brazil, india, china and south africa in the health sector in

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PAPER NR. 14, MARCH 2014

BRAZIL, INDIA, CHINA AND SOUTH AFRICA IN

THE HEALTH SECTOR IN MOZAMBIQUE

Tom De Bruyn

Project coordination: dr. Huib Huyse

Fourth working paper in the series ‘Challenging the Status Quo? The Impact of the Emerging Economies on the

Global Governance of Development Cooperation’

www.steunpuntiv.eu www.hiva.be www.hiva.be

http://www.steunpuntiv.eu/

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BRAZIL, INDIA, CHINA AND SOUTH AFRICA IN THE HEALTH SECTOR IN MOZAMBIQUE

Tom De Bruyn

Research coordinator: dr. Huib Huyse

SAMENVATTING

Dit is het vierde onderzoeksrapport van een reeks die kadert in een vier jaar durend

onderzoek (2012-2015 en gefinancierd door de Vlaamse overheid) over de effecten

van de groeilanden op ontwikkelingssamenwerking. Het rapport beschrijft de

betrokkenheid van (vooral de overheden) van Brazilië, India, China en Zuid-Afrika

(BICS) in ontwikkelingssamenwerking betreffende gezondheid in Mozambique. Het

onderzoek is gebaseerd op geschreven bronnen en interviews met ongeveer 60

ontwikkelingsactoren en Mozambikaanse beleidsmakers in 2013.

De betrokkenheid van de BICS in gezondheid in Mozambique varieert sterk tussen de

vier landen. Gezondheid is één van de voornaamste samenwerkingssectoren van de

Braziliaanse overheid en dit is waarneembaar in het relatief hoge aantal projecten. De

fabriek voor antiretrovirale (ARV) en andere medicijnen is zelfs één van de best

gekende projecten van Brazilië in Afrika. China heeft verschillende projecten

uitgevoerd in het kader van de beloften gemaakt tijdens de fora voor Afrikaanse-

Chinese samenwerking (FOCAC) bijeenkomsten. De Indische en Zuid-Afrikaanse

overheden investeren veel minder in gezondheidssamenwerking, alhoewel één van de

paradepaardjes van de Indische coöperatie – het Pan-Afrikaanse e-Netwerk - ook

wordt uitgevoerd in Mozambique. De Indische farmaceutische industrie is wel de

voornaamste exporteur van medicijnen in Mozambique. De volgende tabel toont de

projecten van de BICS toont die tijdens het veldwerk werden geïdentificeerd.

Brazilië Fabriek voor de productie van antiretrovirale en andere medicijnen Melkbanken Institutionele versterking en voortgezette opleidingen Programma’s ter ondersteuning van onder meer tandheelkunde en kankerpreventie Trilaterale samenwerking met Italië voor opwaardering van krottenwijken Onderhandelingen over trilaterale samenwerking met USAID en CDC Programma schoolmaaltijden Uitwisseling van expertise met een regionale overheid in Brazilië

India Pan-Afrikaanse e-netwerk Dr Agarwal’s ooghospitaal NGO samenwerking in seksuele en reproductieve gezondheid

VR China Bouw en uitrusting van hospitalen Medische teams Cataractbehandeling Malaria controle centrum Verschaffen van medicijnen

Zuid Afrika Akkoord in gezondheid uit 2005

Een belangrijk verschil met de donoren van het Development Assistance Committee (DAC) de Organisatie voor Economische Samenwerking en Ontwikkeling (OESO) is de beperkte aanwezigheid van overheidspersoneel dat projecten opvolgt. Het discours van de BICS benadrukt het belang van gelijkwaardig partnerschap, wederzijdse

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voordelen, solidariteit en het gebruik van expertise die voortspruit uit het beantwoorden van eigen ontiwkkelingsproblemen. Uit de beperkte informatie kan geconcludeerd worden dat de financiële steun van de BICS (uitgezonderd de ARV fabriek) voor gezondheid over het algemeen lager ligt dan dat van de DAC-donoren. Centraal in de aard van de samenwerking is projectwerking. Brazilië geeft vooral technische assistentie, terwijl India en China ook krediet verlenen (alhoewel blijkbaar niet in gezondheid). Andere belangrijke modaliteiten zijn opleiding en het verschaffen van materiaal en medicijnen. De BICS zijn onder meer actief in de preventie en behandeling van overdraagbare ziekten (incl. HIV/AIDS en malaria) en volksgezondheid. De Braziliaanse coöperatie is gekaderd in een structurele samenwerkingsbenadering.

Er is zeer weinig coördinatie en communicatie tussen de BICS en de DAC-donoren in de gezondheid in Mozambique, niettegenstaande de aanwezigheid van enkele pogingen van Brazilië tot trilaterale samenwerking met Italië en de Verenigde Staten.

Deze exploratieve studie vormt de basis van verder onderzoek dat ingaat op de werkwijze en de kenmerken van de BICS.

SUMMARY

This paper is the fourth for the research project (2012-2015) ‘Challenging the status quo? The impact of the emerging economies on the global governance of development cooperation’, commissioned by the Flemish government. It describes the (mostly governmental) involvement of four of the so-called emerging powers - Brazil, India, China and South Africa (BICS) – in development cooperation activities regarding health in Mozambique. The research is based on written sources and interviews with about 60 development actors and Mozambican policy makers in 2013.

The involvement of the BICS in health in Mozambique varies strongly between the four countries. Health is one of the main cooperation areas of the Brazilian government and this is visible in a relatively high number of projects, of which the factory for the production of anti-retroviral (ARV) and other medicines is best known. China has set up and implemented various projects in line with the pledges of the Forum on China - Africa Cooperation (FOCAC) meetings. India and South Africa only marginally engage in health, although one of the flagship projects of the Indian cooperation – the Pan-African e-network - is also implemented in Mozambique. The Indian pharmaceutical industry is also the main provider of medicines to Mozambique. The following table lists the main projects identified: Brazil Factory for the production of anti-retroviral and other medicines

Human milk banks Institutional strengthening and masters courses Support programs in e.g. dental health, cancer prevention Trilateral cooperation with Italy in slum rehabilitation Trilateral cooperation negotiations with USAID and CDC School feeding programme Exchange of expertise with State level in Brazil

India Pan-African e-network Dr Agarwal’s Eye Hospital NGO cooperation in sexual and reproductive health

PR China Construction and equipment of hospitals Medical teams Cataract treatment

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Malaria control centre Provision of drugs and medicines

South Africa Agreement regarding health matters in 2005

An important difference with DAC-donors is the limited presence of governmental personnel or development workers following up projects in Mozambique. The discourse of the BICS in Mozambique emphasises the importance of equal partnerships, mutual benefit, solidarity and the use of own appropriate expertise coming from addressing their own development challenges. From the limited available information it seems that – apart from the ARV factory – budgets are not comparable to those of the DAC-donors involved in health cooperation. Projects take a central position in the BICS’ approaches. Brazil extents primarily technical assistance, while India and China also provide credit lines (although not in health it seems). Other important types of assistance include training and the delivery of equipment and drugs. Areas in which the BICS operate include communicable diseases (esp. HIV/AIDS and malaria) and public health. Brazil’s assistance is framed within a structural cooperation approach.

There is almost a complete lack of coordination and communication between the BICS and the DAC donors in health cooperation in Mozambique, although there are some trilateral projects (negotiations) between Brazil and traditional donors, notably Italy and the US.

This exploratory study will be the basis of future research that delves deeper into the ways of working and the characteristics of the BICS.

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TREFWOORDEN AUTHORS Tom De Bruyn is senior research associate at the Policy Research Centre on "Foreign Affairs, International Entrepreneurship and Development Cooperation" at the KU Leuven and HIVA.

ADDRESS FOR CORRESPONDENCE [email protected] © 2014 by Tom De Bruyn. All rights reserved. No portion of this paper may be reproduced without permission of the authors. Working papers are research materials circulated by their authors for purposes of information and critical discussion. They have not necessarily undergone formal peer review. This research report is the fourth paper in the series ‘Challenging the Status Quo? The Impact of the Emerging Economies on the Global Governance of Development Cooperation’. This research is commissioned by the Flemish Government. Het onderzoek dat aan de basis ligt van dit rapport kadert in het programma ‘Steunpunten voor Beleidsrelevant Onderzoek’ dat gefinancierd wordt door de Vlaamse Overheid. Wij danken de Vlaamse Overheid voor de financiële steun en interesse in het onderzoek.

