11 The Role of Emerging Donors in Global Health Development

Question 1

Overview Summary

Answer 1

Since the creation of the United Nations (UN) system in 1945, the fields of international development and development aid have undergone several transitions, experiencing shifts related to which countries are recipients or donors of development aid, which development issues are prioritized and why, and how international development programming is governed, financed and implemented. This session will provide a brief overview of the historical context and key concepts in international development and development aid, before examining the dynamic landscape of development aid in global health, with a focus on the proliferation and growing prominence of emerging donors. In particular, the expanding influence of a number of countries in the Global South as development aid donors suggests a shift from single polar to multi-polar governance, which suggests a re-balancing of powers at the global level. With a focus on bilateral aid, this session will explore the important implications of this shift for global health governance more broadly.

Question 2

Overview Aims

Answer 2

This session aims to provide students with an understanding of the emergence of new bilateral donors in global health, and how they are changing the global health development landscape

Question 3

Overview Learning outcomes

Answer 3

By the end of this session you should be able to: Describe the actors involved in providing development aid for global health, including the growing number of bilateral aid donors in global health, and the likely implications for “traditional” donors from the global North; Explain the factors influencing the growth of aid donors for health and the possible motivations of emerging donors; Analyse the policy consequences arising from the increased involvement of emerging donors in development aid; and Evaluate the global efforts to address aid effectiveness and their likely impact.

Question 4

Key terms Emerging donors

Answer 4

are considered countries which a) have become donors relatively recently (i.e. in the last 2-3 decades), b) are not part of the DAC or have only recently joined and c) have been recipients of aid in the past (or in some cases, continue to be) (Rosser and Tubilewicz 2015).

Question 5

Key terms Hard Power

Answer 5

Strategies that focus on military intervention, coercive diplomacy, and economic sanctions in order to enforce national interests resulting in confrontational policies vis-à-vis neighbouring countries (Wagner, 2005).

Question 6

Key terms Official Development Assistance (ODA)

Answer 6

government aid that promotes and specifically targets the economic development and well-being of low- and middle- income countries. ODA is provided by official agencies, including state and local governments. (OECD 2019).

Question 7

Key terms Soft Power

Answer 7

the capacity to persuade or attract others to do what one wants through the force of ideas, knowledge and values (Lee and Gomez 2011).

Question 8

Key terms South-South Cooperation

Answer 8

is a broad framework of collaboration among countries of the South, which can take place in different domains (social, economic, political, cultural, etc). Through this type of cooperation, two or more LMICs share knowledge, skills, expertise and resources to meet their development goals through joint efforts (UNOSSC, 2020).

Question 9

Key terms Transaction costs

Answer 9

The costs arising from the preparation, negotiation, implementation, monitoring and enforcement of agreements for the delivery of Official Development Assistance (Fozzard, et al, 2000).

Question 10

Key terms Triangular cooperation

Answer 10

is collaboration in which a traditional donor countries and multi-lateral organisations facilitate South-South cooperation initiatives through the provision of funding, training, management and technological systems as well as other forms of support (UNOSSC, 2020).

Question 11

1 Background

Answer 11

Improving health outcomes and health equity globally requires investment in health systems, social protection policies and addressing the social determinants of health, which is often beyond the financing capacities of some low- and middle-income countries (LMICs) (Taylor and Rowson 2009). The world has seen significant gains in global health development (e.g. through scaled-up response to the HIV pandemic, improved malaria control and significant declines in maternal and child mortality rates), attributed in part to a wide range of global investment in health, through both privately and publicly funded initiatives over the past several decades (Moon and Omole 2013). At the same time, global health outcomes remain starkly inequitable and are characterized in most countries by significant disparities between the wealthiest and poorest segments of the population, a significant and growing burden of non-communicable diseases (NCDs) and weak and under-resourced domestic health care and public health systems.

Question 12

1 Background

Answer 12

The following sub-sections will provide a brief history of development aid and an overview of different types of donors and aid in global health, before introducing certain competing normative theories of international development and development aid. Finally, in section 1.4, we will consider the various motivations donors may have in providing development aid, through an examination of the interconnections of aid and global health diplomacy.

Question 13

1.1 Historical Background of Development Aid

Answer 13

The history of development aid has been shaped by major concurrent political events and economic landscapes. For decades, health development aid and governance was dominated by the largest member states of the Organization of Economic Cooperation and Development (OECD). The OECD’s Development Assistance Committee (DAC) was created to coordinate the official development assistance (ODA) or ‘aid’ of its member states and throughout the 1950s and 60s, the DAC (then comprised of Belgium, Canada, France, Germany, Italy, Portugal, the United Kingdom, the United States of America and the commission of the European Economic Community, as well as Japan and the Netherlands), provided 90% of development assistance (Jing et al. 2020).

Question 14

1.1 Historical Background of Development Aid

Answer 14

While often framed in terms of international solidarity, eliminating poverty and promoting economic development within recently de-colonized states of the Global South, aid has historically been influenced by the economic and political agendas of donors. For example, at the height of Cold War tensions, aid programmes were defined by client-state relationships along geopolitical lines dividing the then Soviet Union bloc and the United States. (Alden et al. 2020). The Soviet Union had an important presence in development during this era, replacing the US and World Bank as sponsors of the Aswan Dam, and with a foreign aid programme that peaked at $1 billion US dollars in 1960 (Asmus et al. 2018). Early economic influences over aid are exemplified in donor patterns of the Gulf states which have been strongly correlated with the rise and fall of oil revenue. During the mid-1970s, aid programmes of members of the Organization for Petroleum Exporting Countries (OPEC) accounted for approximately 30% of aid worldwide, helped along by a simultaneous decrease in aid from DAC countries. Following the 1979 oil shock and around the time of the Gulf War, the OPEC and Middle Eastern donors became a relatively less significant source of aid.

