# Abstract

This article analyzes the Brazilian South South Cooperation in Health in Mozambique, specifically the fight against the AIDS Epidemic through the Antiretroviral Factory, in light of the concept of Structural Cooperation in Health, and with a basis in the literature on Cooperation for Development and Global Health. Thus, the article is divided into four parts: (i) a historical-bibliographic review of health as an International Relations issue; (ii) an overview of the field of health in Mozambique; (iii) an historical-political-conceptual debate about both types of International Cooperation for Development: North-South Cooperation and South-South Cooperation; (iv) a study about the antiretroviral factory, better known as the Mozambican Society of Medicines (Sociedade Moçambicana de Medicamentos). Through a case study, our goal is to verify if the Brazilian actions in Mozambique are in accordance with the concepts defended by the Structural Cooperation in Health, as well as to create new inquiries for academic debate.

International cooperation for development; AIDS; Mozambique; Structural cooperation in health

# Introduction

Everyone knows that plagues are recurring in the world, and yet nevertheless it is difficult to believe when they are slaughtering us. There are as many plagues as there are wars in the world; and, even so, both plagues and wars always take people by surprise11. Camus A. The Plague. Nova Iorque: Vintage International; 1991..

With this observation of Camus11. Camus A. The Plague. Nova Iorque: Vintage International; 1991. as our point of departure, this article proposes that, with nearly two decades of the 21st century behind us, the fight against the AIDS epidemic represents one of the greatest challenges for global and national public health policies. This is confirmed by the UNAIDS report entitled “How AIDS changed everything,” distributed in Addis Ababa during the 3rd International Conference on Financing for Development in July of 2015. Written by the Secretary General of the United Nations (UN), Ban Ki-moon, the preface of the Report affirms that the global response to HIV is incomparable, as it marks a turning point in the recognition of health as a human right.

In this sense, the World Health Organization (WHO) notes that, since its discovery in the 1980s, the epidemic infected approximately 75 million people, of which close to 36 million died. Furthermore, it is estimated that 35.3 million people live with HIV, and that 0.8% of adults aged 15-49 are HIV positive, although the gravity of the epidemic varies considerably between countries and regions22. World Health Organization (WHO). Global Health Observatory (GHO) data. 2017. [acessado 2017 maio 23]. Disponível em: http://www.who.int/gho/hiv/en/
http://www.who.int/gho/hiv/en/...
. Resolution 198333. United Nations Security Council. Resolution 1983. 2011. [acessado 2015 set 28]. Disponível em: http://www.unaids.org/en/media/unaids/contentassets/documents/document/2011/unsc/20110607_unsc-resolution1983.pdf
http://www.unaids.org/en/media/unaids/co...
of the Security Council of the UN (2011) states “HIV poses one of the most formidable challenges to the development, progress, and stability of societies and requires an exceptional and comprehensive global response… of Member States, public and private partnerships, [and] non-governmental Organizations”. The adoption of this resolution is important not only in how it affects the unequivocal relationship between health and international relations, but because it also demonstrates how the illness is an urgent challenge for international cooperation.

In effect, the phenomenon of the international propagation of infectious diseases characterizes what David Held44. Held D. Regulating Globalization? The Reinvention of Politics. London: Sage; 2000. calls “boundary problems.” For Held, the democratic political community is being increasingly contested by regional and global pressures and problems that undermine the boundaries between domestic and international policy, as well as concerns pertinent to the sovereignty of the Nation State and its international insertion. The HIV/AIDS epidemic is included by the author in what he calls boundary problems. In this sense, attention is called to the agenda of global health in the sphere of international policy, as convergence of the fields of study of international and relations becomes fundamental, whereas these are frequently concentrated in an isolated way in their professional areas.

Apart from the (important) discussion about the term “Global Health,” the present article adopts the understanding introduced by Kickbusch55. Kickbusch I. Global health: a definition. New Haven: Yale; 2013., in which the primordial focus is the impact of the global interdependence of the determining factors in health and the political response of the countries, international organizations, and other different actors in this fertile area. Thus, for Kickbusch the objective of “Global Health” would be equal access to health in all the regions of the planet. This perspective highlights that the lower and medium-income countries have critical limits to governance, aside from a lower capacity to formulate and implement public health policies that are efficient for their population. Aside from precarious health systems that do not possess basic technological resources, the professionals in the area – notwithstanding that they are scarce, poorly trained and remunerated – still migrate to developing countries66. Buss P, Ferreira JR. Ensaio Crítico sobre a Cooperação Internacional em Saúde. Revista Eletrônica de Comunicação, Informação, Inovação e Saúde 2010; 4(1):93-105.. Against this background, the poorest countries end up dependent on international aid, which becomes a determining factor for the improvement of the life conditions and health of their populations.