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BRAZIL, INDIA, CHINA AND SOUTH AFRICA IN THE HEALTH SECTOR IN MOZAMBIQUE

Tom De Bruyn

Preface......................................................................................................................... 7

List of abbreviations ................................................................................................... 8

Introduction ............................................................................................................... 10

1. Context of health and development cooperation in Mozambique ..................... 13

1.1 Health challenges .............................................................................................. 13

1.2 Governmental policy and donors .................................................................. 14

2. The presence of Brazil, India, China & South Africa in the health sector in Mozambique .............................................................................................................. 17

2.1 Brazil ...................................................................................................................... 17

2.2 India ....................................................................................................................... 22

2.3 China ..................................................................................................................... 26

2.4 South Africa ......................................................................................................... 29

2.5 Trade between BICS and Mozambique ...................................................... 29

2.6 Overview ............................................................................................................... 34

3. Features of Brazil, China, India and South Africa’s involvement in the Mozambican health sector: main findings and debate .......................................... 37

3.1 Presence .............................................................................................................. 37

3.2 Discourse and objectives ................................................................................ 37

3.3 Budget and financial resources ..................................................................... 37

3.4 Modalities ............................................................................................................. 38

3.5 Collaboration and coordination with DAC-donors .................................... 38

3.6 Future research steps ...................................................................................... 38

Appendix: interview list ............................................................................................ 41

Bibliography .............................................................................................................. 43

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PREFACE

This paper describes the involvement of four of the so-called emerging powers - Brazil, India, China and South Africa – in development cooperation activities regarding health in Mozambique. The prime focus is on the activities and policies of governmental actors, although also development cooperation initiatives of other development actors are mentioned. The research is based on a literature review and fieldwork of two weeks in March 2013 and of three weeks in October-November 2013 in Mozambique during which about 60 representatives of the national government, bilateral and multilateral agencies, NGO’s and private sector actors were interviewed. A first draft paper was distributed to the interviewees and other key actors in autumn 2013. This final version took into account their comments. The paper is the fourth in a series for the four year research (2012-2015) ‘Challenging the status-quo? The impact of the emerging economies on the global governance of development cooperation’. The research is commissioned by the Flemish Government and framed within the Flemish Policy Research Centre for Foreign Affairs, International Entrepreneurship and Development Cooperation and carried out by the Belgian Research Institute for Work and Society (HIVA). It examines the characteristics (actors, motivation, objectives, means, methods) of Brazil, India, China and South Africa (BICS) and their effects on the organisation and methods of development cooperation in general and western donors in particular. Specific attention is given to development cooperation in health in Mozambique, and agriculture and food security (AFS) in Malawi. While the first paper (see De Bruyn 2013a) presents a review of the literature of the BICS’ involvement in health and agriculture and food security, the second working paper (see De Bruyn 2013b) elaborates on the main features of the BICS’ approaches to development cooperation and identifies how these countries might be challenging the approaches of the DAC-countries. The third and fourth papers describe the involvement of the BICS in respectively the AFS in Malawi, and the health sector in Mozambique. The current and future results of the research are presented on the website of the Flemish Policy Research Centre1.

1 See www.prc-if.eu

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LIST OF ABBREVIATIONS

ABC Agência Brasileira de Cooperação - Brazilian Cooperation Agency

AFS agriculture and food security

ANVISA National Sanitary Surveillance Agency

ARV Anti-retro viral

AU African Union

BICS Brazil, India, China and South Africa

CDC Center for Disease Control

CME Continued Medical Education

CPLP Community of Portuguese-speaking Countries

CSO civil society organisation

CSR Corporate social responsibility

DAC Development Assistance Committee

DFID Department for International Development

DIRCO Department of International Relations and Cooperation

CRS Creditor Reporting System

Embrapa Empresa Brasileira de Pesquisa Agropecuária

EU European Union

FAO Food and Agriculture Organisation

FICA Flanders International Cooperation Agency

FOCAC Forum on China - Africa Cooperation

GDP Gross Domestic Product

HPG Health Partners Group

ICCR Indian Council of Cultural Relations

ICHR International Centre for Reproductive Health

INS National Health Institute

IOR-ARC Indian Ocean Rim Association for Regional Cooperation

ITEC Indian Technical and Special Economic Cooperation

MISAU Ministry of Health

MoU Memorandum of Understanding

MRE Ministério das Relações Exteriores – Brazilian Ministry of Foreign Affairs

NGO non-governmental organisation

ODA Official Development Assistance

OECD Organisation for Economic Co-operation and Development

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P4P Purchase for Progress

PAA (1) Programa de Aquisição de Alimentos, (2) Purchasing from Africans to Africa

PARP Plano de Acção para a Redução de Pobreza

PARPA Plano de Acção para a Redução de Pobreza Absoluta

PECS Strategic Plan for Cooperation in Health

PESS Plano Estratégico do Sector Saúde

PNAE Programa National de Alimentação Escolar

PRC People’s Republic of China

R&D Research and development

SADC Southern African Development Community

SCAAP Special Commonwealth Assistance for Africa Programme

TRIPS Trade Related Aspects of Intellectual Property Rights

UN United Nations

UNCTAD United Nations Conference on Trade and Development

USAID United States Agency for International Development

WFP World Food programme

WHO World Health Organisation

WTO World Trade Organisation

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INTRODUCTION During an official visit to Brussels, on the 16th of December of 2012, President Armando Emílio Guebuza of Mozambique was interviewed by the European Centre for Development Policy and Management (ECDPM). He was asked about the involvement of the so-called emerging powers in the country’s development. In the following extract of the interview, some interesting insights into the changing relationships with traditional and the new development partners are given2 (ECDPM 2012: 2):

‘Mozambique has traditionally been quite reliant on development assistance from donors. Now that you are discovering new wealth and new resources, how do you think your relationship with development partners should evolve, notably with the EU? I believe the relationship has to continue. But the relationship will probably change in the sense that as time goes on, and as we have more resources in our budget, we are going to need more business and commercially oriented relations with those countries that have traditionally provided development funding. It will shift as time passes; in about 10 years time we will not be relying on donations like we are today. We can expect a gradual shift in the focus of the relationship.

How do Brazil, China and other emerging players fit in that picture? We connect with these countries. It is an experience we did not have before. We do nurture that relationship: they are investing in Mozambique, creating more jobs, giving us knowhow, and increasing trade.’

Although countries like Brazil, China and other emerging powers or non-DAC 3 development actors have been active in development cooperation for some time, in the last five to ten years there has been an intensification of their governments’ activities in Africa. According to some authors (see De Bruyn 2013a and b), this might challenge the so-called ‘traditional’ or DAC-donor countries in their relationships with the partner countries and may also introduce alternative and more effective development cooperation approaches. However, this ‘new experience’ is not yet studied in detail in all countries or sectors, and hence the effects of the BICS’ involvement are not yet fully understood.

The four year research ‘Challenging the status-quo? The impact of the emerging economies on the global governance of development cooperation’, tries to address this knowledge gap. Two previous papers (see De Bruyn 2013a and b) within this research described the characteristics of four of the non-DAC countries’ (Brazil, India, China and South Africa) development cooperation in general and in the sectors health and agriculture and food security (AFS) more specifically. The two following studies – of which this is the second – delve deeper into the country and sector level: the agricultural and food security sector in Malawi (see De Bruyn 2014) and the health sector in Mozambique. Health was chosen for different reasons: (1) it is one of the main ‘soft’ sectors of Brazil and China’s development cooperation (see De Bruyn 2013a and b); (2) it is one of the focal sectors in which the Flemish government (the commissioner of this research); and (3) health is an important sector for Mozambique’s development challenges. Mozambique was opted as country case study for this research because of the (1)

2 In bold the questions of the interviewer. ECDPM also stated that the interview had been edited and

condensed. 3 DAC refers to the Development Assistance Committee of the Organisation for Economic Co-operation

and Development (OECD).

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limited information of the BICS’ activities in health in this country; (2) it is a partner country of the Flemish development cooperation (the commissioner of this study); (3) the country’s low ranking on the Human Development Index (i.e. 185 on 186 countries in 2012); (4) it is the main African partner of at least one of the BICS, i.e. Brazil.

From 2013 to 2015 case study research of specific programmes and projects of the BICS in Mozambique and Malawi will be carried out to identify the characteristics of the these non-DAC development actors and to assess the importance for the national government of Mozambique4. As a preparation for this research I carried out fieldwork of two weeks in Mozambique at the end of March 2013 and of three weeks in October-November 2013. Similar to the case study in Malawi (see De Bruyn 2014), the objectives included the identification of (1) development cooperation activities and actors of the BICS in the health sector in Mozambique; (2) the knowledge and the opinion of national governmental representatives and of bilateral and multilateral donors and NGOs and private sector actors. This paper reports the main findings of this field visit.

The introduction concludes with a description of the used information sources. A first chapter gives a brief summary of the policy and development cooperation context of the health sector. The involvement of the BICS is described in chapter two, while the third and concluding chapter deals with the main characteristics of the BICS’ approaches and next research steps.

Information sources The first and main information source encompassed 60 interviews carried out between 18 and 29 of March and 28 of October and 17 of November 2013 with representatives of the national government, multilateral and bilateral donor agencies, research institutes and NGOs, as well as representatives of the governments of India, Brazil and South Africa. While most of the bilateral and multilateral agencies were interviewed, it was unfortunately not possible to access the Chinese representation in Mozambique5. Nevertheless, this number of interviews allowed to achieve the objectives of this fieldwork. With the interviewees it was agreed that the paper would refer directly to their names in the paper (except in the overview of interview – see appendix 1). An important conclusion from the interviews is that there is a general lack of knowledge among the traditional donors of what the governments of the BICS are doing in Mozambique. In addition, some information was based on rumors as the interviewees confessed. As far as I could assert, there is no governmental document listing all the activities of the BICS in the health sector in Mozambique.

