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Pa Riggirozzi
To cite this article: Pa Riggirozzi (2014) Regionalism through social policy: collective
action and health diplomacy in South America, Economy and Society, 43:3, 432-454, DOI:
10.1080/03085147.2014.881598
Pa Riggirozzi
Abstract
This paper is concerned with the place of social policy as a driver of region
building in South America. The contention is that while much has been written
about economic integration, institutions and security communities in regionalism,
a discussion of the significance of other regional projects has lagged behind.
Social policy, particularly in the Americas, has been neglected as a policy domain
in the account of regionalism. Changes in the political economy of Latin America
in the last decade suggest that we need to engage afresh with regional governance
and social policy formation in the Americas. By looking at the institutions,
resources and policy action in the area of health within the Union of South
American Nations (UNASUR) this paper reconnects regionalism and social
policy and explores two interrelated, yet largely unexplored, issues: the linkages
between regional integration and social development beyond the historical hub of
trade and finance; and the capacity of UNASUR to enable new policies for
collective action in support of social development goals in the region, and to act
as a broker of rights-based demands in global health governance. In so doing, the
paper contributes towards a more nuanced understanding of regionalism and
regionalization as alternative forms of regional governance.
national focus of social policy, and recognizing a wide variety of domains and
spaces of policy formation and negotiation, political and academic circles
turned their attention to forms of governance capable of ensuring an equitable
global economic order. Transnational co-operation in the delivery of social
policy was part of this thinking; a perspective that essentially proposes that the
causes of, and solutions to, many social issues are not necessarily confined to
national institutions, structures and frameworks but are rather entangled in
processes that extend beyond the bounds of the nation-state (Ortiz, 2007;
Yeates & Deacon, 2006).
This perspective became particularly persuasive as, since the 1990s, global
welfare settlement mechanisms proliferated through donations, technical co-
operation and international aid by international non-governmental organiza-
tions and multilateral institutions within the United Nations system. The
understanding was that in the absence of state capacity, or willingness, global
interventions by private non-governmental organizations and multilateral
development agencies could influence national policy by means of transnational
redistribution, supranational regulations, technical advice and co-operation,
or through conditional aid (Deacon et al., 2007, p. 8; Stubbs, 2003,
p. 320). In practice, significant global policy efforts to eliminate world poverty
became increasingly instrumental, channelling overseas aid to fund North
South transfers, new forms of finance for development and campaigning for a
global social protection floor. In Latin America, global social policy mostly took
the form of compensatory policies, anti-poverty programmes and social
investment, advanced by the World Bank and the Inter-American Develop-
ment Bank to balance the social effects of trade openness, privatization of
public services, such as health, education and pensions, and deregulation of the
market (Cornwall & Brock, 2005). Controversies around these global social
policy programmes mounted as they were seen as intervention in response to
market or government failures, yet disengaged from a broader debate about
models of social development and social transformation (Cammack, 2004;
Deacon et al., 2010).
At the same time, as regional formations were in ascendancy in the 1990s,
increasing cross-border problems such as health pandemics or illegal immigra-
tion highlighted the need to co-ordinate surveillance mechanisms to control
transmittable diseases or to correct inequalities and redistribute welfare
opportunities (Ortiz, 2007, p. 64). In other words, it became clear that social
policy made sense, not only to compensate market policies but also because some
social harms were inherently cross-border, that is, exacerbated or facilitated by
regional developments. In Latin America, for instance, new forms of transna-
tional co-operation emerged in the area of health surveillance and labour
migration as well as in specific areas that could boost market competitiveness
such as higher education and foreign investment policies (Deacon et al., 2010;
UNU/CRIS, 2008). In this context, the debate about regional social policy
revolved around effective ways of securing cross-border co-ordination
and implementation of redistributive projects (for example cross-border
436 Economy and Society
SELA, 2010, p. 8). In the case of MERCOSUR, one of the social policies that
made concrete impact in terms of regulatory policies and regional legislation
was health. Health was not a priority in the foundation of MERCOSUR, but,
as the bloc was working towards trade consolidation, issues of disease control
and epidemiological surveillance in trans-border activities became a priority,
particularly in the triple border shared by Brazil, Argentina and Paraguay,
crossed every day by vast numbers of migrants and thousands of tourists
(Holst, 2009). This led to the creation of the Health Minister Assembly and
the Health Working Group (GTS11), established in 1996 at a ministerial level
for the discussion of health policy and strategies of surveillance (MERCOSUR
Decision CMC No 03/1995). Regulations dealt mainly with issues related to
public health surveillance, control and standardization of sanitary standards
and common regulations on pharmaceuticals for trade and joint health and
safety inspections. But reciprocal social security entitlements related to access
to medicines, health services, and reform of national policies and professiona-
lization of health workers and policy-makers were not addressed by
MERCOSUR. This was the case despite the creation of the Fund for
Structural Convergence (FOCEM) in 2003. FOCEM is a regional budget to
overcome asymmetries in less developed countries. In practice, however, the
funds have been assigned mainly to infrastructure programmes to enhance
border integration and communication systems, in the understanding that
connecting goods to markets, workers to industry, people to services and the
poor in rural areas to urban growth centres would enhance social development.