This article, divided into four parts, seeks to intervene in this present scenario, adding to the growing global debate about the efficacy of international aid. First, we carry out a brief historical and bibliographic review of the field of health in international relations. After this, we sought to outline a general picture of health in Mozambique, specifically the AIDS epidemic and the way in which developed as well as developing countries operate in this field. Furthermore, we engage in a brief discussion about aspects of International Cooperation in its historical and political dimensions. Finally, we problematize the Brazilian cooperation for the fight against AIDS in Mozambique, specifically the Antiretroviral Factory – better known as the Mozambican Society of Medicines (Sociedade Moçambicana de Medicamentos , or SMM), focusing on its possibilities and limitations by way of a conclusion.

## The Pathways of the Text (Methods)

The creation of the article’s text followed three different but complementary paths. The first is comprised of a sketch of the literature on the subject with the intention to situate and contextualize the debate, resulting in points numbered one and two. The first path involves a foray into theory with the intention of looking to support the theoretical conceptualization that comprises the third point of the article. In this sense, faced with the persistence of the HIV/AIDS epidemic in Mozambique, we looked to unravel the theoretical and conceptual differences in relation to North-South Cooperation (NSC), reflect on the activity and projects of South-South Cooperation (SSC), taking as a case study the implementation of the Antiretroviral Factory by Brazil in an Africa country.

For its part, the second path sets forth a documentary reflection guided by an analytical-synthesizing viewpoint and an attentive examination of the source. The analysis of documents is mainly built on publications of Fiocruz (the Oswaldo Cruz Foundation), press articles (Brazilian as well as Mozambican) about the Antiretroviral Factory, and a technical-economic viability study undertaken for the factory installation.

Finally, the third path was comprised of interviews carried out by the author in Mozambique in the month of October 2015. Five Brazilian and Mozambican professionals were interviewed from different institutions: the Brazilian Embassy in Maputo, the Health Ministry of Mozambique (Ministério de Saúde de Moçambique, or MISAU), the Mozambican Society of Medicines, and local doctors. All of the interviews were initially transcribed. This choice, in our estimation, becomes highly relevant since it is established as a way to give a voice to those people who – broadly speaking – can be considered the target population of this project, as well as those that participate in the cooperation promoted by Brazil to combat AIDS/HIV in Mozambique.

## The place of Health in International Policy

The issues of health and the international reach of diseases are long-reaching, as are the agreements of the countries that have sought to discuss the impact of epidemics on international commerce, for example in the First International Sanitary Conference of 1851. However, it was in 1948 with the Universal Declaration of Human Rights that health is recognized as an inalienable right for each and every person, and as a social value to be pursued for all of humanity. From this point onward, various States progressively began to include this and other human rights in their constitutions, making them into fundamental rights.

In the wake of the restructuring of the world after the Second World War, the Economic and Social Council (ECOSOC) held the International Health Conference, in which the Statutes of the World Health Organization were approved. The WHO came to exist in 1948, with a headquarters in Geneva, with the goal of establishing plans and health guidelines for the world, including prevention, protection, and treatment of diseases, global access to medical assistance, emergency care in epidemics, and prioritization of health initiatives for the entire world. In spite of the crisis that permeates the organization, it can still be considered a “moral authority and mouthpiece for health in the world”77. Ventura D, Perez FA. Crise e Reforma da Organização Mundial da Saúde. Lua Nova 2014; 92:45-77..

In effect, experiences like the Ebola epidemic, the H1N1 flu, and the recent WHO declaration that the neurological disturbances and neonatal malformations linked to the Zika virus constitute a Public Health Emergency of International Concern (PHEIC) exemplified that the challenges of health are transborder ones, and therefore need to be resolved in a collective way by countries. In this sense, authors like Kickbusch and Berger88. Kickbusch I, Berger C. Experiências e lições aprendidas no desenvolvimento de capacidades em diplomacia da saúde global. RECIIS 2010; 4(1):141-147. assert that health issues are transcending the purely technical realm and becoming an essential element of foreign policies and security, much like commercial agreements. Thus:

[…] historically, public health has been, above all, an issue of domestic policy, but the developments of the last decade forced public health specialists and diplomats to think of health as foreign policy, that is to say, public health as an important issue for countries’ pursuit of their interests and values in international relations99. Fidler D. Reflections on the revolution in health and foreign policy. Bull WHO 2007; 85(3):243-244..

In terms of Brazil, the strategy adopted by ex-president Luis Inácio Lula da Silva, and carried out by his chancellor Celso Amorim, is widely known and respected: to pursue the greater participation of the country in the international sphere via a greater interdependence between Brazil and the other South American countries, and through a strengthened union with developing countries. Furthermore, it is inevitable that the actions of South-South Cooperation, especially with the African continent, had a great impetus during the Lula administration. Thus, Cepik and Sousa1010. Cepik MAC, Sousa RP. A Política Externa Brasileira e a Cooperação Internacional em Saúde no Começo do Governo Lula. Século XXI: Revista de Relações Internacionais 2011; 2(1):109-134. discuss the initiatives of international cooperation in health via the foreign policy guidelines of Lula/Amorim established in 2003. The authors analyze the consistency between the general guidelines of foreign policy and the challenges for implementation of sectorial public policies in periods of transition, and draw attention to the great diversity and complexity of initiatives in the area of health.