Question 15

1.1 Historical Background of Development Aid

Answer 15

Throughout the latter half of the twentieth century, DAC members shaped the dominant narrative of a development aid paradigm built along a North-South divide, with the aid recipients of major donors often reflecting the lines of former colonial empires. However, forms of South-South Cooperation (SSC) also date to the mid-twentieth century. Both India’s aid to neighbouring Nepal and China’s aid programme to Africa began in the 1950s (Harmer and Cotterrell 2005, Huang 2020). Brazilian development cooperation began in the 1960s and expanded throughout the eighties and nineties. The geopolitics of the Cold War also played a role in the rise of the Non-Aligned Movement (NAM), formed by countries in the Global South to challenge the burgeoning global inequalities and aid dependencies they attributed to a global political and economic system dominated by Northern interests (Gray and Gills 2016). However by 1991, the collapse of the Soviet Union would leave Western ideologies of neoliberal economic globalisation unchallenged, driven by a confidence in “linear material progress through the innovation and the application of modern science and technology” (Gray and Gills 2016, pp. 559) In1993, DAC donors once again accounted for 95% of all aid for almost a decade.

Question 16

1.1 Historical Background of Development Aid

Answer 16

By the turn of the century, significant global economic growth was redefining the global development landscape (Carbonnier and Summer 2012). This period was characterised by the overall growth in development aid, as well as the transition of several countries from low (LICs) to middle income (MICs) status and the beginning of their shift from being net recipients of ODA to net donors (Ying et al. 2020, Kickbusch 2016). For example, India was the world’s largest recipient of aid in the mid-1980s, but by 2008 was allocating $547 million to aid-related activities (Ramachandran 2010). According to the OECD, by 2016 ODA from non-DAC donors was 13.1% of aid globally (OECD 2019), compared to 86.9% from DAC donors.

Question 17

1.1 Historical Background of Development Aid

Answer 17

For health specifically, the period from 2000-2010 is sometimes referred to as the ‘golden age of global health’, wherein development assistance for health (DAH) increased by an average of 11.4% annually (Bendavid et al. 2018). This period of abundant resources was simultaneously marked with disillusionment in existing health institutions due to repeated failures to respond with the agility required to tackle contemporary global health challenges. This contributed to a proliferation of global health actors which will be explored in the following section. Since 2010, though growth in DAH has plateaued at 1.3% annually (Dieleman et al 2019), it continues to remain relevant to global health development. Following sections in this session will show some of the ways in which development aid plays an important role for global health, beyond financial assistance to support specific health development outcomes.

Question 18

1.2 Types of Development Aid and Donors

Answer 18

As we saw in the previous section, development aid has undergone significant shifts throughout time. Given these shifts, an important question that may come to mind is what motivates countries to provide aid when they could be investing in their own economies and health systems? This section will consider these issues as well as introduce different types of aid and donors.

Question 19

1.2 Types of Development Aid and Donors

Answer 19

While at one time considered primarily humanitarian issues, many global health issues have ascended within broader foreign policy agendas due to the acceleration of globalization and resultant increases in political, social and economic interdependence (Khazatzadeh-Mahani et al. 2020). Diplomatic efforts in health often rely on expressions of soft power, or ”a country’s ability to persuade and attract others to do what it wants without resorting to [military or economic] coercion” (Khazatzadeh-Mahani et al. 2020). The relative influence of soft power among countries is highly relevant to global health and development, as it is through global health diplomacy channels that critical decisions around what types of health issues are prioritized and why. Feldbaum and Michaud (2010) emphasize how the health community has drawn on the concept of health diplomacy to raise the profile of health within foreign policy agendas. Indeed, foreign policy priorities of donors can influence relative funding of global health issues (McInnes and Lee 2012, Kickbusch 2011, Jing et al. 2020). As discussed in session 3, this dynamic was exemplified by the rapid and sustained political prioritization of global efforts to respond to HIV-AIDS from the 1990s onwards. Widespread fear in the Global North of the economic and security impacts of the unhindered international spread of HIV-AIDS led it to become the first global health issue to be elevated to the agenda of the UN Security Council (UNSC) in 2000. The shift of HIV-AIDS from the global health sphere to the “high politics” of the UNSC led to significant increases in funding, increasing from 300 million USD in 1996 to 15.6 billion in 2008 (Bergh and Gill 2013, Baringer and Heitkamp).

Question 20

1.2 Types of Development Aid and Donors

Answer 20

Partly as a result of this, we have seen significant growth in the number of actors in global health in the past decades. In 2008 there were more than 40 bilateral donors, 26 UN agencies, 20 global and regional funds and 90 global health initiatives (McColl 2008) and these numbers have only grown since. There are several underlying explanations for the proliferation of new global health actors. An increasing recognition of health as part of sustainable development and the emergence of globally-relevant health risks have contributed to an increasing number of global health actors (McColl 2008, Kickbusch 2016). Certain global health initiatives and partnerships have emerged as more agile alternatives to traditional global health actors like the World Health Organization (WHO), which have been side-lined due to governance gridlocks and institutional lethargy ill-fitted for responding to an ever-changing global health landscape (Spicer et al. 2020). Finally, frustrations with persistent failures of development aid to reduce inequities and improve health outcomes have also led to the emergence of global health actors which challenge traditional architectures of aid delivery, whether through innovative financing mechanisms or new forms of South-South cooperation.