This, however, was insufficient to address structural problems of poverty and
inequality and social determinants of poor health. In other areas such as
education and labour rights, agreements have been reached to standardize
workers rights, and to harmonize quality and recognition of university
programmes and degrees, but further commitments on harmonization of
policies have been erratic and with mixed commitments in terms of
implementation during the 1990s (UNDP, 2011).
Institutionally, attempts at enhancing social participation in policy formu-
lation were led by the creation of two consultation forums: the Economic and
Social Consultative Forum (the Foro Consultativo Economico y Social
[FCES]), formalized in 1994 within the structure of MERCOSUR as a non-
binding social consultation process; and the MERCOSUR Social Institute
(Instituto Social del MERCOSUR [ISM]) in 2006, presented as a hub for
research on social policy and policy recommendation. Disappointingly, the
FCES remained largely limited in its social focus as it has been comprised
mainly by representatives of business groups, trade union federations and some
third sector groups dominated by consumer protection bodies. Bureaucratic
difficulties and ideological cleavages made the FCES highly ineffective,
struggling to find a place within the machinery of social integration (Grugel,
2009). The ISM, on the other hand, evolved as an important referent for civil
society activism and researchers working on social policy issues, although its
reach to policy circles remained limited.
Pa Riggirozzi: Regionalism through social policy 439
(2008) and Peru (2011) was not simply an expression of partisan and
symbolic politics, but a more profound acknowledgement that economic
governance could not be delinked from the responsibilities of the state to
deliver inclusive democracy and socially responsive political economies. In the
wake of crises, alternative strategies for development thus led to the adoption
of a mixed and generally pragmatic combination of welfare and populist
policies that secured not only post-crisis governance but also the control of
poverty and extreme poverty indices. This was possible because the rising tide
of citizenship demands in Latin America coincided with a changing economic
landscape in the region. After years of slow growth and recession, Latin
American economies were expanding in a genuinely unprecedented fashion in
response to rising global demand for minerals, energy and agricultural produce
mainly led by emerging markets in Asia (ECLAC, 2011, p. 77). More
confident and well-resourced Leftist governments not only developed a new
attitude to state building and inclusion, but also to region building. This
became evident in the aftermath of the Fourth Summit of the Americas, which
took place in Buenos Aires in November 2005. The Summit declaration
grounded two opposing views: one view favouring the United States-led
hemispheric regionalist project, the Free Trade Agreement of the Americas
(FTAA) mainly supported by the United States, Mexico and Canada and
countries especially dependent on preferential US trade agreements; and
another view from a dissenting group, including Brazil, Argentina, Venezuela
and Bolivia, which declared themselves against a hemispheric trade agreement
and refused to commit to future FTAA talks (Saguier, 2007). The defeat of the
FTAA was an indication that the previously unquestioned association between
regionalism and the trade/investment agendas was now open for review.
Although the idea of a unified counter-hegemony to supplant neoliberalism
in Latin America is clearly an overstatement, since the early 2000s the region
embraced different regional projects at odds with the US-sponsored Wash-
ington Consensus. This crystallized in the First Summit of South American
Presidents, in 2000, when discussions turned towards renewed commitments
on democratic principles and a broader sense of development (Sanahuja, 2012).
