, since its creation, UNASUR Health has changed the traditional paradigm in health due to the influence of regional actors such as the Latin American Association of Social Medicine (LASM). Moreover, the creation of UNASUR Health was driven by this movement that designed its structure and drafted its fundamental principles and values. This critical political movement, which was always excluded from the state proposals, had an opportunity with the progressive and left-wing governments of the 2000s. Further, an interviewee who played a central role in the founding of the Health Council stated that it was relatively easy to strategically impact on UNASUR because of the long previous experience of working together in ALAMES² (AL04, personal interview. October 9th, 2014). This is a key point, considering that other of the interviewees (who participated at the time of the constitution of the Health Council of UNASUR and has been coordinator of ALAMES) said that the experience of ALAMES (and so of LASM/CH) and many of its members facilitated the conformation of the Health Council and its main values ⁣⁣and principles (AL04, personal interview. October 9th, 2014). When UNASUR was formed, the resolution to set up the Health Council was already drafted (AL04, personal interview. October 9th, 2014). Another interviewee mentioned that the creation of the Health Council of UNASUR was strategically connected to the political shift in the region toward giving back centrality to the public sphere, the recovery of certain perspectives focused on social rights and a new regional integration and south-south cooperation (AL08, personal interview. June 24th, 2014).

The interviewees clearly pointed out that the creation of the Health Council was also due to the influence of some health ministers who took advantage of the opportunity when the Defense Council was built (AL08, personal interview, June 24, 2014). The Health Council was the second to be created and had much more dynamism than the Defense Council.

In my personal opinion, I believe that countries increasingly understand the role of regional integration processes. It is better understood that there are shared needs and challenges and also that there are asymmetries that must be reduced to achieve common goals. (PY02, personal interview. October 23rd, 2014)

Other interviewee mentioned that UNASUR decided to support Universal Health Systems instead of Universal Health Coverage, after a heated debate³ (AL04, personal interview, October 9, 2014). In that decision the representatives of ALAMES had a fundamental influence. UNASUR agreed on this position and discussed it at a meeting of PAHO health ministers. In 2014, Brazil, Chile, Ecuador and Paraguay occupied the Executive Board of PAHO. Finally, it was approved at the 53rd session of the PAHO Directors Board (CD 53/5) with the following denomination: coverage and universal access to health, trying to contain different positions. That common positioning was then taken to the WHO World Health Assembly in 2015. ‘This is a very important success for UNASUR because it ended up taking a joint position (…) since there are more opportunities at some moments than others and that must be taken advantage of’ (AL04, personal interview, October 9, 2014).

The previous one was not the only joint position in the international scene. UNASUR strives for obtaining a voice in global health, gaining political prominence through two parallel movements highly relevant in terms of health diplomacy. To do so, UNASUR has taken its position to the global arena in which there has been an increase in health issues on the agenda (Rio + 20, ICPD + 20, World Conference on SDH, etc.). These scenarios are permeated by two different global movements, one linked to the opening and globalisation of the health market and the other linked to rights (related to Alma-Ata, forums such as Health in All Policies, the Framework Convention Snuff Control). Beyond these two movements that pervade the stage, there is also a change with the emergence of debates on the agenda of health and development in the World Trade Organization (WTO) and World Intellectual Property Organization (WIPO), among others (Coitiño, 2014). Gaining a voice in global diplomacy, UNASUR is a central driving force that also allows regional identity building. For example, it was able to negotiate as a block in the 67th World Health Assembly (WHA) over the report submitted by the Health Development Advisory Panel on Research (ISAGS, 2014). In this case, UNASUR member States took a common position on ten issues: vaccines, disabilities, monitoring of the Millennium Development Goals, Post-2015 Agenda, repercussion of the exposure to mercury, health contribution to social and economic development, access to essential medicines, strengthening of the regulation systems and follow-up of the Recife Political Declaration on human resources and of the report presented by the Consultative Expert Working Group on Research and Development (ISAGS, 2014). Thus, the participation of the Health Council in this kind of international forum was central to the mission of building a shared agenda. An example of this has been the mapping of experiences of primary care in the Americas carried out by the ISAGS that accounts for the various models of comprehensive health care adopted over time and that was submitted to the WHA. The initiative aims to provide governments with information to identify strategic policies for local or regional action, facilitating decision-making.

In its ‘Five Year Plan’ (2010–2015), UNASUR adopted the social determinants approach and a transversal perspective in its policies, promoting the development of partnerships and networks with civil society. It also proposes to increase the number of countries in the region that reorient their health systems towards a focus on social determinants. In this way, the central role that health took in the region-building process helped to position social inclusion within the regional agenda. References to health as a human right and emphasis on addressing social determinants of health are not simply rhetorical in the Five Year Plan. The conformation – and the actions – of the Five Technical Groups (Health Surveillance and Response, Development of Universal Systems, Universal Access to Medicines, Health Promotion and Action on Social Determinants of Health, Development and Management of Human Resources) speak to a real intention to uphold those principles. Likewise, the need to reinforce cooperation mechanisms among countries of the region promoted joint actions and the strengthening of integration, under the recognition of national sovereignties.

