Regional Health Governance in South America: Redefining ... ANDINO DE ESTU… · Since the creation of the Union of South American Nations (UNASUR), health became ‘locus for integration’

Regional Health Governance in South America: Redefining Regionalism and Regional Responsibilities

Pía Riggirozzi

University of Southampton

[email protected]

DRAFT- NOT FOR CITATION BUT COMMENTS WELCOME

To be presented at the UNU/CRIS –UASB Doctoral School, Quito, August

2012

Abstract

In recent years, health has risen as a strategic policy driver redefining the terms of

regionalism in South America. Since the creation of the Union of South American

Nations (UNASUR), health became ‘locus for integration’ creating a new

framework for formal integration with regards to this policy area. The

significance of regional health governance has thus to be seen in the process of

coordination region-building, in the form of what Hameiri and Jayasuriya (2009)

identify as ‘regulatory regionalism’, and as new practices of south-south

cooperation and ‘regional health diplomacy’ beyond traditional goals of trade and

financial markets expansion. This paper is concerned with the place of social

policy as a driver of current dynamics redefining region-building in South

America, projecting alternative forms of regional governance. The contention is

that while much has been written about economic integration, regional institutions

and security communities, a discussion of how significant other regional projects

have been in the process of regionalism has lagged behind. By looking at the

institutions, resources and policy action of the regional Health Council within the

UNASUR this paper reconnects regionalism and social policy and explores two

inter-related, yet largely unexplored, issues: the linkages between regional

integration and social development beyond the historical hub of trade and finance;

and the extent to which we can genuinely talk about a ‘social turn’ in the way

regional organisations deliver new social goals.

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Key words: regionalism, social policy, region-building, regional health governance, UNASUR

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Regional Governance in South America: Redefining Regionalism and Regional Responsibilities

Regionalism can be defined as an instance of policy making of cross border

formation, advanced through institutional arrangements, bureaucracies, political

motivations and social mobilisation. It is seen where state and non-state actors

engage in political projects to relocate the governance of a particular issue or

policy domain beyond the scope of national politics. This is a process by which

regional projects move from one level of policy deliberation, negotiation and

implementation to another, in what Hameiri identified as region-building.1 In the

vast research field of regionalism that has flourished during the last two decades,

however, expectations of what regional governance can deliver have been

evaluated primarily in terms of economic and security governance.2 While much

has been written about economic integration, regional institutions and security

communities, a discussion of how significant other regional projects have been in

the process of regionalism has lagged behind. Specifically, a rather neglected

policy domain in the account of contemporary forms of regionalism has been

social policy. This has particularly been the case in the study of regionalism in the

Americas, where an unrelenting path towards neoliberal political economies, often

marked by the reach of the US as a regional hegemon, has led to a political

decoupling of economic integration and social policies.

However, a process of political renewal underway in Latin America, and mostly

in South America, since the early 2000s, has meant that regionalism may be

‘catching up’ with social concerns. Latin America is experiencing a ‘social turn’

where regional cooperation is re-connecting with new social goals beyond a

rhetorical aspect. 3 Loosening the harness of the neoliberalism as the main

organising principle of political economy in Latin America allowed a process of

transformation and re-composition of regional politics embraced by a new tide of

                                                            1 Shahar Hameiri, ‘Theorising Regions through Changes in Statehood: Rethinking the Theory and Method of Comparative Regionalism’, Review of international Studies, FirstView Articles (2012), 1-23. 2 See Edward Mansfield and Etel Solingen, ‘Regionalism’, Annual Review of Political Sciences, 13:1 (2010), pp. 145-63 3 Jean Grugel, ‘Citizenship and Governance in Mercosur: Arguments for a Social Agenda’, Third World Quarterly, 26:7 (2005), pp. 1061-76.

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Left/Left of Centre governments.4 In this context, new governing arrangements

and practices, as well as ideas to improve redistribution of income and social

services, are reclaiming the regional space for a more ‘positive regionalism’.5

This paper explores the policies and politics of Union of South American Nations

(UNASUR) and regional health as governed by the newly established UNASUR’s

Health Council. Health illustrates a policy area where new institutions, policies

and practices are putting forward new processes of regional governance. It is

argued that, new policies, mechanisms of policy diffusion and negotiation of

regional health policies are driving dynamics of region-building by governments

and practitioners defining a regional project, that not only portrays a new mode of

governance, but also region’s ability to project social concerns in the international

arena. This analysis hopes to contribute directly to the literature in IPE and

regionalism by offering a more nuanced discussion about the links between

regionalism and social policy, as well as of region as an actor engaging in new

forms of regional diplomacy beyond traditional goals of trade and financial

markets expansion.

By looking at the institutional structure, programmes, resources and policy action

of the newly established regional Health Council within the UNASUR this paper

explores two inter-related yet largely unexplored issues: the linkages between

regional integration and social development; and health governance as a new form

of regionalism. The analysis proceeds in three parts. The first part evaluates the

conceptual contributions to the discussion of what region and region-building

means in international relations, and offers conceptual grounds to define region as

both a space of policy and collective action, as well as an actor vis-a-vis the extra

regional environment. The second part looks at the place of social policy in the

process of regionalism in Latin America. It assessed the truncated experience of

social agendas in regional projects within MERCOSUR and the Andean

Community that preceded the formation of UNASUR. The third part evaluates the

                                                            4 See Francisco Panizza, Contemporary Latin America: Development and Democracy beyond the Washington Consensus (London and New York: Zed, 2009); Jean Grugel and Pía Riggirozzi, ‘Post-neoliberalism in Latin America: Rebuilding and Reclaiming the State after Crisis’, Development and Change, 43:1(2012), pp.1-21 5 Fritz Scharpf, ‘Negative and Positive Integration in the Political Economy of European Welfare States’, in G. Marks et al., Governance in the European Union (London: Sage, 1996), pp. 15-39

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factors that allowed for a re-connection between regionalism and social policy in

Latin America, and how new institutions, resources and practices in UNASUR

Health manifest as new modes of practices defining regionalism in South America

as well as UNASUR as an actor engaged in regional (health) diplomacy. The final

part offers some concluding thoughts about the social purpose of regionalism, and

the extent to which we can genuinely talk about new regional responsibilities and

rights defining current regional governance.