To counteract the lack of information and to check collected information, the findings of the interviews were complemented and ‘triangulated’ with other information sources6. First, the AidData website7 compiles figures about projects of donors, and provides some incomplete data on projects and programmes and financial flows of the BICS’ development cooperation with Mozambique. Second, policy documents of the BICS

4 The overall methodology and methods of this four year research will be the subject of a paper which will

be published in the future, although a summary is available on the website of the Policy Centre: www.prc-if.eu. 5 The main reasons included time constraints and unavailability (due to foreign missions) of the

approached officials. 6 There is also the official development assistance to Mozambique website (ww.odamoz.mz.org), but this

lists in essence the ODA of the traditional donors, and suffers from major connection problems – in the period of the fieldwork and the writing up of this report it was most of the time offline. 7 www.aiddata.org

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were consulted. Third, there is a limited number of studies that mention some of the engagement for the BICS. Especially noteworthy is the work of the Future Agricultures Consortium 8 , a collaboration of several international research institutes, that are carrying out research on the involvement of Brazil and China in Mozambique and other countries in the agricultural sector. In addition, Russo et al. (2013), have published an overview of Brazil’s involvement in the health sector in Portuguese speaking African countries, including Mozambique. Furthermore, Timmermans & Vinyals (2012) published a useful overview of the donors’ expenditure in the health sector in Mozambique (but of the BICS only Brazil is mentioned). Lastly, newspaper and other media sources acted as an important instrument to check the existence of certain information (of course taking into account the reliability of these information sources themselves). Besides national newspapers and internet sources, also official news agencies of the BICS (for instance Xinhua of China) and international media were consulted. In essence, nobody could provide an overview of all of the BICS’ involvement. Similarly to the Malawi fieldwork (see De Bruyn 2014), the compilation of information can be compared to the search for correct pieces of a puzzle and assembling these pieces in a comprehensive framework.

8 See http://www.future-agricultures.org

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1. CONTEXT OF HEALTH AND DEVELOPMENT COOPERATION IN MOZAMBIQUE

1.1 Health challenges

Following its independence from Portugal in 1975, Mozambique experienced a civil war between the socialist government represented by Frente da Liberaçao de Moçambique (Frelimo) and by the Apartheid government of South Africa and Rhodesia (the later Zambia) backed rebel group Renamo. In 1990 the Marxist-Leninist rule was ended by Frelimo and a multiparty democracy was installed. In 1992 both parties signed a peace agreement. The 16 year long military and political instability had ravaged Mozambique’s social and economic situation. However, the following two decades Mozambique’s national economy seemed to thrive, with growth rates around 8% of GNP between 1994 and 2008. Even in 2010 the figure was still 6%. This growth will probably still continue, due to the discovery of different precious natural resources in the Northern provinces, such as Tete, making Mozambique one of the main attraction poles for international extractive industrial companies. However, these positive results do not seem to trickle down to the population as a whole (Vlaamse Regering 2010: 9). In 2013, Mozambique still held the 185th position on the Human Development Index. Huge disparities exist between rich and poor and rural and urban regions.

Despite four general elections, international experts perceive the democratic system in Mozambique to be weak. Although Mozambique is a parliamentary democracy, with a directly elected president, who appoints a prime minister, in practice the president possesses most of the political power. The president’s party, Frelimo still holds an absolute majority in parliament (Manning & Malbrough 2012: 1-2). Mattes and Shenga (2008) have described the country as a ‘low-information society’, due to ‘extremely low rates of formal education, high levels of illiteracy and limited access to news media’ (2008: 1). Furthermore, local civil society is weak and has been excluded from decision making powers (Manning & Malbrough 2012: 2), and the country holds the 123th position on 176 countries on the corruption perceptions index9.

Health indicators have improved in the last decades. For instance, maternal mortality decreased from 692 in 1997 to 500 in 2007, under-five mortality rate from 245 to 147 per 100,000 live births and infant mortality from 143 to 93 per 100,000 live births in the same period (Timmermans & Vinyals 2012: 6-7). Nevertheless, the poor socio-economic situation is apparent in the country’s numerous health challenges, such as the high prevalence of HIV/AIDS cases, the relatively low life expectancy, the high number of tuberculosis patients and malaria victims, as well as the very limited access to potable water and sanitation (Vlaamse Regering 2010: 17). Major explanatory factors for the prevalence of these health problems include (ab ibid.: 26-34):

low quality (esp. volume and predictability) of international external financing;

the lack of formally trained health personnel and community workers;

inadequate health infrastructure;

the epidemiological vulnerability to life threatening diseases;

malnutrition and inadequate nutritional habits;

unequal access to health care;

limited alignment and coordination amongst donors;

complexity of the sector of sexual and reproductive health and rights.

9 Transparency International: http://cpi.transparency.org/cpi2012/results

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1.2 Governmental policy and donors

The overall national policy framework for poverty reduction in Mozambique is the Plano de Acção para a Redução de Pobreza (PARP) (2011-2014), drafted by the government in consultation with the World Bank and the IMF10. It sets out the objectives for the government’s five year plan, regarding poverty, governance and human capital, and it is the main document for budget support. 16 donors, known as G1611, have subscribed themselves in the logic of budget support, in line with the principles of the Paris Declaration. As Carrie and Manning (2012: 1) conclude from their study on the evolution of foreign aid in Mozambique, donor support has moved from project support to budget support; from a support of central top local government institutions; from an emphasis on representative democratic institutions to good governance; and towards a focus of local service delivery as entry point for governance programmes. In total these donors12, the US and the UN have pledged US$ 471 million in aid in 2009 (Manning & Malbrough 2012: 4-5). The Mozambican government is still very dependent on external aid – hovering around 50% of the total state budget (Vlaamse Regering 2010: 10). Within four sectors, the G16 donors take on a sector wide approach (SWAp), notably in education, water and agriculture, public infrastructure and health care.

The Health Strategic Plan (or Plano Estratégico do Sector Saúde – PESS), drawn up by the Ministry of Health (MISAU), is the main guiding document for the health sector (WHO 2009: 2). Within the PESS 2009-2012, the government has prioritized the need for strengthening the health system, the development of human resource capacity, the improvement of health care infrastructure, increased community engagement and the expansion of training and deployment of community health workers. In December 2013, the Ministry of Health approved the PESS for the period 2014-2019. This plan lists a number of reforms congruent with the on-going decentralization process. Among other issues, there is a focus on increasing access to and improving quality of primary health care, and reducing maternal mortality and chronic malnutrition. Figure 1.1 shows the organization of the Ministry of Health.

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This followed the Planos de Acção para a Redução de Pobreza Absoluta (PARPA) of 2011-2005 and 2006-2009. In the most recent poverty reduction strategy paper, the Mozambican government did not refer anymore to ‘absolute’ poverty. 11

African Development Bank, Austria, Canada, Denmark, European Commission, Finland, France, Germany, Ireland, Italy, Norway, Portugal, Sweden, Switzerland, United Kingdom, and the World Bank. Belgium, the Netherlands and Spain have recently withdrawn from this group, but they remain, together with The United States and the United Nations, associated members. This means that they attend meetings and coordination initiatives, but do not commit to a common policy. 12

Including Belgium, the Netherlands and Spain who were still members of the budget support donor group at that time.

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Figure 1.1 Organization of the Mozambican Ministry of Health

The cooperation of the MISAU and the development partners is based on the health SWAp13. They provide general and/or budget support, direct project support and off-budget funds. Once a month they meet in the Health Partners Group (HPG). Figure 1.2 shows the disbursements in 2009. There was a broad consensus among interviewees that the donors can be divided into four different groups:

In total 13 of the partners provide pooled-funding (known as the ProSaude group) and have signed a memorandum of understanding. Together they provide about 100 US$ million annually. The major donors are the Netherlands, Ireland, Denmark and Canada.

Next, there are the multilateral agencies, of which UNICEF and the WHO are said to be the most influential.

In addition some global financial institutions, notably the Global Fund to fight Aids, Tuberculosis and Malaria (GFATM) and GAVI alliance have sprung up as major financing institutions.

Fourth, and by far the biggest bilateral donor is the US, via USAID and the Center for Disease Control (CDC).

Furthermore there a number of other important development actors, who also (sporadically) attend the HPG, such as the Clinton Foundation and the network of international NGOs working in the areas of HIV/AIDS and health, that are represented by the organization NAIMA+. Representatives of the HPG meet regularly with the government officials from MISAU in monthly joint coordination meetings and sector coordination meetings twice a year (Martinez 2011: 10).

13

For a recent overview of the SWAp and the allocation of donor budgets, see Timmerans & Vinyals, 2012.

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Figure 1.2 Development assistance disbursement to health by channel of

assistance and funding modality, 2006-2009

Source Timmermans & Vinyals, 2012: 14

From the BICS, only Brazil has attended the HPG meeting. This is also the only country that features in the list of figure1.2. This gives a distorted image of the involvement of the non-DAC development partners in health, because the following chapter shows the BICS are implementing and developing health assistance projects with Mozambique.