In effect, since the beginning of the 2000s, Brazil has been pursuing a more protagonist role in debates over global health by seeking the price reduction of imported drugs and, internally, by the national production of medicines, both fundamental to guarantee distribution. The country’s international engagement was also accompanied by demonstrations from international civil society organizations, such as the British organization Oxfam and Doctors Without Borders, that supported the Brazilian position on the viability of access to antiretroviral drugs (ARVs)1111. Fedatto MS. A Cooperação Internacional na efetivação da Saúde Global: o papel do Brasil no combate ao HIV. BEPI 2015; 21:59-70..

It is worth emphasizing further that, in 2001, the 57th Session of the UN Human Rights Commission approved Resolution 33/200, a proposal by the Brazilian delegation, regarding access to essential medicines as a human right to health. Later, in 2007, the Global Health and Foreign Policy initiative, to which Brazil is a signatory, highlighted that health is one of the most important long-term subjects in current foreign policy, and affirmed the urgency of creating new paradigms for cooperation, emphasizing the connections between foreign policy and health.

Indeed, one cannot speak of new themes in global governance without addressing the alliances between developing countries. In the field of health, it is noteworthy that in 2009, under the leadership of IBSA (India-Brazil-South Africa Dialogue Forum), Resolution 6/29 was approved within the UN Council on Human Rights, recognizing that “access to medicine is one of the fundamental elements for progressively achieving the total achievement of the right to the full enjoyment, at the highest possible standard, of physical and mental health,” and to “point out the responsibility of the States to assure the access of all, without discrimination, to medicines, especially essential medicines.”

Furthermore, keeping in mind the cooperative agenda of the “emerging” countries that comprise the BRICS group – Brazil, Russia, India, China, and South Africa – health assumes a double importance for Brazil. First, the country sought the inclusion of the fight against HIV/AIDS in the social cooperation agenda of BRICS; in second place, the theme is important from the point of view of Brazil’s international insertion, which has health as one of its strongest vectors of activity1212. Esteves P, Maia FNC, Niv A, Fonseca JMEM, Assunção M. Os BRICS e a agenda da Saúde Global. Rio de Janeiro: Núcleo de Cooperação Técnica e Ciência e Tecnologia BRICS Policy Center, Centro de Estudos e Pesquisa BRICS; 2011.. In this sense, the report of the 2012 Global Health Initiative notes that the amount invested in health in the BRICS countries individually has been growing in recent years, contrary to the countries traditionally associated with the Organization For Economic Cooperation and Development (OCDE), such as the United States, that put a freeze on financing for global health because of the 2008 financial crisis.

Health, therefore, is progressively inserted into the strategies of the emergent economies that seek solutions for the common problems of the global South, as well as a greater democratization of the international organizations. The provisioning of medicines for developing countries, for example, has been one of the talking points, but has clashed with the controversial agreement over protection of intellectual property.

Consequently, Souza1313. Souza AM. O Acordo sobre os Aspectos dos Direitos de Propriedade Intelectual relacionados ao Comércio: implicações e possibilidades para a Saúde Pública no Brasil. Rio de Janeiro: Instituto de Pesquisa Econômica Aplicada (IPEA); 2012. assures us that Brazilian foreign policy regarding health has sought to characterize access to essential medicines as a human rights issue and, bolstered by this understanding, accredited itself for the installation of a Antiretroviral Drug Factory in Mozambique. This objective of Brazilian health cooperation is clearly stated in Article 1 of the Complementary Agreement of Cooperation between Brazil and Mozambique:

The present Complementary Agreement has as its objective the implementation of the installation project of the factory for antiretroviral drugs and other medicines in Mozambique, whose purpose is knowledge transfer in the area of production, industrial management, and quality control of antiretroviral and other medicines, seeking the broadening and improvement of access to these medicines on the part of the Mozambican population affected by the HIV/AIDS virus and by other threats to health1414. Cooperação Técnica entre Países em Desenvolvimento. BRA/04/044/S117. Brasil-Moçambique. Capacitação em Produção de Medicamentos Antirretrovirais. Revisão E. Brasília: Agência Brasileira de Cooperação; 2011..

Thus, keeping in mind that South-South Cooperation emerged as a way to circumvent the conditions tied to North-South foreign aid, and seeking to understand the innovations proposed by the CSS with the aim of investigating the veracity and applicability of this concept in cooperative practices, the focus of this article is the main activity of Brazil in Mozambique.