RECASTING REGION AS SPACE FOR POLICY AND ACTION

Region, in many ways like the state, should be seen as a place for deliberation and

collective action over certain policy domains. It could be defined as either or both

a conventional field of institutions and regulations (a sphere of territorial

representation) or a more informal domain of sociability (a space for action). The

concept of region in the field of international relations has largely been debated. i

Hettne and Söderbaum ( ) have persuasively defined the terms of the debate

suggesting that a region is not merely defined in terms of territorial contiguity but

by the space where trans-border practices and cooperation by state and non-state

actors institutionalise a complex regional society. For them, the progression from

mere regional space to deeper institutionalised polity with a permanent structure

of decision-making and stronger acting capability as a global actor: region as

actor. This appreciation gives substance to Van Langenhove’s argument that

regions are both ‘imagined and created in an institutional way’, within borders,

above and across states (2012: 1-2). Or regions are formed by states that create

institutions to regulate trans-national and trans-social cooperation in different

policy areas, to enhance their governance capacity and/or response to global

market competition ( ). Finally, regions can also take a ‘fuzzy’ shape, indicating

images of territory symbolising new models of multilateralism and cross-border

practices. This is illustrated by conceptual representations of ‘Global South’,

repeatedly seen within the literature of international relations and international

political economy, to either locate the new geography of resistance and alternative

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models of (post-Washington Consensus) political economy, or politics of inter-

regionalism.6

Motivations embraced by actors also build regions. Through trans-border

practices state and non-state actors, motivated by different reasons, concerns,

ideological stands, goals and perceptions of regional mission, engage in common

activities. As put by Acharya (2007: 364), collective identities and sense of

belonging of state and non-state actors manifest through interactions within a

common space. As actors interact upon shared values, norms and recognised

interests, they create institutions that support and reproduce those values, norms

and interests reinforcing a sense of identity and belonging, and giving coherence

to a regional project. As political spaces, regional politics and policies are

organised through formal authoritative institutions regulating over certain policy

domains, as well as less formally institutionalised regional networks, being

public-private partnerships and/or civil society networks (Hettne and Söderbaum

2004: 5-6; DeLombaerde 2011). The policies and the projects that emerge out of

this density of flows and interconnections of different kinds of actors within a

region is defined as regionalism (Söderbaum 2008: 3). While regionalism has

been defined as a formal programme, this programme must not be understood as

following a singular logic. Regionalism, in fact, can take a variety of paths and

paces, and overlapping and even competing projects may manifest within one

region as specific practices and different narratives in different domains.ii This

directly leads to resume the question opened by Kessler and Helming (2007: 582)

in their analysis of how to conceptualise regions as actors in world politics; that is,

whether there are different conceptions of integration coexisting within one

region. And by extension, why do some regionalist projects (i.e. trade and

financial integration) prevail over others (i.e environment, health, education,

migration, or a social agenda in a broader sense)? These questions stimulate

further discussion about pathways to region building as a complex process where

different regional projects, forms of cooperation, and modes of regulation and

governance unfold. But they also open a new opportunity to ‘unpack’ regions,

                                                            6 Richard Sandbrook (2011): Polanyi and Post-neoliberalism in the Global South: Dilemmas of Re-embedding the Economy, New Political Economy, 16:4, 415-443; Luk Van Langenhove the EU and the Global South…

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borrowing the claim made by Van Langenhove (2012), refocusing on ‘neglected

games’ in the process of region building, particularly in the areas of social policy

as this has been severely brushed aside in the analysis of regionalism; as well as

on the multifaceted character of regional political projects embracing often

parallels inter-societal, inter-governmental, and supra-national relations.

Unpacking regions allows us to move away from one-dimensional views that posit

regionalism as mainly led by the imperatives of the global economy (Tussie 2003:

100) to address the importance of different types of authority and regulatory

capacity established in areas beyond trade and finance with the capacity to

intervene between the global and the national level. (Jayasuriya 2004: 2). This

takes as to the second dimension in the analysis of regions and regional projects,

that external recognition.

While regionalism is expression of the social practices and mechanisms that

sustain these regional projects, cohesive regional projects can, at the same time,

act vis-à-vis the external environment. In other words, region is not only the place

‘where politics happen’, but an actor in itself that projects the regional programme

through internal coherence and external interactions. Region as actor refers to the

region’s ability to interact autonomously with its external environment, and its

formal and symbolic manifestations as a unit within its internal environment. 7

This perspective focuses not only on which relationships, networks practices and

institutions are created, but also on the regional institutional and legal status, that

is, the formal and informal foundations by which regional arrangements hold

competence to stand independently vis-a-vis national member states and external

actors, states or regions, and to project a sense of identity, mission, or regionness.

This perspective focuses not only on which relationships, networks practices and

institutions are created, but also on the institutional and legal foundations by

which regional arrangements hold competence to stand independently vis-a-vis

external actors, states or regions. In other words, region is not only the place

where agents act, but can also be an actor able to interact autonomously with its

external environment.iii Region as actor thus refers to the region’s formal and

                                                            7 Peter Schmitt-Egner,‘The Concept of 'region': Theoretical and Methodological Notes on its Reconstruction’, Journal of European Integration, 24: 3 (2002), pp. 179-200, 191

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symbolic manifestations as a unit within its internal environment and external

interactions. This directs our attention to issues of region-to-region (power)

relations and how regional politics are played in the broader global political

economy (Buzan and Waever 2003; Katzenstein 2005; also Acharya 2007).

Whereas a region is a category of analysis and an actor in the international

political economy assumes certain economic and political cohesion that enhances

planning and governance capacity of a region (Keating 1998).

A number of scholars in comparative regionalism have traced the meaning of

region-building, and the role of the European Union (EU) as an actor in

international politics, but little has been explored as to what determines region-

building, identity, sense of mission and belonging in other geographical areas.

Despite the benefits of taking the EU as starting point to analyse other regions,

there is much to be done to expanded comparative frameworks.8 Particularly the

study of regionalism in the Americas has overemphasised the economic and

financial determinants of regional politics. Furthermore, theorising about

regionalism in the Americas has been subsumed to binary notions of ‘old’/’close’

vs ‘new’/open’ regionalism based on the characterisation of regional cooperation

agreements associated with post-war economic protectionism, and those taking

place since the 1990s within a fundamental and ongoing neoliberal consensus and

expansion of the EU.9 Academic debate was marginally concerned with socio-

political, ideational and institutional transformations defining region building in

the Americas. This has not been simply academic neglect but the result of inter-

American politics defined mainly by Washington-led policies on trade,

investment, and services, or as a defensive reaction to it.10 Furthermore, when the

economistic view met politics, regionalist projects were seen as outcomes of

                                                            8 See B. Hettne, 'Beyond the 'new' regionalism', New Political Economy, 10:4 (2005), pp. 543-71; Alex Warleigh-Lack and Ben Rosamond, ‘Across the EU Studies-New Regionalism Frontier: Invitation to a Dialogue’, Journal of Common Market Studies, 48:4 (2010), pp. 993-1013 9 Tussie, ‘Latin America: Contrasting Motivations’; Nicola Phillips, ‘The Rise and Fall of Open Regionalism? Comparative Reflections on Regional Governance in the Southern Cone of Latin America’, Third World Quarterly, 24:2 (2003), pp.217-34. 10 See, Monica Serrano, ‘Regionalism and Governance: a Critique’, in. L. Fawcett and M. Serrano (eds) Regionalism and Governance in the Americas: Continental Drift (Basingstoke: Palgrave/Macmillan, 2005), pp.1-24, 13

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hierarchical arrangements in reflection of specific forms of (hemispheric) power

relations and US leadership.11

There is, therefore, a fertile analytical terrain to analyse projects, actors and

processes of regional building and regionalism in Latin America, that is even

more pressing in light of political economic transformations unfolding since the

early 2000s. In this context, we propose to engage afresh with the idea of region

as a space for contention and contestation, as well as arena of consensus-building.