- 50,00 100,00 150,00 200,00 250,00 300,00 350,00 400,00

AustraliaAustria

BelgiumBrazil

CanadaChile

DenmarkEU

FinlandFrance

GAVIGermany

Global FundIDA

IrelandItaly

JapanKorea

LuxembourgNetherlands

NorwayPortugal

SpainSweden

SwitzerlandUNAIDS

UNDPUNFPAUNICEF

AfDFUnited Kingdom

United StatesOFIDWFP

in millions of €

Project Sector Programme Sector budget support

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2. THE PRESENCE OF BRAZIL, INDIA, CHINA & SOUTH AFRICA IN THE HEALTH SECTOR

IN MOZAMBIQUE

2.1 Brazil

2.1.1 Development cooperation in health in Mozambique

Brazil’s development cooperation14 is primarily geared towards Portuguese speaking countries in Africa. Although there is a lack of detailed figures and statistics on Brazilian development cooperation, the available data show that Mozambique is the most important receiver of Brazil’s technical assistance projects (see De Bruyn 2013a and Chichava et al. 2013: 8). So almost all characteristics of Brazil’s development cooperation, as described in De Bruyn (2013a) should be visible in this country. The importance of the country is also apparent in the number of presidential visits of former president Lula and his successor Dilma Rousseff. Reasons for Brazilian-Mozambican cooperation include the countries’ common language, diplomatic bonds, and commercial interests (Stolte 2012: 10). According to figures compiled by Chichava et al. (2013: 8), at the end of 2011 there were 21 active projects in Mozambique and 9 in negotiation. Agriculture receives most of attention, with a number of large projects in different parts of the country (see Chichava et al. 2013: 10-11 for an overview), followed by health and education. This mirrors the general trend of Brazil’s development cooperation (see De Bruyn 2013a). Brazil’s development cooperation intensified from 2003 onwards with the presidency of Luiz Inácio Lula da Silva and in health this process accelerated from 2007-2008 when Fiocruz (see further) opened an office in Maputo.

The website of the Brazilian Agency for Development Cooperation (ABC)15 lists the different development projects in health, as does the AidData website16. In addition, Russo et al. (2013: 13-14) provide a list of different projects. However, these information sources do not entirely correspond. Moreover, the interviewees nuanced the status of some of the projects. Exact figures about the development cooperation of Brazil in health to Mozambique are very difficult to find. All the committed budgets of the projects referring to health in the AidData17 compiled (20 project for the period 2001-2010) amount to approximately US$ 7.85 million.

The Brazilian institutional structure governing the development cooperation initiatives in health is relatively complex. The Ministry of Foreign Affairs (MRE) formulates and designs the general policy, while the ABC coordinates the technical assistance programmes. However, the Ministry of Health designs the health cooperation policies, and the Oswaldo Cruz Foundation known as Fiocruz, is the main implementing agency (Almeida 2010). Fiocruz is a re-known public health institution specialised in training, research, management of health programmes and production of pharmaceuticals. In Brazil it consists of about 20 research and technical institutes and units. In addition there are several other health related institutes that implement international cooperation initiatives (for a list see Russo et al. 2013: 11-12). Representatives of the ABC and Embrapa oversee the large agricultural projects in Mozambique, and personnel of Fiocruz personnel do the same for most of the health initiatives. Fiocruz, opened an office in 2008 in Mozambique (see figure 2.1) and employs 2 people18. In addition there are two people in the country to oversee the anti-retroviral (ARV) drug

14

See De Bruyn 2013a: 11-19, Cabral et al. 2014, Russo et al. 2014 and Russo & Shankland 2014 for an

overview of the Brazilian engagements in health. 15

www.abc.gov.br/projetos 16

www.aiddata.org 17

www.aiddata.org 18

This is a similar structure as in the Brazilian agricultural cooperation, see De Bruyn 2013a and 2014.

18

factory (see below), and during short periods other Brazilian specialists come over to follow up the other projects19.

Figure 2.1 President Lula, the Ministers of Foreign Affairs, Celso Amorim, and of Health, José Gomes Temporão, and the President of the Fundação Oswaldo Cruz, Paulo Buss, inaugurate the Fiocruz office in Maputo.

Source Ricardo Stuckert/PR/Abr

In the wake of the Brazilian governmental presence, there is an increasing number of academicians coming to Mozambique to collaborate with Mozambican, European, American or South African institutes. Until now, Brazilian NGOs seem to be absent in the health sector in Mozambique, although there are examples of involvement or cooperation in other domains (see Tomlinson, 2013: 118-119). Brazilian nationals do work in international NGOs, private companies or for religious organizations in Mozambique. There are some large important Brazilian companies in Brazil, but they are not directly working in the health sector as far as this exploratory fieldwork could assess. However, some large companies in the mining industry (e.g. Vale) and other sectors do have an impact on the health situation of the region in which they are active. Some bilateral and multilateral agencies are trying to set up collaboration projects on corporate social responsibility (CSR) and health assessment. In §2.5.1 this issue will be further dealt with.

Russo et al. (2013: 6) identified the major differences in health development cooperation concepts between DAC-donors and the Brazil government (see table 2.1).

Table 2.1 DAC-donor and Brazil’s development concepts regarding health DAC-donor terminology Brazil’s terminology

Vertical donor-to-beneficiary aid Horizontal partnerships between cooperation peers

Predominantly monetary aid (grants and loans) Predominantly in-kind technical cooperation

Focus on health programmes Health cooperation projects ‘on demand’

Specialization of health functions across countries according to comparative advantages

Industrial health complex

Capacity building Structural cooperation in health

Separation between foreign policy and development (health) goals

Health diplomacy

Source Russo et al. 2013: 6

19

Interview with representative of Fiocruz

19

Brazil does not see itself as a donor in development cooperation but as an equal partner (De Bruyn 2013a), although most of Brazil’s activities described below are characterized by a one way transfer of knowledge and resources. The country offers primarily technical and in kind assistance instead of financial resources and presents or promotes specific development projects during High Level visits to which the Mozambican government reacts with a demand for cooperation. Brazil’s development cooperation in health is also characterized by a belief in the necessity to become independent from foreign expertise and resources for the development and management of a country’s own health care. Russo et al. (2013: 5-6) argue that his might be based on Brazil’s own experiences which were driven by public health institutions and civil society organizations. This policy translates in the development of a country’s own national health care industry and research capacity. In addition, Brazil promotes structural cooperation in health, which entails a package of different interventions, combining amongst other issues, a focus on human resource development, international collaboration between local health institutions and measures to become less dependent on external actors.

Moreover Brazil also acts on the international health level to further its development cooperation and own interests. The country is a vivid lobbyer in the UN and the World Trade Organisation (WTO) for ameliorating the access to medicines and health care and especially those concerning the so-called Trips (Trade Related Aspects of Intellectual Property Rights) (see GHSI 2012: 27). The framework for Brazil’s cooperation with Mozambique is not only provided by its bilateral agreements, but is also supported by international cooperation initiatives, such as the Strategic Plan for Cooperation in Health of the Community of Portuguese-speaking Countries (the PECS/CPLP)20. The CPLP is an organization of eight Portuguese speaking countries21, incl. Mozambique and Brazil, created in 1966, which main objective is to take concerted political and diplomatic actions in different sectors (Buss & Ferreira 2010: 100). The ministries of health have negotiated and agreed upon a strategic plan to create and develop universal access to quality health services in the member states. Arguably, Brazil has been one of the driving forces of this plan and this is reflected in the plan’s priority projects, which include human resources development, research and the development of industrial complexes (ab ibid.: 102).

Compiling all the different information sources of this exploratory fieldwork, it was possible to identify areas in which Brazilian governmental agencies have set up or are planning to set up projects.

2.1.2 Specific initiatives in the health sector in Mozambique

The Brazilian health assistance with Mozambique covers a broad range of projects, from the development of an ARV and other drugs factory, to the establishment of human milk banks, the provision of master courses and various other institutional strengthening initiatives. In addition, several programmes in other domains have a clear health component, such as the school feeding programme and a trilateral agreement with Italy on slum rehabilitation. While these programmes all involve Brazilian national institutes, there is also at least one example of regional level cooperation.

20

Although in the interviews, some of the DAC-donors questioned the effectivity of this organization, as well as its decision making power. It was beyond the scope of this paper to explore this issue further. 21

Brazil, Portugal, East Timor, Angola, Mozambique, Guinea-Bissau, Cape-Verde and St Thomas & Principe. The five African Portuguese countries are also referred to as PALOP.