## Health in Mozambique

We believe it is necessary to clarify the chosen object of study. Mozambique is located in the southern region of Sub-Saharan African, a place where the AIDS epidemic is common. According to an estimate from UNAIDS1515. UNAIDS. HIV and AIDS estimates (2015). [acessado 2017 maio 23]. Disponível em: http://www.unaids.org/en/regionscountries/countries/mozambique
http://www.unaids.org/en/regionscountrie...
, the rate of prevalence in the adult population (15-49 years) is 10.5%. Furthermore, in a population of 24.5 million inhabitants, 1.5 million in the country live with AIDS and 590,000 children are orphans owing to their parents’ death to HIV-related causes. It is worth remembering that approximately 50% of the Mozambican health infrastructure was destroyed during the civil war (1977-1992) that devastated the country, and that in spite of a relative increase only 53% of Mozambicans affected by HIV have access to treatment1616. Instituto de Estudos Sociais e Econômicos. Moçambique, estratégia de assistência ao país (2009-2014). Maputo, 2014. [acessado 2017 maio 23]. Disponível em: http://www.iese.ac.mz/lib/PPI/IESE-PPI/pastas/governacao/agricultura/legislativo_documentos_oficiais/eua_assistencia.pdf
http://www.iese.ac.mz/lib/PPI/IESE-PPI/p...
.

HIV, then, is a challenge that transcends the field of health, involving cultural and religious issues. For example, in the capital Maputo it is estimated that approximately 50% of sexually active persons use condoms, and this percentage falls below 30% in other cities like Nampula. This data is drawn from the National Health Institute of Mozambique which, in partnership with USAID (United States Agency for International Development), issued the publication “HIV in the midst of couples in Mozambique”1616. Instituto de Estudos Sociais e Econômicos. Moçambique, estratégia de assistência ao país (2009-2014). Maputo, 2014. [acessado 2017 maio 23]. Disponível em: http://www.iese.ac.mz/lib/PPI/IESE-PPI/pastas/governacao/agricultura/legislativo_documentos_oficiais/eua_assistencia.pdf
http://www.iese.ac.mz/lib/PPI/IESE-PPI/p...
.

In essence, the most recent data on domestic and international expenditures in the fight against HIV, according to the National Council of the Combat Against Aids (Conselho Nacional de Combate ao SIDA, or CNCS), indicate that in 2014 the record amount of USD 332.5 million was spent on HIV programs, which corresponds to an increase of 28% over the amount for 2011, USD 260.3 million. In this article, we must highlight the strong dependence of the national response to the AIDS epidemic on external funding, which represented close to 95% (USD 314.1 million) of the total expenditures in 2014. The domestic public resources were 4.9% (USD 16.2 million) and private domestic resources close to 0.7 (USD 2.2 million) of the total 2014 expenditures.

In spite of actions of cooperation, as much North-South as South-South, and the high amounts corresponding to foreign aid (as observed above), Mozambique continues to demonstrate lower indexes of human development and is on the list of the poorest countries in the world, with a GDP per capital of USD 1.262 and a HDI (Human Development Index) of 0.393. Thus, this proposal is put forth with the purpose of collaborating for understanding the contribution of cooperative actions on advances in global health.

## International Cooperation: pluralism and solidarity?

Health is equally recognized as a prominent theme in traditional North-South Cooperation as it is in South-South Cooperation. In the face of the accelerated deepening of inequality in the world, countries have intensified proposals of international aid and philanthropy, looking to lesson health problems and improve the life conditions of the populations.

A historical review shows us that the first component of international aid to be institutionalized was North-South cooperation (NSC). However, in the wake of the Cold War, the logic of international security influenced the channels for the influx of resources. In this sense, since its creation, NSC was conditioned by the national, economic, and ideological interests of the great powers, as well as their pursuit of a greater place on the international stage. As Hirst and Antonini1717. Hirst M, Antonini B. Passado e presente da cooperação norte-sul para o desenvolvimento. Buenos Aires: Ministério das Relações Exteriores, Comércio Internacional e Culto da Argentina; 2009. Informe do Encontro Acadêmico Ibero-americano de Cooperação Internacional affirm:

At the same time in which we see the expansion of the demand for cooperation, its runs the risk of an increased emptying of its attributes as an instrument of structural transformations, one that would be capable of mobilizing effective changes in the social and political-institutional conditions of the receiving countries.

One criticism noted by Milani1818. Milani C. Aprendendo com a história: críticas à experiência da Cooperação Norte-Sul e atuais desafios à Cooperação Sul-Sul. Caderno CRH 2012; 25(65):211-231. is that international cooperation and the promotion of development has disseminated political viewpoints that, many times, ignore the contradictions and asymmetries between the social classes, societies, nations, and the international economy. Furthermore, they foster interference of a cultural, social, economic, and political nature in the receiving countries. The author also criticizes the capacity for absorbing the aid delivered to the recipients. In other words, whether the actions of foreign aid bring real benefits to their beneficiaries (governments and society), and if these possess the capacity for implementation of so many projects and programs.