Using the region to express contention, moreover, is not the exclusive preserve of

oppositional social movements; it is a strategy of political action equally available

to state elites and social movements, an arena of competition and cooperation and

a domain for cultural and political communication and policy delivery. This

notion calls reorients our attention to the complexities of new realities and current

models of regional governance that in many ways surpasses the explanatory

capacity of what has been dominant emphasis of regionalism, that is trade and

finance.12

This view is particularly useful to grasp how the profound changes in the political

economic orientation in many countries in the region since the early 2000s are

redefining dynamics in region-building. New forms of regionalism and trans-

national solidarism, although still highly led by state initiatives, reflected more

radical models of political inclusion and citizenship adopted by the so-called New

Left across the region.13 The New Left has been explained as a reaction against

what came to be seen as excessive marketization and the elitist and technocratic

democracies that accompanied market reforms at the end of the 20th century.14 As

                                                            11 See, for instance, Douglas Lemke, Regions of War and Peace (Cambridge/New York: Cambridge University Press, 2002); David Lake, ‘Regional Hierarchy: Authority and Local International Order’, Review of International Studies, 35:1 (2009), pp. 35-58; Philip Nel and Detlef Nolte (2010) ‘Introduction: Special Section on Regional Powers in a Changing Global Order’, Review of International Studies, 36:4, pp.877-79; Andres Malamud, ‘A Leader without Followers? The Growing Divergence between the Regional and Global Performance of Brazilian Foreign Policy’, Latin American Politics and Society, 53:3 (2011), pp.1-24 12 Bjorn Hettne, ‘Globalisation and the New Regionalism: the Second Great Transformation’, in B. Hettne, A. Inotai and O. Sunkel (eds) Globalism and the New Regionalism, (London: Macmillan, 1999), pp. 1-24 13 See for instance, Panizza, Contemporary Latin America; Jason Tockman, ‘Varieties of Post-neoliberalism: Ecuador and Bolivia’s Divergent Paths of Citizenship, Participation and Natural Resource Policy’. Paper presented at the Latin American Studies Association Congress, Toronto, Canada (6-9 October 2010). Available at http://lasa.international.pitt.edu/members/congres-papers/lasa2010/files/3867.pdf (1 February 2011) 14 Grugel and Riggirozzi, ‘Post-neoliberalism in Latin America’

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a project, it is understood as a call for a ‘new form of social contract between the

state and people’ 15 and the construction of a new consensus about state

responsibilities and a vision of a more equal distribution of national income. This

project sits alongside an attempt to ‘reclaim the region’, not simply as a way of

resisting US power and neoliberal dogmatism but more significantly as a new

understanding of what Latin American as a region should do and should look like.

In this context, it makes sense to revaluate what region is and is for and depart

from the dominant assumption that (domestic or transnational) economic

coalitions committed to economic liberalisation shape regionalism. The dynamics

that support regionalism are not taking place within or modelled by neoliberal

economics, nor are responding to the pressures and constraints of a globalised

economy, they are the result of a more complex way by which domestic politics

and regional regimes accommodate. 16 The debate over how to best serve

participatory, redistributive and greater autonomy in both national and the

regional agenda in Latin America opens new questions about forms of regional

governance, shifting the attention towards new policy domains and new ways of

organising regional politics. In this context, region-building in the Americas

demands a closer look at alternative models of development and accumulation

across the region that underpin new principles of regional solidarity and

complementarities expressed in regional projects for sharing resources,

decentralising power, and reconnecting social development and rights in regional

practices.

The regional question in the context of these arguments, we propose, is about

rescaling social relations in a regional space; reclaiming the region as a space for

political deliberation and policy delivery, where the region becomes a space for

the provision of regional goods beyond trade and market competitiveness –

redefining and perhaps reinventing principles of solidarism and responsibility; and

rebuilding the institutional pillars that sustain new projects within the region and

vis-a-vis external actors. Understood this way, region as space for action and as an

actor are two dimensions that reinforce each other defining the nature and

                                                            15 Christopher Wylde, ‘State, Society and Markets in Argentina: The Political Economy of Neodesarrollismo under Nestor Kirchner, 2003–2007’, Bulletin of Latin American Research, 30:4 (2011), pp. 436-45, 436 16 Hameiri, ‘Theorising Regions through Changes in Statehood’, 17

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dynamics of regionalism beyond Europe, beyond the 1990s, and beyond

hegemonic politics. Contributing to this discussion, the remaining part of this

article concentrates on at innovative terms of regional action, responsibility, and

governance advanced in the area or health.

REGIONAL SOCIAL POLICY IN LATIN AMERICA

The proliferation of free trade and single market agreements across the globe in

the 1990s not only established new boundaries for regional politics but also for

how we theorise regionalism. The ways governing arrangements for the

movement of capital, goods, services and workers unfolded within the European

Union and the Americas was marked by a difficult balancing act between ‘market-

making’ policies fostering and deepening the project of neoliberalism, and

‘market-correcting’ policies acting as a counterweight to neoliberal market

integration.17 As such, much of the progress related to social policy has been seen

mainly in the field of labour rights and harmonisation of labour policies.

Specifically in the Americas the way regionalism unfolded has been something of

a paradox; although the appeal to social economy and human development has

been in the regional imaginary and even manifested in institutional forms,

regional integration was crafted on the understandings that trade and financial

investment were the main catalysers of growth and social development. This

indirect connection, or rather disconnection, between regionalism and social

policy, meant that there has been very little dialogue between trade policies and

issues of poverty and inclusion in the definition of regional policies. This has been

particularly the case since the 1980s when developing countries were facing the

collapse of their economies in the wake of the debt crisis. Nationally and

regionally, it was expected that by loosening the restrictions on finance and trade

new market projects could enhance the capacity of states to manage the pressures

                                                            17 Bastian van Apeldoorn and Sandy Hager, ‘The Social Purpose of New Governance: Lisbon and the Limits of Legitimacy’, Journal of International Relations and Development, 13:3 (2010), pp. 209-38

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of the global order. 18 The establishment of the Southern Common Market

(MERCOSUR) in 1991 grouping Brazil, Argentina, Uruguay and Paraguay, and

the North American Free Trade Agreement (NAFTA) signed by the US, Canada

and Mexico in 1994, as well as other resilient projects from the past, like the

Community of Andean Nations (CAN) created in 1969, were established in this

understanding and aimed at locking-in market reforms and embedding capitalism

through regionalisation.19

Despite the emphasis on market-led regionalism some ‘social clauses’ were

introduced in regional agreements, specifically in the Andean Community and

MERCOSUR, where the legacy of developmental welfare states steering

development projects since the 1940s has been significant for the formulation of

commitments in the areas of labour rights, health and education.20 In this sense,

social policy through regionalism is hardly ‘new’ as some cross-border projects

on health, education and labour regulations were supported since the creation of

both Andean Community and MERCOSUR. In the case of Andean Community,

for instance, two managing bodies were created to manage common challenges in

the areas of health and education. The Hipólitio Unanúe agreement and the

Andres Bello Convention established the foundations for the coordination of

health and education policies respectively since the early 1970s. In the area of

health, active policies in relation to the prevention and control of diseases

affecting border areas were implemented, whereas in education, policies towards

the harmonisation of curricula, mobility of students and professionals, and quality

assurance programmes were set up for the Andean region.21 In MERCOSUR a

Health Minister Assembly was established in the mid-1990s as a ministerial

forum for the discussion of health policy and strategies as part of the regional

agenda (MERCOSUR Decision CMC No 03/1995). Similar advances were also

                                                            18 Hettne, 'Beyond the 'new' regionalism'; Hurrell, ‘Regionalism in Theoretical Perspective’; Marchand, et al, ‘The Political Economy of Regions and Regionalisms’ 19 Nicola Phillips, ‘Hemispheric Integration and Subregionalism in the Americas’, International Affairs, 79:2 (2003), pp.327-49 20 See for instance, Manuel Riesco ‘Binding Material for a Young Giant? Regional Social Policies in Latin America’, in Bob Deacon, Maria Macovei, Luk Van Langenhove and Nicola Yeates (eds) World-Regional Social Policy and Global Governance: New Research and Policy Agendas in Africa, Asia, Europe and Latin America, (London: Routledge 2009), pp.108-39 21 UNDP, Regional Integration and Human Development: a Pathway for Africa, (New York: UNDP, 2011)