Question 21

1.2 Types of Development Aid and Donors

Answer 21

From a finance lens, global health actors can be defined broadly by primary roles of providing, managing or spending DAH as depicted in Figure 1.1. In reality, this landscape is further complicated by the emergence of hybrid actors and the fact that some actors perform all three functions (McCoy et al. 2009). Governments provide development aid through a combination bilateral aid (from one country to another, for example through state aid departments such as the U.S. Agency for International Development (USAID)) and multilateral aid (delivered via funding to multilateral institutions such as the World Health Organization (WHO) or to global partnerships like the Global Fund to Fight AIDS, Tuberculosis and Malaria). These two types of aid (also known as Official Development Aid - ODA) can be accompanied by varying conditions or constraints (Harmer and Kennedy 2020).

Question 22

1.2 Types of Development Aid and Donors

Answer 22

The ranks and influence of government donors have expanded in recent decades to include a multiplicity of donor states beyond the traditional donors of the OECD DAC.[1] Non-DAC donors are sometimes referred to as emerging donors, derived from their categorization as emerging economies. Admittedly, the term “emerging economies” is sometimes considered outdated, since countries such as South Korea are among the most advanced economies and China’s economy is the second largest in the world (GSHi 2012). For the purposes of this session, emerging donors are considered countries which a) have become donors relatively recently (i.e. in the last 2-3 decades), b) are not part of the DAC or have only recently joined and c) have been recipients of aid in the past (or in some cases, continue to be) (Rosser and Tubilewicz 2015). In 2016, emerging donors responsible for the largest portions of non-DAC aid include Turkey, Brazil, China, India, Kuwait, Mexico, Qatar, Saudi Arabia, Russia and the UAE (Luijkx and Benn 2016). [1]As of 2020, the DAC comprises 30 members (OECD 2020): Australia, Austria, Belgium, Canada, Czech Republic, Denmark, European Union, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, The Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, United Kingdom, United States

Question 23

1.2 Types of Development Aid and Donors Box 1

Answer 23

Global health has witnessed a growing influence of and financial contributions from non-state donors. Non-state donors encompass a wide range of actors and institutions, including private foundations (eg. Bill and Melinda Gates Foundation, the Ford Foundation, the Wellcome Trust), public-private partnerships (eg the Global Fund, UNITAID, Gavi), and private corporations. Given both the relative and absolute volume of global health financing these non-state donors provide, they play a pivotal role in shaping many of the priorities, new instiutions and development programming in global health, raising concerns around whether a private entity should hold such influence, these actors are not accountable to WHO or any other global governance institution and decisions of which projects will be funded and for how long are subject solely to the philanthropic interests or decisions of the funding mechanisms. Though private or non-state funding for health is difficult to track as it is not universally nor regularly reported, it is estimated that private funding for global health has grown to account for approximately a quarter of all development aid in recent years. However, governments remain by far the largest source of DAH, accounting for about 70% of the global total.

Question 24

1.3 Summary

Answer 24

The geopolitical context, actors, motivations and impact of bilateral aid for global health has undergone several significant transitions since the creation of the contemporary international system in the 1950s. In recent decades, the emergence of non-traditional donors has transformed the global health development sector with wider impacts beyond financial contributions. The following sections will further explore the complexities of development aid and diplomacy in relation to global health governance, drawing on examples from emerging donors.

Question 25

Activity 1 Ongoing debates of whether aid is ‘good’ or ‘bad’, how it should be delivered, and who should be accountable for ensuring its effectiveness have gained prominence in both global health and development since the early 2000s (Taylor and Rowson 2009; Stuckler et al 2013). Read the analysis by Stuckler, Mckee and Basu (2013), “Six concerns about the data in aid debates: applying an epidemiological perspective to the analysis of aid effectiveness in health and development.” Then, drawing from concepts explored in the above section write a short critique of one of the following excerpts . Post your responses in the discussion.

Answer 25

A) “The critics of foreign aid are wrong. A growing flood of data shows that death rates in many poor countries are falling sharply, and that aid-supported programs for health-care delivery have played a key role. Aid works; it saves lives […] Let’s turn back the clock a dozen years. In 2000, Africa was struggling with three major epidemics. AIDS was killing more than two million people each year, and spreading rapidly […] Tuberculosis was also soaring, partly as a result of the AIDS epidemic and partly because of the emergence of drug-resistant TB. In addition, hundreds of thousands of women were dying in childbirth each year, because they had no access to safe deliveries in a clinic or hospital, or to emergency help when needed.[…]Expanded [aid] funding allowed major campaigns against AIDS, TB, and malaria; a major scaling up of safe childbirth; and increased vaccine coverage, including the near-eradication of polio. Many innovative public-health techniques were developed and adopted. With one billion people living in high-income countries, total aid in 2010 amounted to around $27 per person in the donor countries – a modest sum for them, but a life-saving one for the world’s poorest people.” – Jeffery Sachs (2012) B) “There are two factors that clearly contributed to Africa's economic growth over the last decade. One is Chinese foreign direct investment, and the other is the commodity price boom. The notion that aid has created jobs in Africa is completely unfounded. After 60 years and over a trillion dollars, why, miraculously, would aid suddenly become a contributor to growth? I also find laughable the argument that we must eliminate corruption before tackling the problems with aid. They are two sides of the same coin. Most corrupt African governments survive in an environment where they do not tax their citizens and almost wholly rely on foreign aid for funding. Sadly, Africans are getting the governments they paid for.” – Dambisa Moyo (2009)

Question 26

Activity 1 Feedback

Answer 26

The answers to whether aid has been ‘good’ or ‘bad’ are shaped by competing normative theories on aid and development and remain contested among scholars and policy experts. Ideas that could be critiques of Excerpt A include: There are still significant and growing global health inequities which aid has failed to address; Aid is often shaped by the interests of donors rather than the self-determined needs of recipient populations; A growing number of global health actors further complicates already tenuous lines of accountability for decisions surrounding the prioritization, funding levels and modes of program delivery for different health issues. It is fine to cite examples of success, but who is held responsible when aid programmes are ineffective or in some cases, detrimental? And The viewpoint neglects the North-South power dynamics embedded within the traditional aid architecture. The impacts of development aid should not be reduced to only numbers, as aid dynamics reflect relative power relations within broader spheres of global economic and political governance. Ideas that could be included in critiques of Excerpt B include: The excerpt oversimplifies the case of aid and provides no data to support the arguments made; In the field of global health alone, aid is credited for improving health outcomes and saving the lives of millions of people; States from the Global South, including Africa, have increasing agency and influence in the creation and delivery of different global health initiatives; Without aid, what is the alternative in the short and medium term that would achieve better results for global health and development? Read through some of the posts of your colleagues to see what additional ideas they had in response.