However, it was not until the termination of FTAA negotiations that the South
American integration process entered a new phase and dynamism. The Third
Summit held in Cuzco, Peru, in December 2004, established the South
American Union of Nations (SACN) that was later institutionalized as the
Union of South American Nations (UNASUR). The Cuzco Declaration
established three main goals: convergence between pre-existing trade-led
agreements, specifically MERCOSUR and the Andean Community; new
commitments to advance physical infrastructure (roads, energy and commu-
nications), a plan that originated in the First South American Summit with the
establishment of Initiative for the Integration of the Regional Infrastructure of
South America (IIRSA); and political co-operation in health and security
(Riggirozzi & Tussie, 2012).1 That same year, a new regionalist project was
also led by Venezuela, the Alianza Bolivariana de las Americas (ALBA).2
Pa Riggirozzi: Regionalism through social policy 441
The rediscovery of the region as a common space for pulling together resources
manifested in new commitments for institutional innovation and funding in
support of alternative ways of managing economic and human development
beyond traditional forms of state-bounded rights. This is not a minor issue in
societies with high levels of poverty, exclusion and inequality, struggling to
mobilize funding for social cohesion programmes. This is even more the case in
South America where, after years of sluggish growth and recession, a new cycle of
economic growth since the early 2000s saw rates of poverty fall sharply in Latin
America, by more than 14 per cent between 2000 and 2011 (ECLAC, 2011). But
despite these records, economic growth remains ambivalent. Around 168 million
live in poverty, that is around 30 per cent of the population subsisting with less
than two dollars a day, while 66 million live in extreme poverty, earning less than
one dollar per day (ECLAC, 2011, p. 14). Amongst this population, the most
economically and socially vulnerable, namely indigenous, rural poor, slum
residents and migrant workers, face the greatest burden in the povertyhealth
nexus in respect of infectious diseases and disabilities (ECLAC, 2011, p. 9). Some
alarming figures show that in low-income countries, such as Bolivia, Paraguay
and Peru, communicable diseases exert the most important influence on quality
of life and life expectancy. The incidence of endemic infectious diseases such as
malaria, tuberculosis and dengue and other communicable diseases such as HIV
442 Economy and Society
is a significant and growing problem across the region (Barreto et al. 2012). This
social reality reflects unequal economic and health indicators amongst countries
that are also different in terms of their health systems, levels of professionaliza-
tion and technical, scientific and institutional capacities. This bleak situation has
been worsened by limited access to medicines, particularly affecting populations
in rural and tropical areas, which accounts for what has been identified as
neglected diseases and neglected populations across the South (Holveck et al.
2007). It is in these circumstances, in tandem with new opportunities for
mobilization of ideas and resources brought about by the resurgence of growth
since the early 2000s, that the political agenda of UNASUR addressed the
regional integrationpoverty nexus in support of health equity goals. These goals
focus on neglected diseases affecting large populations, which in many cases are
located across shared borders; and the way South America is represented in
global health governance, as risks, regulatory frameworks and resources are
considered disproportionately to affect the developing world (see UNASUR,
2011, p. 15). Ultimately, health governance, as a locus for integration, not only
speaks of a new morality of integration linked to inclusion and human
development, but also of a new form of regional diplomacy.
ISAGS has been a key institution supporting these goals through the
creation and co-ordination of policy-oriented and informative research and the
dissemination of knowledge, training and capacity building.4 ISAGS was
articulated by a leading Brazilian research institution, the Oswaldo Cruz
Foundation, through its Centre of International Relations on Health. This
research institute responded to the newly created UNASUR by proposing an
agenda that considered health not simply as a public policy issue but also as a
problem of regional and global governance. Indeed, it was proposed that a new
institution helped improved the quality of policy-making and management
within the Ministries of Health of UNASUR members. According to its Chief
of Staff, this is an institution that emerged as a laboratory for new approaches
and new strategies for health governance both within and outside the region
(interview, 29 August 2012). The UNASUR Health Council, and ISAGS in
particular, capitalized on the international role of Brazil, which over the past
decade has taken an increasingly protagonist position contesting global norms
regarding access to medicines and right to health in various United Nations
bodies and networks of SouthSouth co-operation (Buss, 2011; Nunn et al.,
2009). But regional activism in health, and in many ways the fact that shared
values about the right to health were relatively quickly taken up by UNASUR
personnel and policy-makers, rests to a large extent on the fact that many of
them were part of what was known as movimiento sanitarista (movement for
public health), a health movement that since the 1970s brought activists and
professionals together and paved the way for a publicly funded, rights-based
health system in Brazil during the countrys democratization process and
constitutional reform in 1988 (Melo, 1993, p. 149, Cornwall & Shankland,
2008). Moreover, subsequent involvement of the sanitarista movements
representatives in official positions within the Ministry of Health created
opportunities for government officials, social reformists and academics to
develop a network that in turn was instrumental in the constitution of
UNASUR Health and ISAGS resembling in many ways what Haas (1992)
Pa Riggirozzi: Regionalism through social policy 445
These practices are also reaching outside the region through SouthSouth co-
operation and UNASUR leadership in health diplomacy. The leadership of Brazil
in the region is undoubtedly critical for these developments as it has been
instrumental in promoting an international presence for UNASUR, yet policy
positions for international discussions concerning the impact of intellectual
property rights on access to medicines, or the monopolist position of pharmaceut-
ical companies on price setting and generics, have been particularly driven by
Ecuador and Argentina, echoing new regional motivations for redistribution and
rights (interviews with International Co-operation Officer at the Ministry of
Health in Ecuador, 30 July 2012; former UNASUR Health Council delegate from
Ecuador, 6 August 2012; and former Co-ordinator of Technical Group for Access
to Medicines, 2 August 2012). UNASUR is establishing itself as a legitimate actor
advancing a new regional diplomacy to change policies regarding representation of
developing countries on the executive boards of the World Health Organization
(WHO) and its regional branch, the Pan-American Health Organization.