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seen in the area of education, which together with health pushed social policy into

the agenda for activities and surveillance with some degree of impact in these

fields (see UNDP 2011). Yet, further commitments and institutionalisation of

cooperation and implementation of social policies have been erratic and with

mixed consequences for human development in both regional integration schemes

during the 1990s. 22 In practice these embryonic regional social agendas were

working on the edges of financial constraints and cross-national asymmetries, and

thus could not overcome difficulties related to lack of action plans and

fundamentally funding constrains.23 In this context some commitments over a

range of social policy areas were made but low levels of institutionalisation for

implementation, coordination and compliance affected the depth and pace of

regional social policies. Politically, rudimentary institutional structures in both

Andean Community and MERCOSUR often delegated decisions over regional

policies and politics to intergovernmental negotiation processes. Inter-

governmentalism, or rather inter-presidentialism, left social policy subject to the

discretion of policy makers, ministers, and private providers – and to their

struggle for distributional benefits.24 Consequently, the capacity of social actors to

penetrate the regional policy debate and negotiation of policies has been severely

curtailed by a regional political culture that sealed off from society while

responding to market pressures.

Despite this difficult relationship between regional politics, social actors, and

social agendas, some initiatives in the direction of social participation were

created, actively creating opportunities for social activism. This has been the case

in MERCOSUR where the establishment of the MERCOSUR Social Institute

(Instituto Social MERCOSUR) supported by the Ministries of Development of its

members in 1999, represented a hub for research on social policy and policy

recommendation. Likewise, a think-tank, Somos MERCOSUR, created in 2005,

opened a new space for civil society and governments to engage in discussions

                                                            22 Riesco ‘Binding Material for a Young Giant?’ 23 Deacon et al, World-Regional Social Policy 24 Andres Malamud, ‘Mercosur Turns 15: Between Rising Rhetoric and Declining Achievement’, Cambridge Review of International Affairs, 18:3 (2005), pp.421-36; Delia Sanchez, ‘Health Integration Processes: Challenges for MERCOSUR in the Health Field’, Cad. Saúde Pública, 23:2 (2007). Available at http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0102-311X2007001400005&lng=en&nrm=iso (22March 2012)

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and deliberation of policy priorities and agendas. While these events and

institutional initiatives helped promoting and reinforcing a more genuine social

agenda, policy action and regional norms remained plagued by procedural

ambiguities and fundamentally held back by economic and financial hardship.25

This was even more the case as, during the 1990s, spending in social sectors was

bundled with macroeconomic reforms, privatisation and deregulation, advanced

by Washington Consensus, supporters which reduced state investment in social

policies. Although there is some evidence to suggest that neoliberal reforms

reduced state inefficiency, controlled inflation, and led to some improvements in

terms of growth, economic restructuring also affected standards of living as

welfare was systematically squeezed and inclusion reduced to those who could

pay for health, good schooling and social security.26 It is perhaps not surprising,

in these circumstances, that social demands for more responsive political

economies erupted after two decades disappointing effects of neoliberal reforms

on poverty reduction in Latin America.27 ‘Reclaiming the state’, as argued by

Grugel and Riggirozzi, began with the rejection of a generation of political leaders

who were responsible for the introduction of neoliberalism in the 1980s and 1990s

and exclusionary politics, nationally and regionally.28 The context paved the way

for the renewal of politics and policies at both national and regional levels. The

rise of New Leftist governments across the region – in Venezuela (1998), Brazil

(2002, 2006 and 2010), Argentina (2003; 2007, 2012), Uruguay (2004), Bolivia

(2005), Ecuador (2006), Paraguay (2008) and Peru (2011) – was not simply as

expression of partisan and symbolic politics, but a more profound

acknowledgement that economic governance could not be delinked from

democratic ethos and the responsibilities of the state embracing socially

                                                            25 Luis Di Pietro, ‘La Dimensión Social del Mercosur. Recorrido Institucional y Perspectivas’, Paper presented at workshop: Integración Regional y la Agenda Social, BID-INTAL, Buenos Aires, November 12-13 (2003); Jean Grugel, ‘Citizenship and Governance in Mercosur: Arguments for a Social Agenda’, Third World Quarterly, 26:7 (2005), pp. 1061-76 26 Nancy Birdsall and Juan Lodono, ‘No Tradeoff: Efficient Growth via More Equal Human Capital in Latin America’, in Nancy Birdsall, Carolina Graham and Richard Sabot (eds) Beyond Tradeoffs: Market Reforms and Equitable Growth in Latin America (Washington, DC: Brookings Institution Press and IADB), pp. 111-45; Robert Gwynne and Cristobal Kay, ‘Views from the Periphery: Futures of Neoliberalism in Latin America’, Third World Quarterly 21:1 (2000), pp. 141-56 27 ECLAC, Social Panorama of Latin America (Santiago: CEPAL, 2010); also Ana Dinerstein, ‘Workers’ Factory Takeovers and New State Policies: Towards the Institutionalization of Non-Governmental Public Action in Argentina’, Policy and Politics, 35:3 (2007), pp. 529-50; Tockman, ‘Varieties of Post-neoliberalism’ 28 Grugel and Riggirozzi, ‘Post-neoliberalism in Latin America’

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responsive political economies. In other words, the move to the Left in Latin

America must not be simply seen as a political swing but as a new opportunity for

new leaders to synchronise governmental policies in the search for greater

autonomy vis-a-vis external actors and greater inclusion in multi-scalar ways. One

important idea is that of a continental identity: that Latin American peoples

belong to a common space, as well as to their own communities and nation states.

This became visible in new trans-societal cooperation in welfare projects and

workers’ cooperatives, in support of a new sense of belonging, identity and

regional mission.29 Politically, this is best expressed through new projects such as

ALBA and UNASUR that, although in different ways and types of organisation,

embraced new regionally-anchored projects addressing the needs for human

development. Of course, this is not simply political voluntarism, but also a new

opportunity given by the unprecedented rise in the global demand for primary

commodities. The movement towards a new regional governance was

accompanied, and in many ways fostered, by a second great transformation in the

global political economy driven by the rise of China, in many ways as an

alternative globaliser redefining global trends in trade, production and finance;30

new geopolitical challenges to the US as an hegemonic power; and a renewed

opportunity in South-South cooperation and alternative trade and financial links.