According to postcolonial studies of International Relations, the States, in spite of the condition of sovereignty, demonstrate serious shortfalls in their internal organization, as well as their development. In this sense, Manzo1919. Manzo L. Beyond house and haven: Toward a revisioning of emotional relationships with places. Journal of Environmental Psychology 2003; 23(1):47-61. argue that, after the Second World War, the international community developed discourses that sought the adoption of global values like human rights, democracy, and humanism, to be based on values and traditions originating in the West, ignoring the existing complexity in the process of the formation of values in new societies. In this context, international cooperation came to be more than an instrument of assistance to impoverished populations, and came to complement the strategies for the construction and maintenance of the global hegemony of the great powers. It is possible, therefore, to perceive an asymmetry between the discourse of solidarity and the practices of NSC, illustrated by way of:

[…] the innumerable projects that required (and still require) the acquisition of equipment and services of the donor States themselves, the almost exclusive use of their specialists, the compliance with a series of political conditions (human rights, good governance, etc.), as well vertical interpretations of the needs of the local population. One can argue that, at the same time, to cooperate for development was considered synonymous with the direct transference of practices and technologies, grounded in developmentalist and, above all, Western models2020. Milani C, Carvalho T. Cooperação Sul-Sul e Política Externa: Brasil e China no continente africano. Estudos Internacionais 2013; 1(1):11-35..

Thus, in 2008, the Organization for Economic Cooperation and Development promoted the 3rd High Level Forum on Aid Effectives, where a change was suggested in the polices of International Cooperation and Development for the countries of the North and the incorporation of the aid recipients as partners in the process. The discussion about the effectiveness of international aid came to be more unanimous beginning in 2011, with the Busan Declaration that tried to coordinate the old and new actors in the field of cooperation:

We also have an architecture of cooperation for a more complex development, characterized by a greater number of state and non-state actors, as well as cooperation between countries in different stages of development, many of them countries of medium income. Triangular and south-south cooperation, new forms of public-private partnership, and other modalities and vehicles for development have gained more prominence, complementing north-south forms of cooperation2121. Parceria de Busan para a Cooperação para o Desenvolvimento. Quarto Fórum de Alto Nível sobre a eficácia da ajuda, Busan, República da Coreia. 2011. [acessado 2017 maio 23]. Disponível em: http://effectivecooperation.org/wp-content/uploads/2016/03/outcome_document_-_final_por.pdf
http://effectivecooperation.org/wp-conte...
.

South-South cooperation gained visibility beginning in the 1970s with an approach more oriented toward Basic Human Necessities (BHN) that allied with one great preoccupation with the social aspects of human development. Lechini2222. Lechini G. Argentina y Brasil em La Cooperación Sur-Sur. In: Lechini G. Argentina y Brasil. Venciendo preconceptos. Las variadas aristas de uma relación estratégica. Rio de Janeiro: Editora Revan; 2009. defines South-South Cooperation as a fundamentally political action that occurs in a bilateral or multilateral form, with the objective that the countries have greater power or act together, and through this achieve a role of greater prominence in the world of international relations.

In this context, we can observe the construction of power in the State, and how the projection of this power represents an important tool to achieve influence and international relevance. Nye Junior2323. Nye Junior J. The future of Power. Nova Iorque: Public Affairs; 2011. argues that in order to reach “smart power” it is necessary to invest in global public goods, offering them to the populations and governments that cannot achieve them on their own. In our case study, this would be to promote economic development, guaranteeing public health.

This reasoning is corroborated by Vaz and Inoue2424. Vaz A, Inoue C. Les économies émergentes et l’aide au développement international: Le cas du Brésil. Paris: IDRC/CRDI; 2007., who argue that cooperation is used as an instrument of foreign policy that seeks to strengthen Brazil’s leadership in Latin America and create markets in other places. In other words, Brazilian cooperation could be understood as an expression of Brazilian smart power.

However, official discourse defends the idea of a foreign policy in solidarity with the field of Cooperation for Development, oriented by national development priorities. According to the Ministry of Foreign Relations2525. Brasil. Ministério das Relações Exteriores. Cooperação Técnica. [acessado 2017 maio 23]. Disponível em: http://www.itamaraty.gov.br/index.php?option=com_content&view=article&id=3686:cooperacao-tecnica&lang=pt-BR&Itemid=478
http://www.itamaraty.gov.br/index.php?op...
:

[…] cooperation with developing countries contributes to consolidating the autonomy of partner countries, promoting sustainable growth that guarantees social inclusion and respect for the environment. […] Technical cooperation given by Brazil to developing countries (South-South) draws on the established capacity of specialized national institutions, without the need to appeal to the mobilization of massive financial resources. It is structured beginning with a specific local needs, emphasizes the appropriation of the results by local institutions, and is developed without conditions – or rather, without demands from the counterparts.

