Health as niche diplomacy: assessing design and practices of Brazilian diplomacy in the beginning of the 21st century, an interview with Nicole Gayard, by Tiago Tasca

Brazilian health diplomacy is a transdisciplinary topic and has been framed through multiple theoretical lenses, specially regarding the country’s capacities, knowledge and expertise in international cooperation for health. One of these theoretical lenses, niche diplomacy, is adopted by Nicole Gayard in the article “Health as niche diplomacy: assessing design and practices of Brazilian health diplomacy at the beginning of the 21st century,” published in the vol. 62, n.1 of Revista Brasileira de Política Internacional – RBPI. Gayard presents the main activities of the Brazilian health diplomacy at the beginning of the 21st century and analyzes Brazil’s engagement with global health, with a focus on the resources employed in this endeavor. According to her, the focus on niche diplomacy sheds light on strategies developed by middle powers for achieving recognition in international politics, even though initial power resources are not much altered.

Gayard’s argument also pointed out that Brazil employed health diplomacy as a form of engaging meaningfully in the global arena, specially through South-South Cooperation, in order to advance international networks for health, to improve regional integration and to provide health supplies under demand from countries or international organizations to the global market. Nicole Gayard, from Centro Brasileiro de Análise e Planejamento, was interviewed by Tiago Tasca, editorial assistant of RBPI.

In order to design the Brazilian health diplomacy in the 2000s you mentioned the “structuring approach,” “which consisted of an ‘innovative paradigm,’ based on the construction of capacities for development.” In this sense, in what degree the niche diplomacy approach differs or overlaps this “structuring approach?”

The concept of niche diplomacy was employed by David Cooper to analyze middle-power activism in certain areas of international politics in the post-Cold War context. This period is marked by an extension of the international political agenda, which now encompasses several social issues. In this context, secondary powers have greater room to ‘prompt policy responses and initiatives’ in the international arena and may assume the lead in specific areas of diplomacy and international engagement.

The analysis of Brazilian health diplomacy from 2000 to 2015 identified some aspects that can be interpreted as a call for leadership, based on a specific framing of international health practices, in which Brazil intends to establish itself as a key promoter. Discursively, national institutions adopted the concept of ‘structuring’ cooperation to refer to the specificity of Brazilian operations in this area. This approach sought to break with previous development cooperation paradigms. The innovation promoted by the structuring approach consisted of the integration between human resources formation, strengthening of organizations and institutional development. In other words, the focus was put on the strengthening of health institutions, in close association with the training of human resources needed for local maintenance of health care, aiming at promoting local capacities and, thus, greater autonomy in the provision of health care and independence from international flows of cooperation in the medium and long terms.

Thus, the article understands that the concept of structuring approach can be categorized as a form of niche diplomacy. We understand that other niches can be identified in the Brazilian performance of the period, which were not analyzed in this article. In this sense, the concept of niche diplomacy goes beyond the performance in Brazilian health presented in the article, but Brazilian health diplomacy is framed as an undertaking of niche diplomacy.

According to your article, global health – and not international health – is contingent on the perspective that “health has become a central issue of global politics that cannot be confined within national borders and which must be dealt with cooperatively under a global instance.” Moreover, an interesting epistemological element to the concept of global health is related to the role played private actors (e.g., Bill and Melinda Gates Foundation) in affecting the decision-making process and its outcome, specially in the World Health Organization (WHO). Could you explain the role played by private actors (and NGOs) in niche diplomacy? In your opinion, do Brazilian private corporations affected Brazilian health diplomacy at the beginning of the 21st century? If yes, how?

As pointed out above, the concept of niche diplomacy is employed to refer to middle powers activism in specific areas of diplomacy since the post-Cold War, and do not encompass non-state actors’ international activities. In contemporary international politics, non-state actors gain increasing projection on the international scene and affect power relations, understandings, and practices related to global issues. When we look at niche diplomacy, we find that it fits into an international context strongly affected by those changing processes and multiplicity of actors. Thus, the role of private actors in niche diplomacy can be described as indirect, but increasingly felt by States in their choices and strategies. Particularly in the global health field, different agendas are pursued by different actors. During the analyzed period, Brazil exercised diplomacy guided by a specific agenda – the structuring approach – which is not the same as that reproduced by traditional international health donors, new public-private partnerships or large philanthropists working in global health. Of course, Brazil’s ability to act is contingent on other national and international forces. The analysis conducted for the article was based on official documents and reports of activities, and did not identify the role of national private corporations in Brazilian health diplomacy. Nevertheless, it was possible to identify a strong engagement of public institutions, such as Fiocruz and the Ministry of Health, in setting and conducting the initiatives.

Some examples provided through the article mention that Brazilian health initiatives are based on the country’s capacities and knowledge, which enabled Brazil to consolidate networks within partner countries, mainly African ones. Could you specify what these capacities and knowledge are about? In addition, could you give some examples about how Brazilian health diplomacy helped the country to gain more space in multilateral arenas such as World Health Organization, Unasul, and BRICS?