20

2.1.2.1 Factory of ARV and other drugs

The best known health project of Brazil in Mozambique is the establishment of a drug producing factory in Matola. It is Brazil’s biggest project in Africa and acts as a showcase for its fight against HIV/AIDS. This project encompasses many elements of the above described health cooperation strategy. President Lula already announced these plans on a visit to Mozambique in 2003 (HJ Kaiser Family Foundation 2003). The objective of the plant is to produce a number of antiretroviral and other types of drugs22, making Mozambique less dependent on the import of medicines to address its HIV/AIDS problem, and eventually even be able to export to other countries (Stolte 2012: 14). The project involves the design and the construction of the factory as well as the training of the personnel. The Mozambican government donated the terrain – an old factory was located there first23 - and the Brazilian government donated about US$ 23 million and the Brazilian mining company Vale added another US$ 4 to 4.5 million (Business Year 2013)24. Fiocruz in collaboration with Farmanguinhos are managing the project but eventually the factory should be managed autonomously by Mozambique. The project suffered severe delays25 and the intended inauguration was postponed with two years to 2012 (Stolte 2012: 14), but production of about 5 medicines has started. Eventually the factory will produce about 21 drugs, of which 6 ARV. Some 55 Mozambicans have received training of which about 30 in Brazil and by the end of this three year project this number should amount to 10026. To control the safety, quality and the pricing of the medicines, the National Sanitary Surveillance Agency (ANVISA) and the Ministry of Health of Brazil support the creation of a Drug Regulatory Authority27 (Stolte 2012: 14 and Russo et al. 2013: 13). The future development of the factory will be studied in more depth in the next steps of this four year research.

2.1.2.2 Human milk banks

One of the best illustrations in which Brazil tries to implement or share own solutions with other countries to tackle specific health problems is the human milk bank programme. This programme promotes breastfeeding and collects mother milk to provide to children without access to this source of nutrition. It also aims to prevent mother-to-child transmission of HIV/AIDS. In Brazil the network includes 200 banks collecting 140,000 litres of breast milk per year. Brazil created milk banks in other Latin American countries in collaboration with the national governments. In 2011, Brazil has signed an agreement with Mozambique, Cape Verde and Angola to create human milk banks, including the provision of technical training and equipment (GHSI 2012: 26). The human milk bank will consist of a reception, a room where women lactate, a room where the milk is pasteurized and kept and a library. It will be installed in the Central Hospital of Maputo. The Fiocruz representative adds that there is not a tradition of breastfeeding children in Mozambique which means that there will be cultural barriers to be overcome28.

22

Sources about the exact number of drugs vary however between 21 and 29 or more different drugs, which include at least 3 to 6 types of ARV drugs (see for instance Stolte 2012:14, Panapress 2012 and Business Year 2013). 23

Interviews with representatives of the Mozambican government and Fiocruz and Farmanguinhos. 24

Although Stolte (2012: 14) mentions that the investment cost soared to about US$ 100 million. The origins of this information is however not clear. 25

see Sotero (2009: 18) for a reaction of President Lula. 26

Interviews with representatives of Fiocruz and Farmanguinhos. 27

The website (www.aiddat.org) gives a committed budgets for this project of about US$ 367,000 in 2008 and US$ 372,000 in 2010. 28

In addition, the high rate of HIV/AIDS prevalence in Mozambique and the limited (or no practical) access of the rural population to this center are additional risks for the effectivity of the project according to interviews with some of the other development actors.

http://www.aiddat.org/

21

2.1.2.3 Strengthening of institutions and master courses

Several projects entail the strengthening of health institutions by Fiocruz. Besides the support to the Drug Regulatory Authority it also collaborates with the National Health Institute (INS)29. The cooperation between Fiocruz and the INS started in 2007 as an official of the Mozambican government explained 30 . The INS was looking for institutional support to ameliorate its services and activities. It was the period in which Brazil was becoming more proactive at the international level. Contacts were established with the President of Fiocruz, an institution with a similar mission as the INS. The additional advantage was the shared language. The institutes agreed on some initial projects, such as the development of a strategic plan and a masters course. The successful collaboration resulted in the idea to collaborate on a more structural basis. At the moment negotiations are going on about the content of this cooperation31. The four research will also analyse this project in depth.

University collaboration and the development and support of master courses are important aspects of the institutional strengthening and capacity building of the Brazilian cooperation in health. Public health is a main topic. Fiocruz collaborates for instance with the University of Mondlane32.

2.1.2.4 Other health initiatives

Furthermore, the AidData website, the ABC and Russo et al. (2013) article also mention several support programs in the areas of dental health (e.g. creation of a laboratory for dental prostheses and epidemiological study)33, cancer prevention (e.g. breast cancer prevention)34, a community care project35, a tele-health system and support to the medical library36, scoping missions on malaria prevention, mental health and other health issues37. However it was beyond the scope of this fieldwork to explore all these projects in detail.

2.1.2.5 Trilateral agreements between Italy, Brazil and Mozambique

Brazil is a relatively active partner in trilateral cooperation programs (see De Bruyn 2013a) and also in Mozambique Brazil cooperates with several DAC-donors such as Japan in the Pro Savanna program in agriculture. There is a trilateral cooperation between the Italian Development Cooperation, the Brazilian Ministry of Cities and the Federal Savings Bank of Brazil (the Caixa Econômica Federal), and the Municipality of Maputo for the rehabilitation and sanitation of the Chamanculo C slum in Maputo (Ministero degli Affari Esteri 2013 and Cities Alliance38). This features in the broader context of a Memorandum of Understanding between the Italian and Brazilian governments of 2007. Although this project does not involve MISAU, it has a health component and would involve a budget of about US$ 3 million (Cities Alliance39).

29

The website (www.aiddat.org) gives committed budgets for this project of about US$ 216,000 in 2007 and 86,000 in 2008. 30

Interview with an official of the Mozambican government. 31

Interview with an official of the Mozambican government. 32

Interview with an official of the Mozambican government and with representative of Fiocruz. 33

www.aidata.org mentions committed budgets of about US$ 476,000 in 2010. 34


Commitment of Brazilian government of about US$ 425,000 according to www.aiddata.org in 2010. 36



and http://www.citiesalliance.org/ca_projects/detail/19785 39

and http://www.citiesalliance.org/ca_projects/detail/19785

http://www.aiddat.org/

http://www.aidata.org/


http://www.aiddata.org/



22

2.1.2.6 Negotiations on a trilateral agreement between USAID/CDC, Brazil and Mozambique

There have been negotiations between MISAU and the US government to set up a trilateral agreement in health. The three governments signed a declaration intend in the beginning of 2012 to collaborate in food security, health and agriculture (AllAfrica2012). Despite several negotiations with USAID and the US Centre for Disease Control and Prevention (CDC) to set up a program on HIV/AIDS, no concrete decisions have been decided upon yet, although there is cooperation on an ad hoc basis40.

2.1.2.7 School feeding program

Although the school feeding program does not reside under the direct supervision of the Mozambican Ministry of Health, malnutrition is an important health issue in Mozambique. A pilot project is set up in 12 schools with the ABC and the Mozambican Ministries of Education and Agriculture41 and support for WFP. Next, the Purchasing from Africans to Africa (PAA) programme is carried out in five African countries, Ethiopia, Malawi, Mozambique, Niger and Senegal in which local production is linked to the school feeding programme. The FAO is responsible for the production side, i.e. enhancing productivity of small farmer holdings, as well as selling their products, while the WFP takes up the purchase and delivery to schools and other vulnerable population groups (FAO 2012). It has been described in the study on activities of the BICS in the agriculture and food security sector. For more background information, see therefore De Bruyn 2014. This project will also be studied more in depth in the next phase of the four year research.

2.1.2.8 Exchange with State in Brazil

Within a department of the Ministry of Health, there is also a small scale initiative to exchange experiences and knowledge with their counterparts within the administration of the State of Bahia42. The rationale behind this is that the State level of Brazil is comparable in terms of scale with that of the national level in Mozambique. The intention is that there will be exchange visits of five people of each country43.

2.2 India


India has diplomatic relationships with Mozambique since the latter’s independence in 1975. In the same year India opened an Embassy in the country. Mozambique established an own Embassy in India in 2011. In the last three decades official relationships between both countries were put into practice via the organization of several high level visits (of which one of the Minister of Health to India in 2012) and business delegations, the signing of several bilateral trade and other agreements and the provision of development assistance44. Newspaper clippings point out that India’s main objectives in its relationships with Mozambique include the promotion of trade and the extraction of mineral resources (Stratsis Incite 2011a & b & 2012). Development

40

Interviews with representatives from DAC-donors, Fiocruz and official representatives of the Mozambican government. 41

www.aidata.org mentions committed budgets of about US$ 1,397,000 in 2010 for the development of a national school feeding programme. 42

The choice for the State of Bahia is explained by personal contacts of the initiator of the projects 43

Interview with representative of Mozambican government. 44

See De Bruyn, 2013a: 20-27 for an overview of India’s cooperation in the health sector.


23

assistance – the term which is used by the Government of India itself - consisted primarily of lines of credit, grants and training and scholarship programmes45.

India extended lines of credit for infrastructural, agricultural and energy projects. These amounted to US$ 140 million before 2010. In 2010, India offered a further US$ 500 million to Mozambique for projects in the same sectors, but again none of them is in the health sector46. The conditions of the lines of credit were not scrutinized in this study. Similar research in other countries (see De Bruyn 2014 for instance) shows that the lines of credit do probably not meet the requirements of ODA (and the Indian government does not seem to contradict this statement) and is in principal tied.

Between 2007 and 2010 the Indian government offered grants of US$ 200,000 up to 5 million in research and training, equipment and infrastructure. This was mainly in the agricultural sector and for community development.