In other words, new national and international drivers are carving out South

America as a distinctive region, where the region becomes a platform for the re-

ignition of new processes of policy-making, and regionalism a manifestation of

those processes. Anchoring new demands for social inclusion and social

development within (regional) institutions, regulations and projects is not simply a

matter of welfare delivery or social compensation, but more profoundly a

definition of regional political economy.

re

Ironically, the re-articulation of regional politics has been decidedly geared by

state-led politics. The establishment of New Leftist governments across the region

 29 Steffen Bohm, Ana Dinerstein and Andre Spicer, ‘(Im)possibilities of Autonomy: Social Movements in and Beyond Capital, the State and Development’, Social Movement Studies, 9: 1 (2010), pp. 17-32; Thomas Murh, ‘Counter-hegemonic Regionalism and Higher Education for All: Venezuela and the ALBA’, Globalisation, Societies and Education, 8:1 (2010), pp.39-57 30 see Bloomberg , ‘China Loans Ecuador $1 Billion as Correa Plans First Bond Sale since 2005’, News, January 24 2012. Available at http://www.bloomberg.com/news/2012-01-24/ecuador-borrows-from-china-seeks-bond-sale.html (28 March 2012)

  15 

created a new political space where the debate about regional social policies re-

emerged yet highly led by inter-governmental arrangements and sense of

solidarity amongst the new governments. Serbin and Saguier highlighted the

contradictions of a process that has been driven by social demands but recreated

by a new surge of inter-governmental politics.31 Nonetheless, it may be suggested

that proposals brought about by social movements and activists for more

responsive models of governance were in practice incorporated within the new

regional projects that anchor welfare reforms and political projects in current

region-building. As such, new practices defining regionalism should be seen as

led by governments but also as opportunities for social actors to engage in

etworks that can advance a broader sense of regional community.

DVANCING NEW FORMS OF REGIONALISM

significance of ethnic politics, supports the notion of ‘post neoliberalism’ as a

n

A

One of the striking characteristics defining current dynamics of political economy

in Latin America is the attempt to redefine new boundaries (geographical and

ideological) for what constitutes regional political economy. A spectrum of

national responses to what manifested crises of many sorts of the neoliberal

project that dominated hemispheric politics for more than two decades. One

manifestation of this has seen the election of a series of Leftist governments in

much of Latin America. At odds with neoliberal policies, these governments

embarked on a search for alternative models of development and governance. The

change in the political orientation in many countries in the region since the early

2000s was not simply rhetorical. In general new Latin American governments

adopted more radical models of political inclusion and citizenship, implementing

highly interventionist policies, redistribution and in cases nationalisation in

support of a new attitude to state-building and representation. This, combined

with a greater emphasis on the inclusion of previously excluded groups and the

 31 Andres Serbin, ‘New Regionalism and Civil Society: Bridging the Democratic Gap?’, in Pia Riggirozzi and Diana Tussie (eds) The Rise of Post-Hegemonic Regionalism: The Case of Latin America (Netherlands: Springer/United Nations University, 2012), pp.147-65; Marcelo Saguier, ‘The Hemispheric Social Alliance and the Free Trade Area of the Americas Process: The Challenges and Opportunities of Transnational Coalitions against Neo-liberalism’, Globalisations 4: 2 (2007), pp. 251-65

  16 

combination of Keynesian welfare politics and socialist. 32 In this context,

reclaiming the region by state and non-state actors became not only a way of

resisting US power but a genuine reflection of what Latin American should do and

should look like. Finally, the change in political economy led to another important

manifestation, the re-discovery of the region as a common space for pulling

together resources in support of alternative practices and in rejection of the idea of

neoliberal-led regionalism. In this context, South American regionalism is the

result of a combination of national level statecraft and the reshaping of the

regional political economy based on new commitments for institutional

innovation, funding and projects in support of region building. ALBA and

UNASUR establish alternative ways of managing economic and human resources

for the provision of new political and social regional goals that in practice can

help to overcome traditional forms of state-bounded provisions of social rights.

This is not a minor issue in societies with high levels of poverty, exclusion and

inequality, and that struggle to mobilise funding for social cohesion programmes.

In the case of UNASUR, a new social agenda integrates the sharing and

development of human resources and institutional development in areas of social

policy, particularly in the field of health. The Constitutive Treaty of UNASUR

establishes a broad acceptance of social policy as an important catalyst for new

models of integration and the need to institute a Health Council that can

coordinate effective governance.33 What makes UNASUR particularly interesting

is its vision of regionalism that builds from, and capitalises on, pre-existing trade-

led agreements, specifically MERCOSUR and Andean Community, but

strengthens new areas of regional cooperation beyond trade and finance, the

domain that defined the path and depth – and the limits – of MERCOSUR and the

Andean Community.34 UNASUR thus must be seen as a project that rebuilds the

regional space capitalising on resilient arrangements of the ‘open’ regionalism of

the 1990s but redefining the complexity of trans-border practices and cooperation.

As a system of governance, UNASUR is heading towards a deep inter-

                                                            32 Tockman, ‘Varieties of Post-neoliberalism’, Grugel and Riggirozzi, ‘Post-neoliberalism in Latin America’ 33 See UNASUR Constitutional Treaty (‘Tratado Constitutivo de la Union de Naciones Sudamericanas’). Available at hrdttp://www.comunidadandina.org/unasur/tratado_constitutivo.htm (3 March 2012) 34 See Malamud, ‘Mercosur Turns 15’

  17 

governmental institutionalised project based on the agreement that South America

has the authority and capacity to autonomously manage natural resources,

infrastructure and security, and the responsibility to reconnect economic growth

and social development through regional practices. New institutions and

permanent structures of decision-making have thus been established in these areas

deepening intra-regional relations, and seeking new inter-regional (South-South)

cooperation.

Although UNASUR crystallised in 2008, its origins must be traced back to the

beginning of the decade when Brazilian president Fernando Henrique Cardoso

called in the 1st Summit of South American Presidents, in 2000. This Summit

created the foundations in which South American integration settled and contested

US continental ambitions. 35 From this perspective, although embryonic, this

emerging model of regional governance needs no trivialisation. The renewed

commitments on social principles, development and rights together with its

institution-building gave new impetus to ambitious projects that since the early

2000s attempted to boost infrastructural and energy integration throughout the

continent, and the autonomous management of security and regional affairs

restricting US power and US-led institutions’ influence and redefining the inter-

American system.36

Certainly, region building in South America reflects complex dilemmas of

politics, where national interests may be pursued in a multiscalar way, and so the

role of Brazil is explained – and perhaps, although more controversial, that of

Venezuela – advancing new goals of regional social and political economy.37 But

region-building involves more than a balance of power between leaders and

followers. It is also a reflection of new choices of policies and political

assertiveness that, in the case of South America, is expressed through numerous

                                                            35 Jose Briceño-Ruiz, ‘From the South American Free Trade Area to the Union of South American Nations: The Transformations of a Rising Regional Process’, Latin American Policy, 1:2 (2010), pp. 208-29 36 UNASUR Agreement 01/09-21/04/2009. Available at http://www.ocai.cl/unasur-english.pdf. (29 March 2012); also Tussie and Riggirozzi, Rise of Post-Hegemonic Regionalism 37 Stefan Schirm, ‘Leaders in Need of Followers: Emerging Powers in Global Governance’, European Journal of International Relations, 16:2 (2010), pp. 197-221; Andres Malamud, ‘A Leader without Followers? The Growing Divergence Between the Regional and Global Performance of Brazilian Foreign Policy’, Latin American Politics and Society, 53: 3 (2011), 1-24

  18 

efforts to build regional projects echoing a generalised spirit of political change

with important implications for inter and intra American relations. Beyond

national interest calculations and symbolic politics, what current regional politics

in South America represents is a clearer commitment to address relegated and

deeply rooted unsolved dilemmas of development, inclusion, and social rights by

reclaiming the regional space for the crafting of policies and policy-making

mechanisms. In this context, the governance of health in UNASUR is a key policy

area based on policy commitments and institutionalised practices that not only

embrace a new sense of regional collective action, but fundamentally a new mode

of regionalism that enables both new responsibilities and a new policy instance

advancing social development.