Question 27

2. Significance of Emerging Donors

Answer 27

In the previous section we discussed different forms of development aid and donors. As we will see in this section, emerging donors have positioned themselves as providers of South-South cooperation, committed broadly to assistance without conditionalities, which distinguishes them from traditional donors (Jing et al 2020, Kickbusch 2016). This counter-position to DAC approaches has been widely analysed for the potential of emerging donors to shift the global health development paradigm (Harmer and Buse 2014) This section explores the significance of emerging donors, specifically in relation to DAC donors and the global aid architecture within which they operate.

Question 28

2.1 Traditional vs. Emerging Donors

Answer 28

Emerging donors are viewed by many as having created an important and new policy space in health and development. However, the extent to which emerging donors depart from the pitfalls of traditional development aid remains debatable. Furthermore, some argue that far from challenging the current global development paradigm, emerging powers are more interested in enhancing their influence within existing global governance structures (Gray and Gills 2020). Nonetheless, the potential significance of emerging donors is often juxtaposed with traditional donors’ repeated failure to deliver on their aid-related commitments to: a) Increase Aid volume: Despite a significant commitment by OECD members to increase their ODA contributions to 0.7% of their gross national product (GNP), only a handful (mostly Nordic) countries have met this target (Harmer and Kennedy 2020); b) Reduce Conditionalities: LMICs have historically been disillusioned with the conditions espoused by established donors (e.g. expectations that required products and services are procured from donor country businesses or of access to recipient markets or natural resources). This contrasts with emerging donors who espouse principles of sovereignty, equality and mutual respect (Jing et al. 2020); c) Enhance coordination and alignment: Studies have shown that when traditional aid agencies (which may be several for each bilateral donor) impose different reporting requirements, transaction costs are predicted to increase for recipients, at times outweighing the value of aid (Pallas and Ruger 2017); and d) Reform aid architecture: Critics of traditional development aid argue that it perpetuates a global system which continues to operate within the Western norms, institutions and structures on which it was built in the 1950s (Jing et al. 2020). For example, some point out that as aid changes with the dynamic donor interests and capacities, the global institutions and rules which govern factors critical to economic growth of such as trade and financial flows continue to systematically privilege the interests of the Global North over those of the South (Jing et al. 2020).

Question 29

2.1 Traditional vs. Emerging Donors

Answer 29

Like many of the global health dimensions explored in this module, the impact of emerging donors for health and development is complex, multi-faceted and dynamic. Table 2.1 illustrates both strengths and limitations of emerging donors for health. In several ways, whether intended or not, the growing operations of emerging donors beyond the governance of DAC necessarily undermines the historical hegemony enjoyed by traditional donors of what constitutes aid and how it should be delivered. For example, emerging donors’ development cooperation often falls outside the theoretical limits of what would be considered DAH. Emerging donors are also often criticized for lack of transparency and coordination with other donors. While this may be problematic in terms of aid effectiveness, it also will render mechanisms like the DAC increasingly less relevant with the expansion of emerging development cooperation.

Question 30

2.1 Traditional vs. Emerging Donors

Answer 30

Like many of the global health dimensions explored in this module, the impact of emerging donors for health and development is complex, multi-faceted and dynamic. Table 2.1 illustrates both strengths and limitations of emerging donors for health. In several ways, whether intended or not, the growing operations of emerging donors beyond the governance of DAC necessarily undermines the historical hegemony enjoyed by traditional donors of what constitutes aid and how it should be delivered. For example, emerging donors’ development cooperation often falls outside the theoretical limits of what would be considered DAH. Emerging donors are also often criticized for lack of transparency and coordination with other donors. While this may be problematic in terms of aid effectiveness, it also will render mechanisms like the DAC increasingly less relevant with the expansion of emerging development cooperation.

Question 31

2.1 Traditional vs. Emerging Donors

Answer 31

Like many of the global health dimensions explored in this module, the impact of emerging donors for health and development is complex, multi-faceted and dynamic. Table 2.1 illustrates both strengths and limitations of emerging donors for health. In several ways, whether intended or not, the growing operations of emerging donors beyond the governance of DAC necessarily undermines the historical hegemony enjoyed by traditional donors of what constitutes aid and how it should be delivered. For example, emerging donors’ development cooperation often falls outside the theoretical limits of what would be considered DAH. Emerging donors are also often criticized for lack of transparency and coordination with other donors. While this may be problematic in terms of aid effectiveness, it also will render mechanisms like the DAC increasingly less relevant with the expansion of emerging development cooperation.