Teixeira (2017) argues that the process of regional integration and cooperation carried out by UNASUR contributes to the promotion of regional health sovereignty, while strengthening the national health sovereignties of each member country. In this line, Mario Rovere (ALAMES member and sanitary specialist in Social Medicine) argues that health sovereignty is achieved by strengthening the capacity of the state to guarantee the right to health and to provide public goods, which is an axis for redefining health policies and through which to build new negotiating capacities within the framework of alternative international health, where the state is the central actor (Rovere, 2011). Thus, the regional project strengthens and broadens the capacity to negotiate and defend its interest in multilateral spaces, in front of the market and other international and transnational organisations, which in turn generates greater autonomy for the countries involved in the process of regional integration.

Health is itself a privileged field for the construction of foreign sovereignty through cooperation, since it can engage continental and global multilateral spaces of negotiation and exercise of sovereignty, spaces which other social areas do not possess (Teixeira, 2017). UNASUR also emerged as a feasible space for the promotion of south-south cooperation (from here, SSC), as countries sought to reduce regional inequities through the creation of spaces for exchange and collaborative action (Vance et al., 2016).

SSC in this arena was early fostered at the Bandung Conference, held in 1955 to promote greater articulation among developing countries to stimulate their own growth (Buss & Ferreira, 2010). SSC is initiated, organised and managed by developing countries themselves, with governments often playing a lead role. SSC can include different sectors and its nature might be bilateral, multilateral, subregional, regional or interregional (Vance et al., 2016). The SSC agenda and initiatives must be determined by the countries of the South, guided by the principles of respect for national sovereignty, national ownership and independence, equality, non-conditionality, non-interference in domestic affairs and mutual benefit. Accordingly, SSC became a fundamental strategy for South American countries based on a horizontal relationship and on cooperation between equals. The creation of UNASUR in 2008 and its ministerial sectorial councils in the following years is one of the most recent experiences of SSC in the region.

UNASUR encouraged the values of SSC through its declarations and, according to our fieldwork, it also fortified a continental as well as a global position for new health diplomacy. This cooperation is also evident in the South American Health Council, its Technical Groups and Structuring Networks, and the South American Institute of Government in Health⁴ (ISAGS). UNASUR’s Five-Year Plan (2010–2015) provided for the creation of the ISAGS, as a centre for high-level study, critical reflection and training of strategic personnel. The intention was to promote the construction of a South American vision and to reinforce critical reflection on global health, aligning positions and fostering a cooperative circle (Vance et al., 2016).

Both UNASUR and ISAGS propose a horizontal model, in which all members contribute to the identification of problems and the development of solutions. For example, ISAGS acts by facilitating the processes of cooperation in health through its spaces of debate (thematic workshops, conferences and courses). Moreover, in accordance with the principles of SSC, the regional block has strict regulations regarding its financing, which does not allow any type of economic support outside of the member countries without the prior approval of its Council of Ministers of Foreign Affairs (Vance et al., 2016).

This regulation seeks to protect the decisions, actions and strategies of the entity against external interests that may oppose the public interest. In this way, the resources that are handled come from the member states. The decision for UNASUR to be financed exclusively through the contributions of its member countries, placing strong restrictions on third-party funds (except those on which all foreign ministers decide otherwise) has also been a wise decision. The fact that decisions are adopted by consensus has generated decisions that acquire greater political weight and legitimacy (Belardo, 2018). We could see a quiet revolution in health diplomacy in the region that promotes a movement towards horizontal cooperation and technical support, away from what its leaders view as an outdated vertical model of donors and recipients (Herrero, 2017).

Conclusion

In Latin America, health, education, employment, and the struggle for land and housing have been long-standing social demands, strongly linked to the concept of citizenship in the XXth century (Roberts & Portes, 2005). LASM/CH are intellectual traditions and political movements committed to the living conditions of the popular majorities. Insofar as they recognise the social and political dimension of diseases, they have given great importance to studying – and reporting – the social determinants of health and disease processes and to considering health as a human right.

With the consequences of neoliberal policies and the deepening of social inequality, representatives of the Social Medicine and Collective Health movements fought for the need to recover the role of the State. With the emergence of leftist and progressive governments in the region, a ‘window of opportunity’ was opened for the ideas of Social Medicine and Collective Health to occupy a dominant place on the agenda of some States, as well as at the regional level. In this scenario, and from its origins, UNASUR has understood health as a right for all and a duty of States. That is why UNASUR has embraced the principles of solidarity, social justice and equity and focuses on the social determinants of health and the struggle for universal health systems. The construction of new blocks in the Latin American region (as UNASUR, CELAC or ALBA) revived the idea of Simon Bolivar of the construction of a Great Fatherland (the ‘Patria Grande’ project) to recover our sovereignty.

UNASUR represents an attempt to establish an alternative paradigm for the integration of the twelve countries of the region. The creation of this international organisation responded to a geopolitical vision based on principles such as independence, sovereignty, solidarity and complementarity among the member countries. This eminently political and intergovernmental initiative emerged with the aim of generating regional autonomy in a great diversity of aspects (health, defense, infrastructure, energy, education, social and cultural development), enhancing the scale of individual efforts, and with the purpose of setting common positions on the world stage.