Governing Health in UNASUR

The political complexities within the field of health are often defined by tensions

between the interests of the pharmaceutical industry, national health systems and

citizens’ access to medicine.38 In Latin America these tensions became clear in

the 1980s as the region engaged with neoliberalism through the Washington

Consensus, supported by the political and economic authority of the US and the

international financial institutions, and the private sector. That is why in the face

of the neoliberal crisis that manifested in the early 2000s, revisiting this

relationship became priority in the reformulation of politics and political aims at

national and regional levels.

In the creation of UNASUR, social policy was presented as a critical aspect

reconciling in many ways the lack of progress in the social agenda and the region

as a space where social politics happen and rights are enforced. UNASUR official

documents speak of a new morality of integration linked to a right-based approach

to health as it is considered a transformative element for societies, a vehicle for

inclusion and citizenship; and an active aspect in the process of South American

                                                            38 Robert Geyer, ‘The Politics of EU Health Policy and the Case of Direct-to-Consumer Advertising for Prescription Drugs’, 13 (2009), pp.586-602, 586

  19 

integration. 39 Health from this perspective became ‘locus for integration’,

incorporating efforts and achievements from previous regional integration

mechanisms but creating a new framework for formal integration with regards to

health. The way UNASUR embraced new commitments of social development

was visible in the health area. This unfolded as a three levels of policy practice: (i)

institutional, as a regulatory actor; (ii) diplomatic, engaged in extra-regional

relations; and (iii) project-led, engaged in intra-regional activities. These levels

are interconnected in novel forms of exchange of human and economic resources

and institutionalisation of regulatory frameworks and best practices. In many ways,

UNASUR health responds to social needs in the region while strengthen the

autonomy of South America vis a vis external actors.

Institutionally, the South American Health Council or UNASUR Health was

created in December 2008 to provide an opportunity for integration with regard to

health. The UNASUR Health Council was one of the first Councils to be

approved in UNASUR with the aim of reducing social and health inequities in the

region. The UNASUR Health Council works at the ministerial level to consolidate

South American integration in the health field by means of the establishment of

policies based on mutual agreements, coordinated activities and cooperation

efforts between countries.40 The UNASUR Health Council establishes policies

and the agenda for regional provisions on health. The agenda is implemented by

Technical Groups formed by members’ representatives to tackle five issues that

defined the South American health agenda, or the Five Year Plan (Plan

Quinquenal) approved in 1999.41 The Five Year Action Plan outlines actions,

coordinated financial resources, capacity building activities and regulatory

frameworks through the establishments of new institutional arrangements

coordinated by specific Working Groups. The Working Groups coordinate the

following specific goals: Creation of the South American ‘epidemiological shield’

                                                            39 UNASUR Salud, Report of the Pro Tempore Secretariat, 2011. Available at http://isags-unasul.org/site/wp-content/uploads/2011/12/Informe-2011.pdf (28 March 2012), 15. Also, Presidential Declaration (UNASUR, Declaración Presidencial) Quito, 10 August 2009. Available at http://www.comunidadandina.org/unasur/10-8-09Dec_quito.htm (16 September 2011) 40 UNASUR, Declaración Presidencial de Quito, 10 August 2009. Available at http://www.comunidadandina.org/unasur/10-8-09Dec_quito.htm (20 January 2011) 41 UNASUR Plan Quinquenal, 2010-2015 Available at http://www.ins.gob.pe/repositorioaps/0/0/jer/rins_documentosunasur/PQ%20UNASUR%20Salud.pdf (20 March 2012)

  20 

for the coordination and surveillance through networks implementing

international health regulations. The priorities in this area are early detection and

response to outbreaks and elimination of communicable diseases such as malaria,

dengue fever and tuberculosis. Within this framework, new regulatory procedures

have been established to enhance surveillance capacity through committees

thatmonitor prevention and control of communicable diseases, intoxications due

to pesticides and the quality of water, and coordination among countries for these

and similar risks as well as to enhance the delivery in terms of regulations and

health systems for the most vulnerable groups.42 A second area of priority relates

to the development of universal health systems in response to peoples’ universal

right to health. Likewise, the promotion of universal access to medicines has been

prioritised by establishing new drug policies and the development of a South

American health production complex. To achieve this goal an innovative network

of professionals and practitioners has been institutionalised within the South

American Institute of Health Governance (Instituto Sudamericano de Gobierno en

Salud, ISAGS).43

ISAGS leads a network of similar country-based institutions dedicated to the

production of knowledge and preparation of key professionals for the

management of national health systems. 44 The establishment of ISAGS is a

pioneering step that creates an institutional pillar to tackle issues of management

and redistribution of resources in the form of human capacity for better governing

of health as a regional goal as well as professionally for enhancing research and

development. ISAGS activities range from the organisation of seminars, courses,

internship programs, and other initiatives to improve leadership at the level of

health systems, to the coordination of research programmes in support of a more

autonomous pharmaceutical industry. In this respect, ISAGS seeks to identify

existing industrial capacities in the region to coordinate common policies for

production of medicines and other goods, advancing the industry and creating

competitive advantages in global negotiation and provision for regional health.

                                                            42 Ibid, 8-10 43 For information about ISAG, see website of the Instituto Suramericano de Gobierno en Salud. Available at http://isags-unasul.org/site/sobre/?lang=es (2 April 2012) 44 See UNASUR Plan Quinquenal 2010-2015

  21 

The implications for this new institutional force is particularly significant for the

regionalisation of human capacity and knowledge as tools that can give leverage

in negotiations vis-à-vis private and multilateral organisations. UNASUR Health

institutions, the Council and ISAGS, are crucial mechanisms for establishing rules

and regulations for the managing of health regionally. While the Health Council

essentially organises the rules and procedures fostering relationships between

actors; the ISAGS represents an important mechanism, a type of knowledge bank,

in support of policy making and policy action, while establishing new boundaries

between public and private actors.