Question 32

2.2 How are Emerging Donors changing the way Development Aid is provided?

Answer 32

With these strengths and weaknesses in mind and given their significant share of both the world’s population and the global market, emerging countries are expected to shape the next era of global health (Kickbusch 2016). The very existence of emerging donors, which by definition have been recipients or in some cases remain simultaneously both donors and recipients of development aid, challenges the North-South division on which traditional aid relies. Whether, where and how emerging donors choose to invest in health will increasingly form the ideas and institutions of global health governance (Tang 2017, Kickbusch 2016). Although emerging donors have been criticized for opaqueness in their approaches to development, and for a lack of formal engagement in certain aspects of global health agenda setting and norm development (Huang 2020), there are many examples where strategies to influence global health have been employed, beyond traditional ODA approaches. For example, emerging donors have distinguished themselves from DAC donors through their emphasis on south-south cooperation and triangular cooperation. Below we explain each of these:

Question 33

2.2 How are Emerging Donors changing the way Development Aid is provided? South-South Cooperation

Answer 33

South-South Cooperation is a broad framework of collaboration among countries of the South, which can take place in different domains (social, economic, political, cultural, etc). Through this type of cooperation, two or more LMICs share knowledge, skills, expertise and resources to meet their development goals through joint efforts (UNOSSC, 2020). South-South cooperation is guided by the principles of respect for national sovereignty, national ownership and independence and horizontal relationships between partners based on non-conditionality, non-interference in domestic affairs and mutual benefit (UNOSSC, 2019). Examples of these partnerships have been shown by Brazil which created a network to share technology and best practices to improve access to pharmaceuticals in Lusophone countries in Sub-Saharan Africa. South Africa, on the other hand, directs 70% of its development aid to neighbouring countries, comprised within the Southern Africa Development Community (SADC).

Question 34

2.2 How are Emerging Donors changing the way Development Aid is provided? Triangular Cooperation

Answer 34

Triangular cooperation is collaboration in which a traditional donor country or multi-lateral organisation facilitates South-South cooperation initiatives through the provision of funding, training, management and technological systems as well as other forms of support (UNOSSC, 2020). Since 2002, Germany has financially supported Brazil’s efforts to establish and increase AIDS programmes in Paraguay, Colombia, El Salvador, Dominican Republic and Uruguay. Egypt and Turkey cooperate to offer professional health training in several African countries. This type of trilateral cooperation may also occur with institutions. For example, Argentina working with the Pan American Health Organization (the WHO branch for the Americas) to offer technical assistance for polio eradication in Nigeria; and training health care workers on organ transplantation in Paraguay (PAHO 2009).

Question 35

2.3 Summary

Answer 35

Emerging donors have an increasing presence in global health development spaces which have historically been dominated by the Global North. They have bolstered the delivery of improved health outcomes across LICs while modelling development assistance without interference (Gu et al 2016). However, the impact of emerging donors has not been universally positive and the extent to which they are genuinely motivated to transform global governance structures remains debated. Yet, as emerging donors increasingly influence the norms, priorities and approaches underpinning global heath development, a global architecture defined by North-South relations is no longer sufficient for understanding the dynamics of global development aid (Gray and Gills 2016). In the next section, we will discuss specific examples of emerging donors and their impact.

Question 36

3. BRICS and Other Emerging Countries

Answer 36

As we saw in the previous section, emerging donors have exhibited new ways of providing development aid and this is also demonstrated in the partnerships that they have created with other similar countries. Since the creation of the contemporary global political system, states have been motivated to organize themselves into different political groupings or ‘clubs’, often in pursuit of a common goal or to strengthen channels of political, economic or military cooperation. This type of international diplomacy is sometimes referred to as global summitry. Examples include the G7 and G20, and well as groups like the Non-Aligned Movement (NAM) and regional or sub-regional organisations such as the Southern African Development Community (SADC). Unlike the rule-based and universal U.N. system, these groups are usually exclusive, interest-based, high-level political clubs, which sometimes serve as interesting and powerful channels for influencing global agendas (Huang 2020; Amaya et al. 2015). From a growing list of emerging economies, this section focuses on BRICS (Brazil, India, China and South Africa), particularly given their political formalisation, regional influence and relatively significant engagement in global health.

Question 37

3. BRICS and Other Emerging Countries

Answer 37

The term BRIC (originally used to denote the grouping of Brazil, Russia, India, and China) was coined in 2001, based on the shared and newly advanced economic status of these nations. (WHO 2014). The first official BRIC dialogue was a meeting of foreign ministers in 2006, followed by its first summit in 2008. South Africa was subsequently inducted in 2010, marking the formation of BRICS. BRICS as an analytical category has been joined by other, similar groupings of countries composed by emerging economies on the global scene. For example: Next Eleven (N-11) (Bangladesh, Egypt, Indonesia, Iran, Mexico, Nigeria, Pakistan, Philippines, Turkey, South Korea, and Vietnam) coined in 2005; CIVETS (Colombia, Indonesia, Vietnam, Egypt, and South Africa) in 2008 (Moore 2012); and MINT (Malaysia, Indonesia, Nigeria and Turkey) in 2014.

Question 38

3. BRICS and Other Emerging Countries

Answer 38

Among the above groupings, BRICS is unique because despite beginning as category of economic analysis, these countries have formalized as a political bloc that has survived the divergent economic performance of its members.

Question 39

3.1 BRICS Characteristics

Answer 39

BRICS countries account for 40% of the world’s population and more than 25% of global gross domestic product (GDP) (Huang 2020). None are members of the OECD, though all five are members of the G20 (Pinto 2020). Since transitioning to net-donors at the turn of the twenty-first century and increasing their engagement in global health, BRICS nations have garnered growing attention for their potential to offer distinct and innovative alternatives to an otherwise Western-dominated paradigm of DAH (Harmer and Buse 2014, Huang 2018, Ying et al 2019).

