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wrong reasons, obesity is increasing at alarming rates, and alcohol consumption and violence are unacceptably high and have far-reaching consequences.6,7 What is needed now is continued political will to tackle dicult questions and make the right decisions based on the countrys most important priorities. As Cesar Victora and colleagues8 conclude in the nal paper of the Series: the challenge is ultimately political, requiring continuous engagement by Brazilian society as a whole to secure the right to health for all Brazilian people. Brazil is in transition. But the country is in an excellent position, thanks to its historical commitment to public health and its current political and economic strength, to achieve its ambitious aspirations. A strong emphasis on health as a political right, together with a high level of engagement by civil society in that quest, might also mean that other countries can look to Brazil for inspiration (and evidence) to solve their own health predicaments. Brazil is a complex country not a country for beginners, as Tom Jobim, the popular 20th-century composer, famously said. But we hope this Series does show why Brazil should not only be taken more seriously by the international health and science communities, but also be admired for implementing reforms that have put health equity at the centre of

national politicsan achievement many readers might wish for their own countries. Sabine Kleinert, Richard Horton
The Lancet, London NW1 7BY, UK
1 Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; published online May 9. DOI:10.1016/S0140-6736(11)60054-8. FIOCRUZ. Getting to know Fiocruz. http://www.ocruz.br/cgi/cgilua.exe/ sys/start.htm?UserActiveTemplate=template%5Fingles&sid=185 (accessed March 6, 2011). Leahy J. Brazil claims it is fth largest economy in world. Financial Times March 3, 2011. http://www.ft.com/cms/s/0/89ad55ba-45d7-11e0-acd800144feab49a.html#ixzz1HFE3E6sB (accessed March 6, 2011). Rousse D. Address of President Dilma Rousse: inaugural speech to the Brazilian public. Jan 1, 2011. http://www.brasil.gov.br/news/history/ 2011/01/03/address-of-president-dilma-rousse-inaugural-speech-to-thebrazilian-public/newsitem_view?set_language=en (accessed March 6, 2011). World Bank. Brazil country brief. Oct 4, 2010. http://web.worldbank.org/ WBSITE/EXTERNAL/COUNTRIES/LACEXT/BRAZILEXTN/0,,menuPK:3223 51~pagePK:141132~piPK:141107~theSitePK:322341,00.html (accessed March 6, 2011). Zitko-Melo P, Franco-Marina F, Rodrguez-Garca J, et al. Comparative risk factor assessment for 11 Latin American countries. Global Health Metrics & Evaluation: Controversies, Innovation, Accountability; March 1416, 2011; Seattle, WA, USA (abstr). Tiene de Carvalho Yokota R, de Moura L, Medeiros Mascarenhas MD, et al. Evaluation of the Brazilian national violence surveillance system, 200609. Global Health Metrics & Evaluation: Controversies, Innovation, Accountability; March 1416, 2011; Seattle, WA, USA (abstr). Victora CG, Barreto ML, do Carmo Leal M, et al. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; published online May 9. DOI:10.1016/S)140-6736(11)60055-X.

Brazil: structuring cooperation for health

Published Online May 9, 2011 DOI:10.1016/S01406736(11)60354-1 See Perspectives page 1738 See Series page 1778 See Online/Series DOI:10.1016/S01406736(11)60138-4, DOI:10.1016/S01406736(11)60202-X, DOI:10.1016/S01406736(11)60135-9, DOI:10.1016/S01406736(11)60053-6, and DOI:10.1016/S01406736(11)60055-X

One of the least known components of Brazilian health policy is its international cooperation. However, although Brazil has not formally dened its foreign policy in the area of healthas have the USA, the European Union, and the UKit does not mean that the country is not internationally active. Brazil has a long history in world healthin 1945 it was represented at the UN Conference on International Organizations held in San Francisco, CA, USA, the conference that was the founding of WHO. At the meeting delegates from Brazil and China proposed that a general conference be convened...for the purpose of establishing an international health organization.1 Moreover, Brazil was among the 61 nations that signed WHOs Constitution in 1946, and a Brazilian, Marcolino Candau, was Director-General for almost 20 years (195373), the longest tenure of this position in WHOs history. Early in the 21st century, Brazil entered the international scene with more determination and strength, positioning