Therefore, in contrast with international aid, Brazilian cooperation proposes to be more participatory and oriented towards the need, decoupled from immediate commercial interests, and guided by the principle of solidarity and of non-indifference. It is fundamental, however, to emphasize that the difference is not found in the absence of Brazilian economic interests in the receiving countries, but in the absence of imposed conditions, especially of the macroeconomic variety, and of the context of the cooperation.

The actions of SSC, however, also present limitation, among which we highlight the absence of a coordinating organ for actions such as, for example, the Development Assistance Committee for North-South cooperation organized under the OCDE. In addition, many countries that promote SSC do not have a registry of their actions, quantities, and beneficiaries, which makes the analysis of the scale and progress of cooperation very difficult2626. Puente CAI. A Cooperação Técnica Horizontal brasileira como instrumento da política externa: a evolução da cooperação técnica e com países em desenvolvimento – CPTD – no período 1995-2005. Brasília: Fundação Alexandre de Gusmão, Ministério das Relações Exteriores; 2010.. Hirst2727. Hirst M. Aspectos conceituais e práticos da atuação do Brasil em Cooperação Sul-sul: os casos de Haiti, Bolívia e Guiné Bissau. Rio de Janeiro: IPEA; 2012. Texto para Discussão nº 1687. further emphasizes that the countries which cooperate in this modality possess limited financial resources and the greater part of the recipients possess an elevated institutional fragility, such as critical limitations in governance, adding to a lower capacity to formulate and implement efficient public policies.

Taking into account a 2014 study from Brown University which notes that since 1980 there are a growing number of infectious diseases deriving from an equally increasing number of sources, we agree with Buss and Ferreira66. Buss P, Ferreira JR. Ensaio Crítico sobre a Cooperação Internacional em Saúde. Revista Eletrônica de Comunicação, Informação, Inovação e Saúde 2010; 4(1):93-105. on the need for international cooperation in health, as well as the prognosis for the field in general. For the author, the assessment of international health cooperation seems positive, while they perceive a gulf between the intention and the materialization of actions in the area. This perception is central to the goals of this article.

## Structuring Cooperation in Health: The Mozambican Society of Medicines

The National Program of STDs/AIDS was created in Brazil in 1986, in an atmosphere of sociopolitical reforms, characterized by an organized movement of civil society in defense of health as a right of all and an obligation of the State. Later, this right was recognized in article 196 of the Federal Constitution of 1988, serving as a basis for the creation of the Unified Health System (Sistema Único de Saúde, or SUS) in 1990, whose basic foundation is universal, equitable, and integral access to health services.

The Brazilian response to the AIDS epidemic is supported by Law No. 9313/1996, which in its first article guarantees the free distribution of medicines by SUS to all HIV-positive persons that have a need to receive them, and was the first governmental initiative in the world to promote universal access to antiretroviral drugs.

The goal of the National Program of STDs/AIDS is to formulate and encourage public policies seeking to contain the transmission of HIV, as well as to promote the health of persons living with AIDS. In this sense, it develops a unified policy of prevention, diagnosis, and treatment of the disease, offering services in a decentralized manner, by way of the referral centers of the Support Houses, in addition to training health professionals and supporting research2828. Meiners CMMA. Patentes farmacêuticas e saúde pública: desafios à política brasileira de acesso ao tratamento anti-retroviral. Cad Saude Publica 2008; 24(7):1467-1478.. The educational and prevention campaigns that include distribution of condoms are also significant, as well as the campaigns directed at vulnerable populations, such as sex workers, injectable drug users, and homosexuals2929. Brasil. Ministério da Saúde (MS). Cooperação Saúde nº 3. Boletim de Atuação Internacional em Saúde. Brasília: MS; 2010..

Therefore, the fight against the AIDS epidemic in Brazil can be considered a successful example, demonstrated by the fall in the mortality and morbidity rate since 1996 and sustained by the organization of the services network, by the distribution of antiretroviral medicines, and by preventative actions.

This situation – domestically as much as internationally – combined with the priority that South-South Cooperation had under the Lula government, gave Brazil the credentials to propose its most ambitious project of international cooperation for development: the implementation of an Antiretroviral Drug Factory in Mozambique. As noted previously, the history of the negotiations and the implementation of the cooperative agreement were analyzed by the author in her Master’s dissertation titled “Fiocruz and the Cooperation with Africa during the Lula Government3030. Fedatto MS. A Fiocruz e a cooperação para a África no governo Lula [tese]. Brasília: Universidade de Brasília; 2013..” Here, we seek to understand if there was an effective practice of the concept of Structural Cooperation in Health.