Question 40

3.1 BRICS Characteristics

Answer 40

BRICS countries are characterised by having large, growing, young populations and having experienced rapid economic growth in recent years, though this is declining in some countries. While this rapid growth has resulted in overall increase in wealth and resources, BRICS countries have also experienced significant increases in health inequities (Gomez 2016). One of the inadvertent effects the rise of this group within the global development landscape is that the poorest segments of the world’s population are no longer located in the lowest income countries (Carbonnier et al. 2012) This creates an interesting paradox whereby BRICS countries are being looked to as a ‘new force’ in global health, while still struggling to tackle complex domestic health challenges associated with poverty, inequality and weak or dysfunctional health systems (Huang 2020, Gomez 2016).

Question 41

3.1 BRICS Characteristics

Answer 41

Despite domestic challenges, all five countries have made significant contributions to global health over the past two decades, in terms of development aid, institutional influence and shaping underlying normative values (Harmer and Buse 2014, Huang 2020, Jing et al 2019). All BRICS countries are donors to prominent global health initiatives like the Global Fund and Gavi, and all of them have invested in growing development assistance programs for health. Some examples of the contributions of the BRICS countries to aid for global health include: Between 1990 and 2011, China built one hundred hospitals in fifty-two countries, and held over four hundred training courses for fifteen thousand foreign healthcare personnel (Huang 2020); Since 2009 India has committed at least US$100 million to bilateral health projects in nearly twenty countries in Africa and South and Southeast Asia (Tytel and Callahan 2012); and Brazil has provided substantial technical and material support to HIV/AIDS prevention and treatment programs globally, including investments in building anti-retroviral (ARV) production centres in Mozambique and Angola (GSHi 2012, Huang 2020).

Question 42

3.2 BRICS Criticisms

Answer 42

Despite increasing wealth, influence and investments in development aid, BRICS countries share many of the weaknesses common to emerging donors, that we explored in section 2. Relevant weaknesses among the BRICS with regard to global health development include:

Question 43

3.2 BRICS Criticisms

Answer 43

Gaps in domestic health financing and systems (Gomez 2016). BRICS countries remain behind in relation to certain global health goals, with relatively weak domestic health systems. Brazil has achieved notable success in certain areas of public health and health system strengthening, for example in the distribution of anti-viral therapies (ARTs) for HIV/AIDS (Pinto 2020, Huang 2020). However, Brazil has achieved mixed results from its efforts in pursuit of Universal Health Coverage, with substantial and persisting disparities between public and private health systems (Marten et al. 2014). India has seen a declining investment in health and experienced greater inequities in access to medicines and healthcare (Gomez 2016). Russia experienced great setbacks in health care after the fall of the Soviet Union, both in population health and the national health system (Marten et al 2014). Russia also has high HIV prevalence and is one of the few regions in the world where the epidemic is still growing (Amirkhanian 2016). Finally, South Africa has performed slightly better than its counterparts in ensuring access to medicines, and keeping out-of-pocket expenditures on health to a minimum, though the country still struggles with health system infrastructure and human resources (Gomez 2016).

Question 44

3.2 BRICS Criticisms

Answer 44

Lack cohesive or collective translation of policy rhetoric into action (Huang 2020). BRICS countries have been criticized for a weak track record translating health rhetoric into action and have rarely acted as a unified bloc in relation to global health or development issues (WHO 2014, Huang 2020). There are major differences between BRICS countries in terms of political institutions, economic structures, and foreign policy (Huang 2020), at times resulting in diverging priorities on various global agendas. One example of this is the lack of representation of the Global South on the UN Security Council (UNSC). As permanent members of the UNSC, neither Russia nor China have shown support for UNSC reform, despite advocacy efforts by their fellow BRICS member, India (Gray and Gills 2016). Although BRICS countries have positively influenced the global prioritization of certain development issues important to the Global South (e.g. access to medicines, HIV/AIDS, social determinants of health and health equity), their prominent voices as “regional leaders” do not always represent the health and development priorities of many LICs across Sub-Saharan Africa, South Asia and Latin America (Gray and Gills 2016).

Question 45

3.2 BRICS Criticisms

Answer 45

An ad-hoc and ill-defined alternative model of development (Puppim de Oliveira and Jing 2020). While various elements of development assistance across BRICS countries have at times been analysed as an aggregate ‘BRICS development approach,’ there continues to be little evidence of DAH elements or support for global health initiatives common to all five countries (Harmer et al. 2013). DAH from China, South Africa and India for example, continues to be primarily delivered through bilateral channels, rather than in coordination with other countries or institutions (Huang 2020).

Question 46

3.3 Role of BRICS at the Global Level

Answer 46

While BRICS members have been critiqued for state-centric development approaches which are not coordinated with other development and health actors, there are tangible examples of BRICS influencing the institutions, networks and norms of the global health arena. This section will present several prominent examples of how BRICS countries have begun to shape certain dimensions of global health development.

Question 47

3.3 Role of BRICS at the Global Level

Answer 47

The BRICS’ New Development Bank From early on in the creation of the bloc, BRICS members expressed interest in creating a global financial institution which could rival the International Monetary Fund and the World Bank. Consequently, the New Development Bank (NDB) and the Contingent Reserve Arrangement (CRA) were signed into treaty in 2014 and began operations in 2015 (Huang 2020) with all five countries holding equal shares. The stated purpose of the New Development Bank is to “invest in infrastructure and sustainable development projects in BRICS and other emerging economies and developing countries, complementing the existing efforts of multilateral and regional financial institutions for global growth and development” (NDB n.d.). The creation of this institution has been observed as an example of the maturity of the BRICS process, which could lead to a shift in global economic and political power.