The significance of these developments has to be seen in the process of region-

building and modes of ‘regulatory regionalism’, as expressed by Hameiri and

Jayasuriya, in response to social and redistributive needs. 45 But the

institutionalisation of new discourse and practices is not only opening a new space

for action in regional social development but also new practices that are projected

externally, mainly in terms of ‘regional health diplomacy’ and south-south

cooperation, defining the region as an actor.46 Regional action is hugely supported

by the more confident presence of Brazil in the international arena, which in the

case of global health has taken an increasingly active role and new protagonism

over the past decade. 47 Nunn et al explored the various efforts of Brazilian

diplomats and health officials to change global norms regarding access to

medicines as a human right in various United Nations bodies, World Trade

Organisation negotiations, and campaigns involving South-South cooperation.48

But while Brazil has been instrumental in promoting discussions over policies in                                                             45 Hameiri, ‘Theorising Regions through Changes in Statehood’ ; Kanishka Jayasuriya, ‘Regulatory Regionalism in the Asia-Pacific: Drivers, Instruments and Actors’, Australian Journal of International Affairs, 63:3 (2009), pp. 335-47 46 Paulo Buss, ‘Brazil: Structuring Cooperation for Health’, The Lancet, 377: 9779 (2011), pp. 1722-23 47 Paulo Buss, and Maria do Carmo Leal ‘Global Health and Health Diplomacy’, Cadernos da Saúde Pública, 25:12 (2009). Available at http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2009001200001&lng=en&nrm=iso&tlng=en (2 February 2012); Eduardo Gomez, ‘Brazil's Blessing in Disguise’, Foreign Policy, July (2009) Available at http://www.foreignpolicy.com/articles/2009/07/22/brazils_blessing_in_disguise (28 March 2012); Maria R. Soares de Lima, and Monica Hirst, ‘Brazil as an Intermediate State and Regional Power: Action, Choice and Responsibilities’, International Affairs, 82: 1 (2009), pp. 21-40 48 See Amy Nunn, Elize Da Fonseca, and Sofia Gruskin, ‘Changing Global Essential Medicines Norms to Improve Access to AIDS treatment: Lessons from Brazil’, Global Public Health: An International Journal for Research, Policy and Practice, 4:131 (2009). Available at http://www.informaworld.com/10.1080/17441690802684067 (11 June 2011)

  22 

important areas concerning the impact intellectual property rights on access to

medicines or the monopolist position of pharmaceuticals on price setting and

generics, it has also acted in tune with a region that is redefining the terms of

redistributional politics, managing common resources and harmonising policies

and capacities, while using the region as a platform for contestation in

international negotiations. From this perspective, UNASUR has increasingly

emerged as a legitimate and pro-active actor in pursuit of controversial aspects

within the global health diplomacy, in particular issues of intellectual property

rights and access to medicine. 49 For the first time, joint actions are being

promoted at the Pan-American Health Organisation and the World Health

Organisation to change policies regarding representation of developing countries

in the executive boards of these bodies. Likewise, UNASUR governments have

settled a strategy of joint negotiation, through the revolving fund of the Pan-

American Health Organisation (PAHO) to guarantee equitable access to

medicines. In another manifestation of collective action, UNASUR countries have

committed not to buy medicines above the prices settled by the PAHO's fund,

attempting to prevent commercial interests taking advantage of panic and

uncertainty caused by epidemics. Patents and access to medicine have demanded a

more nuanced assessment of how regional arrangements can maximise and

enhanced the reach and outcomes of public policy, emphasising that economic

interests in the global health industry and intellectual property laws should not

impede efforts to protect public health.50

The presence of UNASUR in this type of global health diplomacy, and its

coordinated efforts to redefine rules of participation and representation in the

governing of global and regional health, is pointing at a new rationale in regional

integration in Latin America that in many ways resembles the region becoming an

international ‘actor’. The notion of region as actor denotes a space for new policy

coordination and collective action through regional institutions and

responsibilities for the delivery of common policies in issue areas. In the case of

 49 See Ilona Kickbusch., Gaudens Silberschmidt, and Paulo Buss, ’Global Health Diplomacy: the Need for New Perspectives, Strategic Approaches and Skills in Global Health’, Bulletin of the World Health Organization. Available at http://www.who.int/bulletin/volumes/85/3/06-039222/en (12 July 2010); also Buss, ‘Brazil: Structuring Cooperation for Health’. 50 UNASUR Salud, Report of the Pro Tempore Secretariat

  23 

health, this is an important development with tangible results for national

governments in terms of how to deliver better and more inclusive policies, and for

local populations in terms of improving their well-being.

Finally, at the level of policy implementation, UNASUR is coordinating new

transnational risks projects and effective funding for health and food security

programmes in specific countries. One of the most salient interventions has been

the reconstruction and health cooperation with Haiti after the earthquake in

January 2010. The 12 members of UNASUR disbursed US$ 70 million, out a total

of US$ 100 million committed to the reconstruction of Haiti. These funds are

allocated for the implementation of 144 projects identified, coordinated and

funded by UNASUR. 51 UNASUR provided relief supplies to assist counter-

cholera efforts targeting Haiti’s dire sanitation crisis after the earthquake. Within

the coordination of UNASUR, Venezuela sent medicine supplies to help combat

the outbreak of cholera in the island. Likewise, a UNASUR mission has also

undertaken an extensive vaccination against H1N1 influenza and dengue. 52

Additional bilateral aid from Ecuador and Dominican Republic provided support

in the form of funds, logistics, sanitation, and personnel, reinforcing the regional

response. UNASUR’s cooperation with Haiti has also complemented health

assistance with food sovereignty and improvement of infrastructure, housing and

institutional strengthening. 53 The Secretary General of the UNASUR, María

Emma Mejía, made clear that the regional cooperation with Haiti not only focuses

on ‘circumstantial support to deal with emergencies arising from the earthquake

[i.e. immediate needs related to budget support, maintenance, shelters], but also

interventions to help the country move forward’.54 In view of this, an important

food programme has been implemented, the so-called ‘Pro Huerta’ project, which

provides technology and training to farmers for the implementation of technology

in agro-ecological self-production of food. The project is based on an investment

of USD$3 million and capacity building from an Argentine agronomist, involved                                                             51 APS, 12 July 2011, ‘Unasur ha aportado 70 millones de dólares para reconstrucción de Haití’. Available at http://www.apc-suramerica.net/?p=1137 (12 March 2012) 52 PAHO, ‘UNASUR’s Role in the Vaccination Against Pandemic Influenza’, Pan-American Health Organisation, Immunisation Newsletter, 32:4 (2010). Available at http://new.paho.org/hq/dmdocuments/2011/SNE3204.pdf (12 March 2012) 53 Página 12/ Argentina, 1st September 2010, ‘La UNASUR ya tiene Oficina en Haiti’ 54 Agencia Latinoamericana de Informacion, 13 July 2011, ‘Cooperación UNASUR-Haití: Hora de hacer un balance completo’. Available at http://alainet.org/active/48018 (2 April 2012)

  24 

in the Pro-Huerta programme in Argentina, a programme that has been running

since the mid 1990s in that country. Another important project supported by

UNASUR in Haiti is the so-called "roof for my country", in collaboration with the

Chilean Foundation of the same name, which aims to build just under a thousand

houses, surgeries and schools.55 UNASUR Health Council also played a key role

in the support for reconstruction after the earthquake in Chile in 2010. What these

institutional arrangements, projects and practices suggest is that health is

becoming a salient element redefining the terms of region building as a space for

new political and social manifestations away from the trade-led and financial

rationale, and as an actor that faces and negotiates more confidently the challenges

of the global political economy. In this context UNASUR is moving towards the

consolidation of a regional complex on which trans-border practices and

cooperation are deepening intergovernmental relations and their commitments

towards social inclusion, development and autonomy.

THE SOCIAL PURPOSE OF REGIONALISM: NEW CORDINATION,

NEW SOCIAL CONTRACT?