UNASUR also led successful discussions on the role of the WHO in combatting
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 Organization (Interpol) and funded by
developed countries engaged in intellectual property rights enforcement. Contro-
versies focused on the legitimacy of IMPACT and its actions, seen as led by
technical rather than sanitary interests, in unfairly restricting the marketing of
generic products in the developing world (interview with Senior Official at the
Ministry of Health in Ecuador, 30 July 2012). At the 63rd World Health Assembly
in 2010, UNASUR proposed that an inter-governmental group replace IMPACT
to act on counterfeiting of medical products. This resolution was approved at the
65th World Health Assembly in May 2012. The first meeting of the inter-
governmental group was held in Buenos Aires in November 2012. In the course of
this meeting, UNASUR also lobbied for opening negotiations for a binding
agreement on financial support and research enhancing opportunities in innova-
tion and access to medicines to meet the needs of developing countries. More
recently, led by Ecuador, UNASUR presented for discussion an action plan for
greater recognition of the rights of disabled people within the normative framework
of the WHO. Finally, UNASUR is seeking recognition to act through regional,
rather than national, delegates at the World Health Assembly, just as the EU
negotiates as a bloc across a wide range of agenda items (interview with Senior
Government Cabinet Official and former UNASUR delegate, 29 August 2012).
The presence of UNASUR in this type of health diplomacy and its co-
ordinated efforts to redefine rules of participation and representation in the
governing of global and regional health, and production of and access to
medicine via international negotiations, are indicative of a new rationale in
regional integration in Latin America based on international leadership and
long-term policy-making. These actions create new spaces for policy co-
ordination and collective action where regional institutions become an
opportunity for practitioners, academics and policy-makers to collaborate and
448 Economy and Society
Although regional formations have mostly been associated with, and studied
from, the perspective of trade concerns, they are far from passive objects in
either debates or practices pertaining to issues of poverty, inequality and social
development. They are indeed likely to become more active and significant in
the future. As illustrated by the developments in the policy domain of health,
UNASUR is advancing a more prominent role in the definition and achievement
of regional social developmental goals. Regional health governance in South
America is an expression of a new alignment between national socio-economic
goals, regional mobilization of resources and collective action and regional
(health) diplomacy. This is possible as UNASUR established a new normative
structure and practices through formal institutions and informal networks
engaging state and non-state actors involved in the formulation, negotiation and
implementation of health policies. These developments, it was argued, reconnect
national motivations, models of political economy and regional integration,
breaking at the same time with presumptions of external determinants of region-
building and the regionalismglobalization relationship. We are thus able to
move beyond arguments about the relative importance of economic globalization
as a structure of constraints for developing regions to speculate about how
regional social policy, as a policy endeavour and as social justice, can be
articulated by regional structures designed to produce a rights-based model of
governance and regional diplomacy.
The implications of these developments are twofold. In the first place, they
confirm that regional formations are significant actors in on-going attempts to
address and mitigate trans-border social issues and harms, contributing with
innovative normative frameworks, formal and informal networks and different
mechanisms of socialization and practices, engaging actors who potentially
have a significant impact on national policy-making and management. As
Pa Riggirozzi: Regionalism through social policy 449
Notes
References
Note on contributor