Question 48

3.3 Role of BRICS at the Global Level

Answer 48

Advancing Global Access to Medicines BRICS countries have had important influence over dimensions of global agenda-setting in health, both through forceful demands for policies that benefit LMICs and advocacy for the coordination of health-related policies across different sectors such as aid and trade. For example, BRICS countries strongly advocated on behalf of health-related interests of LMICs during World Trade Organization (WTO) negotiations of Trade-related Intellectual Property Rights (TRIPS) (Huang 2020).The contributions of BRICS countries, in particular South Africa and Brazil, were critical to securing flexibilities within this agreement, which under certain circumstances would allow the generic manufacturing or importation of otherwise patented medicines. These flexibilities would create possibilities for governments in the Global South to procure drugs at substantially lower prices, thereby potentially drastically expanding access to essential medicines. While far from perfect, TRIPS flexibilities have had important impacts. For example, within a global trade paradigm which would in theory permit access to generic alternatives, Brazil along with 11 other Latin American governments and 26 drug companies reached an agreement in 2005, to lower the prices for HIV/AIDS drugs in the region (Okie 2006).

Question 49

3.3 Role of BRICS at the Global Level

Answer 49

The increased power and prominence of BRICS nations in international policy spheres represents progress towards balancing the negotiating positions of established donors and can strengthen the representation of LMIC interests and needs at the global level. Overall, development assistance from BRICS countries contributes a relatively small proportion of the total global DAH. Nevertheless, this group along with other emerging actors has shown its potential to challenge the values, principles and approaches of the traditional development aid architecture.

Question 50

3.4 Summary

Answer 50

BRICS countries represent an important force in global health, whether considered in terms of demographics, economic projects, or as emerging donors within the shifting context of global health and development. By some measures – meeting domestic health challenges, redefining a cohesive new paradigm for development, and leveraging their collective power as a political bloc – they have not performed as well as by others. Yet, there are growing examples of BRICS contributing to new norms, networks and institutions that impact global health.

Question 51

Activity 2 Choosing one of the BRICS countries, briefly research how the current political and economic situation of the country may affect their role as donor. Post your results on the discussion forum and respond to one of your colleague’s responses.

Answer 51

As you have learned in this section, BRICS countries are characterized by very different geopolitical contexts, regional dynamics, resources and political institutions, all of which could influence their roles as donor. As you were reflecting on the current political situation in one of the BRICS countries, did you remember to consider the following points? The role of a donor can be defined both in terms of material contribution and soft power; in cases where the political situation may be a constraint on development aid, is there evidence of engagement in health diplomacy? Or vice versa? How is the current political positioning of the country you chose effected (or not) by dynamics among traditional DAC donors?

Question 52

4. Development Aid Cooperation and Aid Effectiveness

Answer 52

The entry of BRICS nations into development aid not only had an impact on the countries they supported but also the work of traditional donors. As discussed in the previous sections, emerging donors have in many ways challenged the status quo of development aid as it was originally envisioned by OECD DAC donors. In this section, we will look at recent efforts to improve aid effectiveness globally and how this has been impacted by emerging donors.

Question 53

4.1 High-level Forums on Aid Effectiveness

Answer 53

While different forms of development cooperation have proven more or less effective in different contexts, the volume and complexity of actors, interests and needs encompassed by ODA and health pose significant challenges for global governance and international cooperation. Recognizing the diversity of new development actors and the validity of their questioning of the aid paradigm, there have been several attempts at coordination of different donors around common principles for aid effectiveness.

Question 54

4.1 High-level Forums on Aid Effectiveness

Answer 54

Convened by the OECD, a total of four High-level Forums were hosted from 2003 to 2011, bringing together ministers, heads of development agencies and civil society organisations from more than 100 countries, to examine the impacts of and identify ways to improve the efficacy of development aid. These forums represent important diplomatic efforts to address several dimensions of development aid for health that we have already explored in this session.

Question 55

4.1 High-level Forums on Aid Effectiveness

Answer 55

First, these high-level political efforts can be understood in part as a response to competing normative theories of aid, and a recognition by traditional donors that aid has not been an altruistic panacea for eliminating poverty. Second, they can be viewed as an effort to increase coordination and alignment in a context marked by an increased volume and diversity of development actors and approaches. Third, by focusing on aid effectiveness, these efforts arguably accommodate existing relationships between aid and self-interest, theoretically without compromising development outcomes. As Bendavid and others (2018) note, “irrespective of whether explicit or implicit goals are pursued, the Paris Declaration on Aid Effectiveness calls for donors to align their support, whenever possible, with recipient-country government priorities” (p. 304).

Question 56

4.1 High-level Forums on Aid Effectiveness

Answer 56

The first high level forum resulted in the 2003 Rome Declaration, marking the first-time principles for aid effectiveness were defined in a declaration. However, it is the 2005 Paris Declaration for Aid Effectiveness, endorsed at the second High-Level Forum for Aid Effectiveness, that has been used as a benchmark to evaluate how well donor and recipient countries are working in partnership to meet their development commitments. The declaration is based on five principles which are: 1 Ownership - defined as recipient countries exercising effective leadership over their development policies; 2 Alignment - where donors base their overall support on partner countries' national development strategies, institutions and procedures; 3 Harmonization – Donors’ actions are more coordinated, transparent and collectively effective; 4 Managing for Results - Managing resources and improving decision-making to obtain tangible results; 5 Mutual accountability - Where donors and partners are accountable for development results.

Question 57

4.1 High-level Forums on Aid Effectiveness

Answer 57

During the Paris forum, Brazil, Cuba and Nigeria did not ratify the Declaration, rather choosing to emphasize guiding principles such as respecting the national sovereignty of partner countries. Brazil signed as a recipient only, citing principles of non-interference and its commitment to cooperation that is not linked to political conditionalities. Criticisms of the Paris Declaration included lack of clarity and depth of its principles, as well as poor monitoring, accountability and financing mechanisms to ensure its implementation (Spicer et al. 2020).