First, it is necessary to clarify that the concept of Structural Cooperation in Health, developed by the Oswaldo Cruz Foundation (Fundação Oswaldo Cruz, or Fiocruz), is central to the activity of International Health Cooperation in Brazil. Thus, Almeida3131. Almeida C. A concepção brasileira de “cooperação Sul-Sul estruturante em saúde”. Revista Eletrônica de Comunicação, Informação, Inovação e Saúde 2010; 4(1):23-35. elucidates that the focus of Structural Cooperation is the training of human resources and the creation of capacities for research, teaching, or services, as well as the strengthening or creation of “structuring institutions” of the health system, such as health ministries, schools of public health, national institutes of health, universities or technical courses, polytechnic schools in health, institutes of technological development and the production of inputs, including factories for medicines. The proposal is that these institutions act together in national and regional networks, and support the efforts of structuring and strengthening the health systems of their respective countries.

In effect, in November of 2003, ex-president Lula and the ex-president of Mozambique Joaquim Chissano signed the “Protocol of Intent between the Government of the Federal Republic of Brazil and the Republic of Mozambique on Scientific and Technological Cooperation in the Field of Health.” The established objectives were: (a) guarantee the provision of ARV (Antiretroviral drugs) for the treatment of HIV in the country; (B) begin the manufacturing of generic pharmaceuticals in Mozambique, allowing for the fulfillment of the goals of the national policies of Primary Care and pharmacists; (C) to reduce the dependence of the country on donations and imports of pharmaceuticals; and (D) to contribute to the creation of a local capacity for pharmaceutical production and industrial management3232. Brasil. Ministério das Relações Exteriores (MRE). Protocolo de intenções entre o Governo da República Federativa do Brasil e o Governo da República de Moçambique sobre Cooperação Científica e Tecnológica na Área da Saúde. Brasília: MRE; 2003..

Subsequently, the Brazilian Ministry of Health and Fiocruz carried out a technical-economic viability study about the installation of the factory. In spite of being widely known as “the factory of Brazilian antiretroviral drugs” because of its initial focus on supporting the national fight against AIDS, the company was officially registered as the Mozambican Society of Medicines when the complexity of producing antiretrovirals (ARVs) with few resources became apparent. Beyond this, in spite of the great expectations in the African country during the time of the agreement, currently the factory is not often spoken of in the country, even in the institutions that were involved, such as the Ministry of Health. It is understood, domestically, that it is in a phase of establishing and creating processes with long-term goals (Interviewee 1).

Regarding the financial attributions, the project predicted that Brazil would donate the factory’s equipment – an estimated total of USD $5,000,000 – as well as all the necessary documentation for the manufacturing and quality control of the products to be made3030. Fedatto MS. A Fiocruz e a cooperação para a África no governo Lula [tese]. Brasília: Universidade de Brasília; 2013.. This documentation consists of the registration files, which are a description of the entire manufacturing process and the analytical information to produce each of the medicines. This was the beginning of the transference of technology (Interviewee 2). On the other hand, Mozambique would be entrusted with the labor for installation of the factory, in an estimated total of USD$5,400,0003030. Fedatto MS. A Fiocruz e a cooperação para a África no governo Lula [tese]. Brasília: Universidade de Brasília; 2013.. However, after the purchase of an old serum factor in Matola, the Mozambican government confirmed that it was not able to finance construction. This brought about the first impasse. In this sense, it is worth remembering that the Structural Cooperation promoted by Brazil does not focus on financial contributions. The impasse and the three interviewed subjects – from different institutions – corroborated this characteristic. The resolution arrived via the donation of 75% of the costs of construction by the Brazilian company Vale do Rio Doce to complete the Mozambican counterpart3333. Lopes R. O Governo Brasileiro e a Cooperação Sul-Sul com Moçambique no Campo da Saúde Pública [dissertação]. Rio de Janeiro: Universidade do Grande Rio; 2013..

Currently the Mozambican Society of Medicines team has 11 Brazilians and 51 Mozambicans. The expectations were that there would be a larger local team, however one interviewee reveals the difficulty of hiring owing to the lack of specialization in the population: “for the three openings for pharmacist, we had four candidates, of which only one had a background in chemistry.” Furthermore, the need for training the local team is notable, as the mastering of the technology of manufacturing and the technical knowledge for that manufacturing to meet the required regulations is essential (Interviewee 2). Regarding the training of human resources, we may recall that it constitutes one of the components of Brazil’s international technical cooperation:

In The Brazilian CGPD is done for the transference of Brazil’s technical knowledge and experience, on a non-commercial basis, as a way of promoting the autonomy of the involved partners. For this purpose a high value is placed on the following tools: consultations, trainings, and the eventual donation of equipment3434. Agência Brasileira de Cooperação (ABC). CGPD - Coordenação Geral de Cooperação Técnica entre Países em Desenvolvimento. [acessado 2017 maio 23]. Disponível em: http://www.abc.gov.br/SobreABC/Direcao/CGPD
http://www.abc.gov.br/SobreABC/Direcao/C...
.

In this way there is a continual and progressive transfer of knowledge. Until October of 2015, 55 stages of training had already been carried out. To conventional training in Maputo – undertaken by the Brazilian Agency for Cooperation, where Brazilian technicians administer short-term courses on specific themes – is added “immersive” training of Mozambicans for approximately one month at Farmanguinhos [a pharmaceutical training institute run by Fiocruz in Brazil] and “the possibility of making visits to other pharmaceutical industries to have a broader vision of the process.”