While the extent to which regional institutions can close the gap of unequal

development in South America is still to be seen, UNASUR offers a new

institutional architecture, policies and action plans that opened a new space for

action in a field of high social sensibility and practices for integration that can

have enormous consequences on social development. But UNASUR also speaks

of a social policy as a transformative element in terms of delivery of policies, a

vehicle for inclusion and rights. The implications of these developments are

twofold. In the first place, it confirms the importance of understanding the

connection between national politics and regional politics, something that far from

being obvious has been largely overlooked in the analysis of regional governance.                                                             55 UNSC, ‘Recognizing Interconnected Nature of Haiti’s Long-Term Development Challenges, Security Council Reiterates Need for Sustained International Support’, UN Security Council 6510th Meeting, April 2011. Available at http://www.un.org/News/Press/docs/2011/sc10218.doc.htm (28 March 2012); see also UNASUR Bulletin: ‘Ecuador and Domenican Republic agree to cooperate in the reconstruction of Haiti’ (Ecuador y Republica Domenicana subscriben convenio para reconstruccion de Haiti), 4November 2010. Available at http://www.pptunasur.com/contenidos.php?id=1100&tipo=27&idiom=1website (28 March 2012)

  25 

Regionalism has been defined as and by a regionalism-neoliberal globalisation

relationship and therefore little attention has been paid to how states respond to

their own national commitments and to region-building projects. This is a pressing

research question as the relationship between neoliberal globalisation and

regionalism does not hold firmly any longer. Regional politics not only contest the

established architecture but go beyond it to align national institutions and socio-

economic goals with new forms of regional regulation and policy delivery in a

combination of national level statecraft and regional political economy. From this

perspective, a research agenda on current regionalism beyond Europe needs to

further explore the ways and extent to which regional politics can narrow

inequality and asymmetries in the region. How can regionalism support national

policies? Can we talk about regionalism as an alternative way of delivering social

development and strengthening rights-based domestic policies? At the same time

new questions are opened for further investigation on how regional arrangements

sit against global negotiations. Can we genuinely talk about a new regional

diplomacy in global health? In this view, UNASUR Health and its Five Year Plan

could be seen as both the outcome and context of a developing regional political

community that is transiting towards a deeper institutionalised polity with a

permanent structure of decision-making, capacity building institutions and

supportive nationally-based projects. In practice, these elements define new

responsibilities within the region as well as an enhanced, or more confident,

capacity to be a global actor. Theoretically, this gives substance to arguments

about region-building and regionness that has been productively applied to

explain social cohesion and social governance in EU but largely overlooked in the

study of Latin American regionalism.56

Second, the analysis of the UNASUR Health system gives new substance to what

Jayasuriya termed the ‘domestic political mainsprings of regional governance’ by

which regionalism is not only expression of inter-governmental arrangements but

also a driver of change of national practices.57 From this perspective, regional

regulations, institutions, and procedures engender distinctive forms of ‘regulatory

                                                            56 Riggirozzi, ‘Region, Regionalism and Regionness’ 57 Kanishka Jayasuriya, ‘Introduction: Governing the Asia-Pacific: Beyond the ‘New Regionalism’, Third World Quarterly 24:2 (2003), pp. 199-215, 199

  26 

systems’ that affect national practices. In other words, regional policies may be

originally driven by national interests but have the potential to develop formal and

informal forms of coordination that create a sphere of authority independently

from national interests and inter-governmental politics. In the case of UNASUR,

this is seen in the way new institutions regulate a range of policy domains, from

external relations to the sharing of material and epistemic resources through the

coordination of research and development. These institutions have the capacity to

act in reflection of regional interests and to establish at the same time new

benchmarks, targets and goals of policy that can affect practices or redistribute

resources at national levels of implementation. In addition, regional epistemic

communities and professional associations, such as the Working Groups and

ISAGS, open new opportunities for the participation of non-state actors in the

definition of regional policies and practices, with the potential to downplay the

excessive inter-governmentalism that underpins current regional developments. If

so, the reconfiguration of regional politics, and the role of region in South

America will transcend forms of bureaucratisation and institutionalisation towards

a more fundamental place where state and society can re-enact their social

contract reinforcing and rescaling social concerns at different levels of policy.

CONCLUSION

This paper conceptualises the relationship between regional governance, social

policy and the political space that this relationship generates. There are elements

to sustain that the governing of regional health in UNASUR represents a new

form of regionalism anchored in the institutionalisation and practice of goals that

are at odds with traditional goals of trade and finance, while creating new

capacities for a more confident South American regional actor to negotiate goals

vis-a-vis external actors. Regulatory aspects and practices of UNASUR Health

reconnect national motivations, models of political economy and regional

integration, breaking with deterministic assumptions of external determinants of

region building and the regionalism-globalisation relationship. From this

perspective, we are able to move beyond arguments about the relative importance

of globalisation as a structure of constraints for developing countries and

developing regions that have often considered regionalism as a defensive reaction

  27 

to external pressures and influence. As the analysis in this article suggests,

regional cooperation in health, although allegedly embryonic, has the capacity to

drive a transformative process, creating new spaces for action in which to re-

embed socially-responsive models of development and citizenship rights.

Of course this process is not free from contradictions. All politics engender

struggles that in the case of region building in South America can be defined by

the lack of participation of civil society organisations in the definition of

UNASUR social policies, agendas and institutions. In fact, the creation of

UNASUR has not seen yet new mechanisms for the incorporation of social actors

in the definition of social agendas. This creates a contradiction in spaces that

embraced real commitments with regional provisions for social policy – despite

social actors’ demands having been brought in under the auspices of the state into

new dynamics of regional cooperation and integration. Nonetheless, a lack of an

institutionalised broader dialogue may inhibit the transformative capacity of

UNASUR as a new instance of social policy delivery. These challenges will

define the prospects of social policy through regional integration and the extent to

which we can identify a new route to public policy at a cross border level of

governance. As such, while health is a thriving case in terms of new regional

practices and policies, the politics that may affect furthering this social turn in

regionalism are still an open agenda of investigation.

At the moment, Latin America is a continent of contradiction where diversity in

motives, ideologies and leadership aspirations are driving alternative (post-

neoliberal) models of integration. Despite the much longer route to walk in terms

of social policy and regionalism, undeniably the region recovered a novel capacity

to reassert new modes of regional organisation with an enormous potential for

social development. Those interested in regionalism and development cannot

afford to ignore this issue. The lesson we can draw from the case of UNASUR

Health in particular is that, unlike the past experiments in regional governance, we

can now talk about a new start, analytically and politically, on the bases of

concrete explorations of institutions, practices, new opportunities for collective

action, and projects on the ground. New forms, and domains, of regional

governance allow us to speculate about the complexities and contradictions of

  28 

  29 

social-based regionalism as well as a new sense of the value of the region as

another policy making instance enacting social goals.

 i See Rick Fawn, ‘Regions and their Study: Wherefrom, What for and Whereto?’, Review of 

International Studies, 35:1 (2009), pp. 5‐34 

iiBjorn Hettne and Frederick Söderbaum, ‘Theorising the Rise of Regionness’, New Political 

Economy, 5:3 (2000), pp.457‐74; also Hettne, Inotai, and Sunkel 2000 and 2001; 

Söderbaum and Shaw 2003; Breslin et al. 2002; De Lombaerde 2003;  

iii Peter Schmitt‐Egner,‘The Concept of 'region': Theoretical and Methodological  Notes on its 

Reconstruction’, Journal of European Integration, 24: 3 (2002), pp. 179‐200, 191