Question 58

4.1 High-level Forums on Aid Effectiveness

Answer 58

The 2008 Accra Agenda for Action sought to intensify progress towards the Paris Declaration (OECD, 2008). This agenda also led to the development of other international commitments such as the Bogota statement, which focuses on South-South cooperation and the Dili Declaration, specific for aid in fragile and conflict-affected states. Surveys have shown that the Paris Declaration and Accra Agenda for Action have improved the alignment of programmes but there is still much to be done in terms of coordination (OECD, 2012).

Question 59

4.1 High-level Forums on Aid Effectiveness

Answer 59

The 2011 forum in Busan marked a turning point in discussions around aid effectiveness, leading to the establishment of a framework for development co-operation that takes into account traditional donors, South-South cooperation, the BRICS countries, civil society organisations and the private sector. The Busan agreement defined concrete actions to implement the Paris and Accra commitments, seeking actions such as developing review plans to untie aid as much as possible and using results-based frameworks and country-led coordination arrangements to reach the four newly agreed-upon principles of effective development co-operation: country ownership, a focus on results, inclusive partnerships, and transparency and mutual accountability (UN 2020). Importantly, all of the BRICS countries endorsed the Busan Partnership for Effective Development Cooperation. Furthermore, as a result of the Busan high level forum, the Global Partnership for Effective Development Cooperation was established in 2011 to track the implementation of the Busan agreements and enable the 2030 agenda. Since its establishment, this Global Partnership has adopted the Mexico Communique (2014) the Nairobi Outcome Document (2016, a negotiated outcome, like the Busan Agreement), and the Co-Chair’s Statement on the Senior-Level Meeting (2019) (GPEDC, 2020).

Question 60

4.1 High-level Forums on Aid Effectiveness

Answer 60

Without diminishing the importance of political commitments and shared rhetoric more generally (Harmer and Buse 2014), the extent to which countries follow agreements made at the abovementioned high-level forums is difficult to determine and impossible to enforce. Thinking back to Session 1 of this module, remember that many agreements or policies in global health are non-binding and sovereign states are not under any obligation to act in accordance to Busan agreements, let alone share data regarding their development aid. Despite the diplomatic efforts and positive signals of High-level Forms for Aid effectiveness encompassing a diversity of global actors and interests, global health and development landscapes continue to be fragmented, with aid effectiveness impeded by significant coordination challenges (Spicer et al. 2020)

Question 61

4.2 Summary

Answer 61

The confluence of changing political and economic dynamics with competing normative theories on the global aid architecture have created space within the development for: a) new forms of cooperation (and actors) to gain prominence, and b) renewed efforts to ensure this cooperation is coherent and effective. Emerging donors challenge the dominant narratives in development through their departure from North-South/Donor-recipient binaries and through emphasis on different forms of South-South and triangular development cooperation. The significance of emerging donors has been marked in part by the expansion of development aid governance to include a diverse range of traditional, emerging and non-state actors, as exemplified in by the nature of the four High-level Forums for Aid Effectiveness convened since 2003 by the OECD. Though the agreements produced through such forums are symbolic of a shifting global development landscape, their impacts beyond this have so far been understood to be limited.

Question 62

Activity 3 Choose one of the targets of Sustainable Development Goal 3 ,“Ensure healthy lives and promote well-being for all at all ages” and find an example of a related health initiative or development programme which is either an example of South-South or Triangular Cooperation. Post a summary of the initiative you have selected in the discussion, including an explanation of why you chose it. In your response, reflect on the pros and cons of different forms of development aid, particularly with regards to aid effectiveness. Please compare your post with that of one of your classmates’ and post a response.

Answer 62

There are many different possible responses to this mini-research activity. Take a look through the answers of your peers for a sense of the diversity and number of examples of this.

Question 63

Integrating activity You have been hired to work at the ministry of health or foreign ministry of a BRICS member of your choice. An effective vaccine to COVID-19 has recently been developed by a U.S. pharmaceutical company, and you have been asked to provide a briefing to a senior official on how your government can best support the equitable distribution of the vaccine, particularly in a low-income country with which you have existing development partnerships. Drawing on the concepts and characteristics you have learned about emerging development donors and health aid, consider the following: 1 What are the economic factors that you will need to account for, to ensure the feasibility and effectiveness of your proposed solution? 2 Which types of development cooperation or tools would be most helpful for reaching this objective? 3 Are there any multilateral fora, or mechanisms through which you could leverage greater influence, or which might contribute to the success of your proposed approach? (e.g. a regional bloc or international organization, or agreed upon international principles or agreements). Post your results within the discussion board and compare your response with at least one other student.

Question 64

Summary

Answer 64

This session has explored the dynamics and impacts of emerging development donors as a global policy issue for health. Against a background of ideas, actors and concepts comprising development aid for health, the session examined how several rapidly growing economies have recently transitioned from recipients to net donors of DAH, and the ways it has begun to impact the traditional aid architecture.

Question 65

Summary

Answer 65

Considering trends in development aid through a lens of global health diplomacy, it is evident that the policy consequences of the emerging donors for global health extends beyond financial impacts.

Question 66

Summary

Answer 66

In summary, during this session you learned that: Global health and development are increasingly influenced by emerging donors. This is due to different factors in a changing global landscape, including rapidly growing economies in the Global South, dissatisfaction with traditional global health actors, and an outdated global development aid architecture; Both traditional and emerging bilateral donors are motivated to provide aid for a mix of different reasons which are shaped by global geopolitical and economic circumstances; Emerging donors offer distinct approaches to DAH, in certain instances challenging the prevailing development aid paradigm through the creation of new institutions, principles and forms of development cooperation; and at other times, advancing their interests or influence within existing global structures; and The entry of more donors raises the issue of increased transaction costs, coordination issues and transparency; emerging donors will have to follow the already set aid effectiveness agreements or create their own systems of accountability.