The accompaniment, support, and supervision of the factory’s activities by specific Brazilian professionals (pharmacists, chemists) sent to Maputo is also notable. This accompaniment is considered by Brazilians as “complementary training,” as it is based on the need to bring these professionals up to date with the new activities in development, as well as aiming to guarantee the correct application of the knowledge acquired in the “formal” training. However, in a general way, “today, training is done through the continuous activity inside the factory, and learning is in the practice and the manipulation of activities within the production and quality control” (Interviewee 2).

The Mozambican Society of Medicines, until October of 2015, had manufactured Haloperidol, previously Propranolol, and – at the time of interviews – was working with three batches of Captopril. Note that none of these medicines are antiretroviral, as predicted in the 2013 project. Logistical issues constitute the main impediment to the manufacturing of antiretroviral drugs, keeping in mind that all the supply inputs are sent from Brazil to Mozambique. Thus, production ends up dependent on what is made available by Farmanguinhos. Another obstacle is the difficulty of creating activities in areas that were formerly non-existent, as much on the Brazilian side as on the Mozambican side. For example, Farmanguinhos, as a producer of medicines, used to import their supplies; today, they are having to export supplies to Mozambique (Interviewees 2 and 3).

Overall, aside from the complexity of the project’s implementation as proposed by the Brazilian government – such as the lack of specialized workers, bureaucratic obstacles, and a complex and interdependent production chain – the persistent challenges of SSC in general are an additional burden. These include the nonexistence of public policies that guarantee planning, coordination, and sustainable flow of resources to respond to the growing demands in both countries.

# Final Considerations

To conclude this study, we find that we have reached the proposed goal in contributing to the academic debate on the importance of health as a theme in international relations and of countries’ foreign policies, seeing that Camus’ alarm cited in the epigraph remains relevant for the twenty-first century. In other terms, the article adds to the voices that call attention to the fact that epidemics know no borders, and therefore demand concrete actions to fight them.

In our view, these reflections reinforce the idea that cooperation and diplomacy can and should work together to broaden the vision of health beyond the control of diseases, and taking into account their social determinants. Or rather, this partnership leads to the revision of the concept of health, which sheds its domestic limits and emerges as a universal right.

Likewise, we can note the Brazilian pioneering spirit and audacity when we analyze the Mozambican Society of Medicines. We see that, for the first time, a project of International Cooperation simultaneously provided transference of knowledge and technology, training of human resources, and investment in infrastructure. It was a process whose goal was and remains long-term autonomy, in administration as well as the technical area of production, with the installation of a factory to be managed in its entirety by Mozambicans. Nevertheless, the Mozambican Society of Medicines does not operate for the ends for which it was created: the production of retroviral drugs. This is a lamentable fact, on one hand, considering that AIDS is spread through the country’s population, but on the other hand it has enabled the government to provide medicines for chronic diseases. The argument about the complexity of the production of antiretroviral drugs, however, should not in our view serve as a pretext for not fulfilling the original proposal. This “deviation of function” of the Mozambican Society of Medicines leads back to the necessity of taking the local reality, its history, and its culture into consideration before “imposing” any cooperation project.

In light of Structuring Health Cooperation, it is possible to affirm that in the case in question there was the practical application of these concepts. This conclusion is supported by the transference of technology beginning with the donation of the registration files and all documentation describing the productive process for each of the medications, in the continual training of local labor resources, and investing in the establishment of a national health institution that has a structuring character to assist in the development of a national health system. However, in our view the term “structuring” implies/requires more than the “goodwill” of the donating country. That is to say, we are informed by the interviews that Mozambique lacks the qualified laborers to guarantee the efficient functioning of the Mozambican Society of Medicines.

The documentary analyses complemented by the interviews corroborated the discourse defended by the developing countries, in the case of Brazil, that South-South Cooperation is fundamentally different from the vertical actions of international aid promoted by the countries of the North. SSC, as much in its discourse as in the observed practice, is guided by the needs of the beneficiary countries, by mutual responsibilities, and not by imposed conditions.

Finally, the challenges that the Mozambican Society of Medicines will confront (and which it has been confronting since the beginning of the cooperation agreement) are apparent. It should be emphasized that the absence in the country – as much in the pharmaceutical industry as in a system of higher education with quality and relevance for the provided training – has impeded the hiring of specialized and experienced local labor. This is a paradoxical situation, as local labor is a requirement for the Medicine Society and central to the concepts of Structuring Cooperation. We note again the logistical and bureaucratic difficulties, the elevated sanitary requirements, and the interdependent pharmaceutical production chain that involves importation of inputs, manufacturing, distribution, and commercialization of medicines, in addition to technical and analytical expertise.

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# Publication Dates

• Publication in this collection
July 2017