A third feature of India’s assistance entails the provision of longer and short term training and scholarships in India. Main providers are the Indian Technical and Economic Cooperation (ITEC) / Special Commonwealth Assistance for Africa Programme (SCAAP) (41 training slots), the Africa Scholarship Scheme of the Indian Council of Cultural Relations (ICCR) (34 scholarships) and the Indian Ocean Rim Association for Regional Cooperation (IOR-ARC) (2 slots). The Indian government covers the airfare, stay, training course and study material. However, some of these programmes (e.g. IOR-ARC) exclude medicine, dentistry & nursing47. According to the representative of the High Commission48, language problems are one of the main reasons why Mozambicans do not apply for Indian training courses in nursing and paramedicine in India.

The Mozambican case confirms the conclusion from De Bruyn (2013a) that health is but a small focus of India’s development cooperation. Worldwide, India has pledged a minimum of US$ 100 million to bilateral health projects in recent years according to GHSI (2012), mainly aimed at the construction or renovation of hospitals, medical supplies and equipment. However in Mozambique the Mozambican officials, traditional donors and the representative of the High Commission could only identify one governmental Indian cooperation project in the health sector: a project of telemedicine, part of the Pan African e-Network. Furthermore there is interest from the Mozambican government to collaborate on traditional medicine. Visits of the Mozambican health officials paid attention to this domain for instance, but at the time of the fieldwork for this study, no concrete decisions were taken yet. Besides India, health official in traditional medicine also look towards China and Brazil for gaining expertise49.

This does not mean that India’s influence or importance for the health sector is negligible. In fact the private sector plays a very important part. Firstly, an unknown number of Indian doctors are working private hospitals. Secondly, although very limited

45

Interview with representative of Indian High Commission and website of the Indian High Commission: www.hicomind-maputo.org. 46

According to the website of the Indian High Commission (www.hicomind-maputo.org, consulted on 15/7/2013): ‘(i) US$20 million Food security project, (ii) US$13 million project for setting up Solar Photo Voltaic Module Manufacturing Plant, (iii) US$250 million project for improving the quality of power supply in Maputo, Matola and surrounding areas, and (iv) US$20 million rural drinking water project. Two projects i.e. US$149 million project for rehabilitation / construction of Tica-Buze-Nova Sofala Road in Sofala and US$47 million project for construction of 1200 houses in Maputo, Tete, Nampula and Sofala are under consideration in India.’ 47

website of the Indian High Commission (www.hicomind-maputo.org, consulted on 15/7/2013) 48

Interview with representative of High Commission of India. 49

Interview with representative of MISAU.

http://www.hicomind-maputo.org/

http://www.hicomind-maputo.org/

24

in number, some Indian private hospitals are setting up branches in Mozambique, such as the Dr Agarwal Eye Hospital. Thirdly, the pharmaceutical industry exports drugs and medicines to Mozambique50 (see §2.5).

The Indian NGO sector is virtually absent in Mozambique. Still, in the fieldwork one specific NGO-cooperation was identified.


The Pan-African e-network is the only health assistance project form the Indian government with Mozambique. Other involvement in health includes the private sector, and the one civil society organization.

2.2.2.1 Pan African e-network

The Pan African e-Network is a flagship project of the Indian development cooperation. The Indian government promotes it as ‘a shining example of South-South cooperation’51. It is a joint project of the African Union (AU) and the Indian Government and was launched in 2009 and intends to connect hospitals and universities of the 53 members of the AU with similar institutions in India via a satellite and fibre optic network (see figure 2.2).

Figure 2.2 Indian Pan-African e-network architecture

Source www.panafricanenetwork.com

This should enable 10,000 African students to receive tele-education (i.e. long distance education with communication between the continents via ICT) from Indian educational institutes in five years time. Secondly, the network provides ICT to Heads of State. A third pillar of the project encompasses tele-medicine, i.e. Indian medical specialists

50

Interviews with according DAC-donors. 51

See www.panafricanenetwork.com

25

assist their African counterparts in medical consultation via online networks. In other words, the patient comes to an African hospital for examination. The findings are sent to Indian hospitals were the diagnosis is made and the treatment is proposed, or were the Indian specialists give their opinion about the illness or complaint. Video equipment is installed to ensure communication. According to the website of the project, since 2009, ‘regular Continued Medical Education (CME) sessions have been started (..) from 11 Indian Super-Specialty hospitals. So far 654 CME sessions have been conducted on this network’52. Of the four regional super specialty hospitals, none of them is in Mozambique, but the country hosts one of the 45 learning centers and one patient end hospital (i.e. the Central Hospital of Maputo). The Indian Ministry of External Affairs coordinates the project while Telecommunications Consultants India Limited (TCIL) is the implementing partner. The tele-medicine project clearly targets tertiary medicine, given the fact that it provides expert services to hospitals that are equipped with instruments such as electro-cardiograms, Ultra Sound, and X-Ray53. Some of the DAC-donors raised questions about the capacity building objective, since most of the know-how stays in India54. Nevertheless, the project also has and an education component 55 . According to Roy (2012) India provides a total grant of US$ 117 million to implement and finalise the project in Africa in the following years.

In Mozambique all the necessary medical equipment has been installed and a class room to enable medical personnel to follow courses in India through direct video and audio communication (including a satellite dish) is in place at the top floor of the central hospital of Maputo. Although all the infrastructure is operational it has hardly been used by the Mozambican counterparts56. Reasons for this will be studied and elaborated upon in the next phase of this four year research.

2.2.2.2 Dr Agarwal’s Eye Hospital

Dr Agarwal eye hospital started in the 1950s and is one of the main chains of eye care centres and hospitals in India, of which the majority are based in Tamil Nadu. The company decided to expand its operations to Africa, because of the limited access to eye care in large parts of the continent. According to the representative of the hospital in Mozambique, the company opened its first African eye hospital in 2010 in Mauritius, and in the years afterwards Rwanda, Madagascar and Mozambique followed. In 2013 centres were opened in Maputo, Nampula and Matola, while the intention is to cover all provinces of Mozambique. At the moment 45 people are employed in Mozambique and 5500 were registered. In addition, the company offered 100 cataract operations for free in the last year57.

2.2.2.3 NGO cooperation sexual and reproductive health

The Mozambican NGO the International Centre for Reproductive Health (ICHR) is one of the partners in a five year collaborative project, called DIFFER (‘Diagonal Interventions to Fast-Forward Enhanced Reproductive Health’). This started in 2011. The other include Ashodaya Samithi in India, ICRH-Kenya, MatCH & the Centre for Health Policy of the University of the Witwatersrand in South Africa and University College London, UK, while ICRH-Belgium takes the lead. The DIFFER project is funded within the European Commission’s 7th Framework programme. The objective of

52

www.panafricanenetwork.com 53


Interviews with representatives of DAC-donors 55


Interviews with representatives of the implementation of this project. 57

Interview representative of Dr Agarwal’s Eye Hospital in Mozambique.

26

the project is to ameliorate access to sexual and reproductive health (SRH) for vulnerable population groups. This initiative focuses on female sex workers, and the general reproductive health services. A key feature of the programme is the exchange of information and best practices from India (and i.c. from Ashodaya Samithi, active in Mysore) to three African regions: Mombasa (Kenya), Durban (South Africa) and Tete (Mozambique).

The first one and a half year concentrate on the project design, next a SRH services will be developed and then these will be implemented58.

2.3 China


Mozambique and China’s relationships date from before the former’s independence in 1975. China supported the independence struggle of the Liberation Front of Mozambique (FRELIMO)59. Official diplomatic relationships started in 1975 and the first official visit of the Mozambican President to China occurred in 1978. One year later this event was reciprocated by a visit of the Chinese Prime Minister. In the following decades both countries organised several official visits and upheld good relationships (Jansson & Kiala 2009: 2). It is difficult to distinguish specific development assistance projects, since China’s cooperation with Mozambique entails a mixture of aid and investments. This blending of aid and business is typically for Chinese development cooperation (see De Bruyn 2013a). China invests primarily in the Mozambican infrastructure, agriculture and mining sector and promotes trade between both countries (Escobar 2011). Jansson & Kiala (2009: 6) identified aid projects between the period of 1975 and 2007. These include mainly grants and concessional loans for emergency relief, the construction of factories, housing and public buildings, agricultural infrastructure and some health projects.