itself as a major actor, for instance, in the establishment of the World Trade Organizations Doha Declaration on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement and Public Health (2001) and to WHOs Framework Convention on Tobacco Control (2003).2,3 Health was prominent in Brazilian foreign policy during President Luiz Incio Lula da Silvas (Lulas) administration (200310), not only because of the technical expertise generated by the originality of its universal, integral, and free health-care system, but also because of the general guidelines of Brazilian foreign policy, and the policy of the President, directed at strengthening SouthSouth cooperation and prioritising South America and Africa. In response to the prioritisation of health, the Ministry of Health created the International Health Advisory Oce, which is chaired by a diplomat and is supported by several health and international relations professionals. One of the most active organisations in this cooperation is the Oswaldo Cruz Foundation,4 a 100-year-old
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Brazilian institution linked to the Ministry of Health that is dedicated to research and development, education, production of health goods (ie, vaccines, drugs), and consultancy in various areas of public health. Brazilian SouthSouth cooperation has been reinforced on two dierent fronts: within the Health Council of the Union of South American Nations (UNASUR)5 and its 201015 Quinquennial Plan,6 and by the Strategic Plan for Cooperation in Health of the Community of Lusophonic Countries (CPLP).7,8 The model for SouthSouth cooperation adopted by Brazil has been called structuring cooperation for health,9 which is based fundamentally on capacity building for development. This new model is innovative in two ways rst, by integrating development of human resources with organisational and institutional development; and second, by breaking the traditional model of passive unidirectional transfer of knowledge and technology and mobilising each countrys existing endogenous capacities and resources. Progression beyond traditional forms of international aid is centred on institutionally strengthening partner-country health systems, combining concrete interventions with local capacity building and knowledge generation, and promoting dialogue between actors, so that they can take the lead in health-sector processes and formulate the agenda for future health development (gure). In such a context, the role of international organisations changes substantially. The choice of this mode of cooperation is a product of criticism of current models,10 which greatly dier from principles and practices broadly recommended and accepted by the Paris Declaration and, more recently, the Accra Agenda for Action.11 So far, the results of such cooperation are encouraging. UNASURs Quinquennial Plan and the CPLPs Strategic Plan for Cooperation in Health are underway, and both include the creation of dynamic networks of institutions capable of structuring the organisation and operations of health systems, which build capacity for sustainable development of health systems and professionals. For UNASUR, the South American Institute for Health Governance, due to be inaugurated this year, will lead a network of similar country-based institutions dedicated to the production of knowledge and preparation of key professionals for the management of national health systems. To further improve Brazilian international cooperation in health, many of its institutions need to be harmonised,
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Capacity building for development Structural cooperation in health

Integrates: human resources development, organisation development, and institutional development Role of international agent

Breaks: traditional passive transfer of knowledge and technology

Strengthening health systems

Exploring countrys potential endogenous capacities and resources

Figure: Model for structuring cooperation for health

and a law is needed for international cooperation by the National Congress that can dene new concepts and provide mechanisms to improve the countrys international eorts. Paulo Buss
Oswaldo Cruz Foundation, FIOCRUZ Center for Global Health, Rio de Janeiro 21040-360, Brazil buss@ocruz.br
I declare that I have no conicts of interest. 1 2 PAHO. Pro salute novi mundi: a history of the Pan American Health Organization. Washington, DC: Pan American Health Organization, 1992: 296. World Trade Organization. Declaration on the TRIPS agreement and public health. Nov 14, 2001. http://www.wto.org/english/thewto_e/ minist_e/min01_e/mindecl_trips_e.htm (accessed March 22, 2011). FCTC. WHO Framework Convention on Tobacco Control. http://www. who.int/fctc/en (accessed March 22, 2011). Ministrio da Sade, Brazil. FIOCRUZ. http://www.ocruz.br/cgi/cgilua. exe/sys/start.htm?UserActiveTemplate=template%5Fingles&tpl=home (accessed March 22, 2011). Health Council of the Union of South American Nations. http://www. pptunasur.com/contenidos.php?menu=3&submenu1=7&idiom=1 (accessed March 22, 2011). 201015 Quinquennial Plan. http://www.unasursalud.org/images/stories/ documentos/plan_quinquenal_ingles.pdf (accessed March 22, 2011). Buss PM, Ferreira JR. Health diplomacy and South-South cooperation: the experiences of UNASUR Salud and CPLPs strategic plan for cooperation in health. RECIIS Rev Electron Comun Inf Inov Saude 2010; published online March. http://www.revista.icict.ocruz.br/index.php/ reciis/article/view/351/520 (accessed March 22, 2011). CPLP. Strategic plan for cooperation in health. http://www.cplp.org/ id-1787.aspx (accessed March 22, 2011) (in Portuguese). Almeida C, Pires de Campos R, Buss PM, Ferreira JR, Fonseca LE. Brazils conception of South-South structural cooperation in health. RECIIS Rev Electron Comun Inf Inov Saude 2010; published online March. http://www.revista.icict.ocruz.br/index.php/reciis/article/view/343/528 (accessed March 22, 2011). Buss PM, Ferreira JR. Critical essay on international cooperation in health. RECIIS Rev Electron Comun Inf Inov Saude 2010; published online March. http://www.revista.icict.ocruz.br/index.php/reciis/article/view/350/517 (accessed March 22, 2011). OECD. Paris Declaration and Accra Agenda for Action. http://www.oecd. org/document/18/0,3343,en_2649_3236398_35401554_1_1_1_1,00. htm (accessed March 22, 2011).

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