The capacities and type of knowledge undertaken in South-South technical cooperation are mainly those related to the training of human resources, the production of health inputs such as medicines, and knowledge related to public health management. Those are knowledges typically developed in the institutions that were involved in health cooperation: Fiocruz, which has several schools for human resources training in health management and care, as well as knowledge and technologies for the production of generic drugs; and the Ministry of Health, which has knowledge related to public health management on national scale. The establishment of various networks of knowledge and experience exchanges involving these (and other) types of knowledge was one of the axes of the Brazilian diplomacy during the analyzed period. In addition to networking and to the provision of technical cooperation, health has been the subject of regional integration initiatives and multilateral forums. In these cases, we argue that Brazil sought recognition in these arenas based on its purposeful performance in health provision since 2000. In some cases, health networks were employed as part of integration projects and multilateral politics. Within Unasul, for instance, networks of international health agencies had Fiocruz as a main promoter, and the institution appeared as a key actor for the actor continuity, as it was the greatest public institution for health in the subcontinent.

Within multilateral arenas for health, the main Brazilian actor was the Ministry of Health, which sought to project Brazil’s image through the country’s activism and capacities in public health. An example is BRICS engagement in health, with the annual meeting of health ministries of BRICS’ countries since 2011. The Beijing Declaration that resulted from this meeting reinforced the importance of public health and of South-South cooperation among BRICS countries and represents a coordinated engagement of member countries with the promotion of those values in the global health agenda. This move represents an engagement of this multilateral grouping of middle countries with health as a central theme of contemporary international politics, in which Brazil and other members claimed its position as proponents of an agenda for thinking and furthering global health policies. Also, they called for the need to reform the World Health Organization, in order to reinforce its capacity to lead the global health agenda. Brazil’s engagement with health was also recognized within the OCDE, that concede to the country the role of observer in health debates within the organization.

In the article, you discussed five main axes of Brazilian health diplomacy. Two of them are about improving regional integration and Brazil as a meaningful player in multilateral forums within health debates. In your opinion, how the current Brazilian administration under Bolsonaro undermines or fosters this Brazilian role in multilateral health forums? And how the weakening of regional institutions (specially Unasul and ISAGS – Instituto Sul-Americano de Governo em Saúde) hinders the future of Brazilian health diplomacy towards regional integration?

Brazilian engagement with South-South technical cooperation has seen a decline since Dilma’s Rousseff government. This decline, nonetheless, did not represent a rupture with the initiatives promoted in the previous government. In Bolsonaro’s government, a rupture of foreign policy intentions from those pursued in PT’s governments is clearly identified, both discursively and in practice. The current government has shown a radical change in the direction of Brazilian foreign policy, breaking several agreements with countries governed by “left” governments, which can be noticed, in the health area, by the suspension of the ‘Mais Médicos’ Program with Cuba, which was coordinated through a triangular cooperation between the governments of both countries and PAHO. This rupture may point to a tendency to break with the model of cooperation conducted so far by the country, and its engagement with PAHO. Regarding regional integration efforts, different paths can be identified. Although the Bolsonaro government and other South American right-wing governments have announced their departure from Unasur and, in this sense, hindered ISAGS, there seems to be a continuity in other integrative efforts, such as Mercosur, in which health cooperation is expected to continue. BRICS health initiatives are also expected to continue if the group’s initiatives are maintained. In this sense, it is important to highlight that health appears as one of the areas that were covered by the regional integration processes. Integration is broader than health, and depends on a variety of processes and interests. Where regional integration has been maintained, a continuation of Brazilian engagement is to be expected, perhaps along the lines of what has been done so far. In other axes of Brazilian diplomacy, such as technical cooperation with southern countries, there may be a more decisive redirection or break. This will largely depend on the relationship woven between Fiocruz – a central actor of Brazilian South-South cooperation in the Lula and Dilma governments – and the federal government. In multilateral forums, health engagement may continue, being led by the MoH. This process will be strongly marked by the priorities of the Minister of Health and the foreign policy direction of the current government, which are not clear from the outset.

Read the article

Gayard, Nicole. (2019). Health as niche diplomacy: assessing design and practices of Brazilian health diplomacy at the beginning of the 21st century. Revista Brasileira de Política Internacional, 62(1), e012. Epub August 19, 2019.

About the authors

Nicole Gayard, Centro Brasileiro de Análise e Planejamento, São Paulo, Brazil

Tiago Tasca, editorial assistant of RBPI.

How to cite this interview

Cite this article as: Editoria, "Health as niche diplomacy: assessing design and practices of Brazilian diplomacy in the beginning of the 21st century, an interview with Nicole Gayard, by Tiago Tasca," in Revista Mundorama, 01/10/2019,