Table 2.2 Pledged actions regarding medical care and public health made by China in the Bejing Action Plan (2012-2015) presented at the FOCAC Forum in 2012

Sections Pledges

5.2.2 Implement the ‘African Talents Programme’. In the next three years, China will train 30,000 African professionals in various sectors, offer 18,000 government scholarships and take measures to improve the content and quality of the training programmes

5.5.2 Will step up high level exchanges in the health field and hold a China-Africa high-level health development workshop at an appropriate time

5.5.3 Expand their exchanges and cooperation in the prevention, treatment and port control of HIV/AIDS, malaria, tuberculosis and other major communicable diseases, health personnel training, maternal and child health, health system building and public health policies

5.5.4 Continue to provide support to the medical facilities it has built in Africa to ensure their sustainable development and upgrade the modernisation level of the hospitals and laboratories

5.5.5 Continue to train doctors, nurses, public health workers and administrative personnel for African countries

5.5.6 Conduct the ‘Brightness Action’ campaign in Africa to provide free treatment for cataract patients

5.5.7 Continue to send medical teams to Africa. In this respect, it will send 1,500 medical workers to Africa in the next three years

Source FOCAC, 2012; Buckley, 2013

58

See http://differproject.eu and 59

See Jackson 1995 for a detailed description of Sino-Mozambican relationship prior and after the independence of Mozambique.

http://differproject.eu/

27

In terms of health the cooperation is framed by a technical and economic cooperation agreement between both countries signed in 2004 and by the High Level Forums on China-Africa Cooperation (FOCAC) of which the last one was held in Bejing in 2012. Table 2.2 lists the actions pledged by the Chinese government to Africa.


As mentioned in the introduction, it was unfortunately not possible to meet a representative of the Chinese government for this exploratory study. In the next phase of the four year research this gap will be addressed. Still, based on interviews and other information sources, it was possible to gain information about the main initiatives of Chinese health cooperation in Mozambique. These include construction of hospitals and delivering equipment; the sending of medical teams and a team to treat cataract; the support of malaria control services; and the provision of medicines. These initiatives are in line with the pledges made at most recent FOCAC meeting.

2.3.2.1 Construction and equipment of hospitals

There is confusion between interviewees about the involvement of the Chinese in the construction of hospitals in Mozambique. Unfortunately written material could not be found within the scope of this exploratory fieldwork. China might be involved in two ways. Firstly, by the provision of loans for the construction of hospitals, but within the fieldwork figures were not found. Secondly, some of the hospitals are built by Mozambican companies that are led by Chinese nationals.

There is no doubt about the provision of medical equipment to some hospitals. For instance, according to Xinhua (2013) the Chinese and Mozambican governments signed an agreement for the provision of equipment worth of US$ 1.6 million for the dental section at the Maputo Central Hospital. In 2012, the Chinese government also donated medical equipment to the Maputo military hospital, but this featured under the military cooperation between the two countries.

2.3.2.2 Medical teams

Medical teams are a typical feature of Chinese development cooperation (see De Bruyn 2013a and figure 2.3). Chinese provinces play an important part in the dispatching of the medical teams, since one province is assigned one African country. For Mozambique, Sichuan is the dispatching province since 1976 (Li 2011: 9-10).

Figure 2.3 Promotion for Chinese medical teams in Africa (from 1972)

* the banner reads: “The feelings of friendship between the peoples of China and Africa are deep Source Shanghai renmin chubanshe1972, copied from http://chineseposters.net/posters/e15-837.php

http://chineseposters.net/posters/e15-837.php

28

Since then 17 teams of about 12 doctors, accompanied by a chef and one interpreter, have been sent, each for a two year period. Chinese medical teams offer health assistance in remote areas and difficult circumstances, although in Mozambique they tend to operate mainly in the Central Hospital of Maputo and at Mavalane General Hospital. They get an intensive language course, but will depend mostly on their interpreter according to the Centre for Chinese Studies that evaluated the project in 2010. However, the language remains a big problem, since only one translator has to cater for 12 doctors. Interns are therefore used as back up (Centre for Chinese Studies 2010: 91-92).

2.3.2.3 Cataract treatment

Within the ‘Brightness Action’ campaign, a delegation of Chinese medical experts came to Mozambique in September 2011 to carry out about 300 cataract operations in the Central Hospital of Maputo. The patients were selected by the Mozambican health officials60. From the information gathered during the fieldwork it could not be concluded whether this initiative will be repeated in the next years.

2.3.2.4 Malaria control centre

Malaria is one of the main health areas in which the Chinese government cooperates with other countries. Medical teams, the provision of drugs (esp. Cotecxin), training programmes are all measures that have to contribute to the fight against malaria. Another important feature is the creation of malaria control centres. This resulted from the FOCAC meeting in 2006. The objective is to share Chinese knowledge about the treatment of malaria with African counterparts. The centres are set up by Chinese experts and the Chinese government provides for the first three years facilities and drugs for free. Also Chinese specialists are sent to the centres to work in them. Ultimately, the centres should act as national centres for anti-malaria research, exchange of technology and training of medical staff (Li 2011: 17). In Mozambique the process of implementing the centre has not been straightforward. According to the Center for Chinese Studies (2011: 90-91), there were delays because of diverging views about the planned location of the centre. The Mozambican government opted for a psychiatric hospital in Infulene, but the Chinese rejected this because the hospital was known to treat mentally ill patients61. Eventually, the center located in Polana Caniço, an area of Maputo, according to a representative of MISAU.

2.3.2.5 Provision of drugs and medicines

Anti-malaria drugs are the main medicines that China provides within its development cooperation. The AidData website62 mentions that China agreed to donate anti-malaria drugs in 2010, but there is no information ‘on the amount of medicine provided, dates the medicine reached the country, and the completion status’. According to the Centre for Chinese Studies (2011: 91), at the FOCAC meeting of 2006, the Chinese Ambassador to Mozambique pledged to donate US$ 700,000 worth of medication for the period 2008/2010. The Centre argues that this donation also acts as a subsidy to China’s own pharmaceutical companies.

Several DAC-donors mentioned in the interviews their expectation that China’s pharmaceutical sector will become increasingly important for the provision of drugs to Mozambique in the future.

60

Interview with Mozambican health official. 61

The AidData website and article of AllAfrica ((2009) state erroneously that the centre is located in

Infulene. 62

www.aiddatachina.org

29

2.4 South Africa


The current diplomatic relations between South Africa and Mozambique were shaped after the apartheid era in 1994 and were framed within a Joint Permanent Commission for Cooperation63, which has recently been replaced by a binational commission. The bulk of the cooperation is focused on conflict prevention, economic issues and investments. This mirrors South African development cooperation policy with other countries (see De Bruyn 2013a). South Africa’s main foreign policy framework is on the one hand the Southern African Development Community (SADC), which main objective includes regional integration, and on the other hand the New Partnership for Africa’s Development (NEPAD), the economic development programme of the African Union (South Africa High Commission 2013). The health sector is thus not among the priority areas of South Africa’s development cooperation. Nevertheless, Mozambique and South Africa signed an agreement in health matters in 2005 (see below). Furthermore, the private and academic sectors collaborate with or invest in Mozambique. Some of the private hospitals are owned and managed by South African and Mozambicans who can afford it, visit hospitals in South Africa (notably in Nelspruit). At the academic level there is for instance exchange program with students Mondlane University in Maputo and the University of the Western Cape64.


2.4.2.1 Agreement in health of 2005

The agreement in health matters of 2005 focuses on collaboration in joint surveillance, control and management of communicable and non-communicable diseases, strengthening of immunization programmes human resources planning and development and patient referral systems. Mozambique and South Africa committed to exchanging health professionals for purposes of sharing new techniques and technologies, including training and education programme; exchange and dissemination of information on health issues; creating partnerships between South Afria’s health institutions and organisations; exchange in biomedical and health system research; and exchanging information and share experience in human resources management in the context of decentralisation to local facilities (Department of Health SA 2005).

2.5 Trade between BICS and Mozambique

2.5.1 General trade relations and the importance of the Tete province

Figures 2.4 to 2.7 and tables 2.3 and 2.4 give an overview of the trade importance of Brazil, China, India and South Africa. South Africa is the most important trading partner, but China and India are gaining ground. In 2012 the latter two were respectively the second and third most important exporter to Mozambique and the second and most important export destination. Aluminum and coal have become the two main export products (Campbell 2012). Although Brazil is lagging behind in comparison to China, India and South Africa in terms of trade volumes, it has become the most important foreign investor. In the first 9 months of 2012 for instance, the Ministry of Planning and Development of Mozambique reported according to that Brazilian investments amounted to more than € 605 million (ab ibid.).

63

http://www.dfa.gov.za/foreign/bilateral/mozambique.html 64

Interview with representative of Mozambican government.

30

Another type of presence of the BICS’ impact on the health situation is the private mining, construction and energy industry. Especially in the northern province of Tete, where several companies of the BICS (and other countries) are active. For Brazil this includes Vale, the second biggest mining company in the world, Odebrecht, Camargo Correa and Andrade Guttierez (Chichava et al. 2013: 8-9). The national legislation of some of the BICS stipulates that the companies have to re-invest a part of their profits in social projects, including health projects for their own labor force as well as the population, that is impacted upon by the activities of the companies (see Azevedo Gomes 2010). Some of the bilateral and multilateral agencies are attempting to set up collaborative corporate social responsibility (CSR) projects or programmes and health impact assessments with one or more of the companies65. These initiatives are still in the negotiation phase and it is not clear if or to what extent the governments of the BICS are involved. Next research activities within the four year research will focus particularly on this issue.

Figure 2.4 Total import of all products from BICS in Mozambique 1995-2012 in billions of US$

Source http://unctadstat.unctad.org

Figure 2.5 Share of total import of all products from BICS in Mozambique 1995-2012 (in %)


65

Interviews with bilateral and multilateral donor agencies.