Ten years after the emergence of UNASUR, we can affirm that health had a prominent place in its agenda. The values, principles and alternative approaches in health were incorporated into the organisation’s policies thanks to the intellectual and militant efforts of a group of committed professionals, belonging to the long tradition of Latin American Social Medicine / Collective Health, who visualised an opportunity to influence both nationally and regionally. This conceptual framework allows UNASUR to discuss health policy guidelines instead of ‘programs’ for specific diseases, as traditionally done by PAHO, which resulted in the imposition of programmes designed in Washington to our countries.

However, some of its strengths can become weaknesses or limits. The fact that policy decisions are adopted unanimously gives greater power and legitimacy to the measures. But when the political representation of the member countries changes significantly, necessarily UNASUR, in a context of different interests and conflicting ideological visions, can enter a situation of stagnation. That is the situation that UNASUR is going through now.⁵Another weakness of UNASUR is that as a regional organisation, it aims to harmonise public policies but not to implement them or their recommendations. Then, there may be a general consensus, but each country implements that consensus in a different, even opposite, way. For example, there is a general consensus about the need for universal health. However, countries interpret this universalisation in a very different way. This translates into different national health systems. Finally, despite the fact that several articles of the Constitutive Treaty of UNASUR proclaim citizen participation in health, this popular participation has not been made effective or institutionalised (Belardo, 2018).

Despite the mentioned weaknesses, UNASUR has been considered an example of political-technical cooperation between countries without requiring members to relinquish individual sovereignty and to establish consensual cooperation agreements. UNASUR is also demonstrating that regional integration is possible without supranational governance. And finally, the Health Council, its Technical Groups and Structuring Networks, and ISAGS are spaces for strengthening integration and SSC recognising that health is a bridge to peace and the development of peoples.

After a decade of work in favour of integration, the experience of UNASUR is threatened by the emergence of conservative leaders in the region and the recent decision of Argentina, Brazil, Chile, Colombia, Paraguay and Peru to leave the bloc. This decision jeopardises the continuity of joint plans and projects in the area of health, weakening the initiative of integration.

Acknowledgements

The authors gratefully acknowledge to all the participants, who kindly shared their experiences, knowledge, and opinions and made this study possible. Also, warmly thanks to Adriana Greco for her comments to the early versions of this paper. Finally, we want to especially thank the editorial board of this journal for an invaluable contribution with their careful review and the assistance in the edition of the final draft.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

María Belén Herrero http://orcid.org/0000-0002-6941-0580

Jorgelina Loza http://orcid.org/0000-0003-1442-5782

Marcela Beatriz Belardo http://orcid.org/0000-0001-9032-3919

Additional information

Funding

The field work mentioned in this article was carried out with support from the UK Economic and Social Research Council (ESRC), Grant Ref. ES/L005336/1. The article and does not necessarily reflect the opinions of the ESRC.

Notes

1. LASM/CH promoted the analysis of the category of social determination of health (Breilh, 2013). This differs from the concept of social determinants, used above all by PAHO and WHO. The concept of Social Determination of Health had a great importance in the development of LASM/CH. For the purposes of this article we will not delve into this debate since, to our knowledge, UNASUR has used both concepts interchangeably, and more frequently that of ‘social determinants of health’. Also, for more information authors recommend this lecture: ALAMES (2015).

2. The Latin American Association of Social Medicine (ALAMES) is a political organisation made up of people linked to different fields of theory and practice of Social Medicine/Collective Health in Latin America. It was formally constituted in 1984 during the 3rd Latin American Seminar on Social Medicine, held in Ouro Preto, Brazil.

3. Universal health coverage and universal health systems are two different and opposed ways of understanding the right to health. The first is supported by the WHO, the World Bank and the IMF and is also supported by the Rockefeller and Bill and Melinda Gates foundations. The second is supported by the movements of collective health and social medicine in Latin America. Both currents of thought are framed in the need for health reforms but the proposals are different. Universal health coverage proposes the entry of the market into the health sector and for this purpose opts for ‘insurance’ or ‘coverage’ with multiple administrators, buyers and providers of health services and the channelling of fiscal subsidies to support it. The most important Latin American examples are the reforms of Chile, Colombia and Mexico. The other current raises a public health system. It is inspired by the Social State where health services are public precisely to guarantee equal and free access to the services required of the entire population, thus guaranteeing the right to health. This approach claims the redistributive role of the State in the form of providing social services. The most prominent Latin American examples are Cuba and Brazil.

4. ISAGS is a centre of high studies and debate of public policies, its actions contribute for the development of governance and leadership in health in South America. The headquarters of the Institute are in Rio de Janeiro, Brazil.

5. In the current context of conservative’s governments other visions of regional integration begin to gain strength, even with agreements that overlap as the alliances linked to the interests of the United States as well as the rapprochement between the Pacific Alliance and MERCOSUR or the attempts of alliance between the European Union and MERCOSUR.