0

1

2

3

4

5

6

7

1995 2000 2005 2010

World

South Africa

China

India

Brazil

0

10

20

30

40

50

60

1995 2000 2005 2010

South Africa

China

India

Brazil

31

Table 2.3 Ranking of importers in Mozambique 1995 -2012 Rank 1995

Country In US$ 1000

In % Rank 2012

Country In US$ 1000

In %

1 South Africa 321615 44 1 South Africa 1887439 31 2 Portugal 47589 7 2 China 783758 13 3 United States 40841 6 3 India 729881 12 4 Zimbabwe 35631 5 4 United States 331256 5 5 India 23430 3 5 Portugal 312381 5 6 France 23017 3 6 Australia 279203 5 7 Japan 20679 3 7 Thailand 136478 2 8 Italy 19750 3 8 Japan 117573 2 9 Swaziland 19476 3 9 Singapore 116488 2

10 United Kingdom 18475 3 10 Brazil 112831 2 .. .. .. ..

19 China 7440 1 24 Brazil 4342 1

Source http://unctadstat.unctad.org Figure 2.6 Total export of all products from Mozambique to BICS 1995-2012 in

billions of US$


Figure 2.7 Share of total export of all products from Mozambique to BICS 1995-2012 (in %)


0

1

2

3

4

1995 2000 2005 2010

World

South Africa

China

India

Brazil

0

5

10

15

20

25

30

35

1995 2000 2005 2010

South Africa

China

India

Brazil

32

Table 2.4 Ranking of export destinations from Mozambique Rank 1995

Country In US$ 1000

In % Rank 2012

Country In US$ 1000

In %

1 Spain 31771 18 1 South Africa 1177955 29 2 South Africa 28824 17 2 China 461948 11 3 Japan 23898 14 3 Belgium 430966 11 4 Portugal 18107 10 4 Netherlands 288027 7 5 United States 16442 9 5 India 231252 6 6 India 7175 4 6 Spain 221214 5 7 Malawi 7156 4 7 Turkey 120263 3 8 Zimbabwe 5112 3 8 United Kingdom 111268 3 9 France 4412 3 9 Italy 110240 3

10 Italy 3944 2 10 Zimbabwe 88372 2 .. .. .. .. .. .. .. ..

25 China 509 0 12 Brazil 20700 1 55 Brazil 17 0


2.5.2 Import of medicinal and pharmaceutical products

For this report it is useful to look specifically at the import of medicinal and pharmaceutical products from the BICS into Mozambique (export from Mozambique to the BICS is almost non-existent). Figure 2.8 and 2.9 and table 2.5 show that India has become the most important exporter of medicinal and pharmaceutical products to Mozambique in the last ten years. Table 2.10 shows that these products make up about 10% from India of the export basket to Mozambique, while for the other countries this is much lower. Figure 2.8 Total import of medicinal and pharmaceutical products from BICS

in Mozambique 1995-2012 in millions of US$


0

20

40

60

80

100

120

140

160

1995 2000 2005 2010

World

South Africa

China

India

Brazil

33

Figure 2.9 Share of total import of medicinal and pharmaceutical products from BICS in Mozambique 1995-2012 (in %)


Figure 2.10 Share of total import of medicinal and pharmaceutical products in

total of import for each of the BICS and the world in Mozambique 1995-2012 (in %)


Table 2.5 Ranking of importers of medicinal and pharmaceutical products in Mozambique 1995-2012

Rank 1995

Country In US$ 1000

In % Rank 2012

Country In US$ 1000

In %

1 Portugal 8551 37 1 India 45804 34 2 Denmark 3687 16 2 France 42171 32 3 Netherlands 2169 9 3 Belgium 19983 15 4 China, Hong Kong

SAR 2109 9 4 Portugal 6283 5

5 Canada 1891 8 5 South Africa 4558 3 6 South Africa 1630 7 6 China 2389 2 7 China 744 3 7 Japan 2387 2 8 Italy 483 2 8 Switzerland 2217 2 9 Germany 417 2 9 Germany 2008 2

10 United States 302 1 10 Netherlands 732 1 .. .. .. .. .. .. .. ..

14 India 110 0 12 Brazil 610 0


0

10

20

30

40

50

1995 2000 2005 2010

South Africa

China

India

Brazil

0

10

20

30

40

50

60

1995 2000 2005 2010

World

South Africa

China

India

Brazil

http://unctadstat.unctad.org/

34

Drugs and pharmaceutical items feature among the main Indian export items to Mozambique. For instance in the market of ARV generic medicines, Indian manufacturers would dominate 80% of annual purchase volumes according to a study of Waning et al. (2010). The number of Indian generic manufactures supplying ARVs worldwide increased from 4 to 10 between 2003 and 2008 and the number of Indian-manufactured generic products grew from 14 to 53. Of a 100 countries in the study 96 (including Mozambique) bought Indian generic ARV. The Indian ARV medicines were consistently less expensive than other generic medicines.

According to the media, Indian pharmaceutical companies would try to increase their presence in Africa in the future via the South African market (Stratsis Incit 2011c). In addition, at least one international donor is looking into possibilities to procure generic ARV medicines from Indian manufacturers in order to decrease costs and also at least one national department prospected collaboration in the past66.

2.6 Overview

Table 2.6 on the following pages provides an overview of all the projects or programmes of the BICS in the health sector in Mozambique identified during the fieldwork. The information that lacked conclusive evidence has been marked with a question mark (and as the reader will notice, there are many of them). References to the data can be found above.

66

Interview with DAC donor and with national government official.

35

Table 2.6 Overview of development cooperation initiatives of Brazil, India, China and South Africa in the health sector in Mozambique

Project Type of cooperation

Leading Mozambican institutions

Leading BICS institutions

Other partners Budget (in US$) Time period

Brazil ARV, construction and other medicines factory

Grant, technical cooperation

MISAU Ministry of Health & Fiocruz

- US$ 23 million? Ideas presented in 2003 and ongoing

Strengthening the pharmaceutical department’s regulatory agency

MISAU ANVISA - About US$ 639,000?

Ongoing

Human milk banks Technical cooperation

MISAU Ministry of Health & Fiocruz

- US$ 425,000? In negotiation

Strengthening of National Institute of Health

Technical cooperation

MISAU, National Institute of Health

Ministry of Health & Fiocruz

- About US$ 300,000?

2007 and ongoing

Master programme in health sciences


University of Mondlane?

University of Brasília & NGO?

- ? Ongoing

Projects related to cancer prevention



- US$ 324,000? started

Dental health projects Research, technical cooperation


- US$ 476,000? started

Community care project Technical cooperation

? ? - US$ 425,000? 2010?

Tele-health system and support to the medical library

? ? ? - US$ 123,000 2010?

Scoping mission on malaria prevention, mental health and other health issues

? ? ? - US$ 47,000? 2010?

Support to FARMAC? ? MISAU? Ministry of Health & Fiocruz

Ongoing

Trilateral cooperation in slum rehabilitation

? Municipality of Maputo

Brazilian Ministry of Cities and the Federal Savings Bank of Brazil

Italian development cooperation

US$ 3 million 2011 and ongoing

36

Trilateral cooperation in HIV/AIDS

? Ministry of Health & Fiocruz

CDC & USAID In negotiation

School Feeding and Food Purchase Programme


Ministry of Education, Ministry of Agriculture

ABC WFP, FAO US$ 1,397,000? Ongoing

Exchange of experiences in HR


MISAU State of Bahia - ? Not started yet

India Pan-African –Network:

tele-health equipment Equipment, technical cooperation?

MISAU Indian government

African Union ? 2010 - 2014

China Construction and equipment of hospitals

Construction and equipment

Government of Mozambique

Government of China

- At least US$ 1,6 million?

?

Cataract treatment MISAU Government of China

2011

Medical Teams MISAU Chinese government & Sichuan province

- 1976 and ongoing

Anti-malaria centre Grant, technical cooperation

Government of Mozambique

Government of China

- ? 2009

Provision of medicines grant Government of Mozambique

Government of China

- US$ 700,000? 2008-2010?

South Africa

Agreement in health ? Government of Mozambique

Government of SA

? ? 2005

37

3. FEATURES OF BRAZIL, CHINA, INDIA AND SOUTH AFRICA’S INVOLVEMENT IN THE

MOZAMBICAN HEALTH SECTOR: MAIN FINDINGS AND DEBATE

In this last chapter, the main features of the BICS’ approaches and initiatives are summarized and confronted with the opinions and perceptions of other development actors. These issues will be further explored and contextualized in next research steps, which will be presented at the end of this chapter.

3.1 Presence

The involvement of Brazil, India, China and South Africa in the health development cooperation with Mozambique is very dissimilar. Although it is not the main sector, health is one of the prioritized domains of Brazil’s governmental development cooperation. China has set up a number of cooperation initiatives and - based on the pledges of the FOCAC meeting – might increase its activities in the future, while India and South Africa’s governments only marginally engage in health cooperation with Mozambique. An important difference with DAC-donors is the limited presence of governmental personnel or development workers following up projects in Mozambique. Brazil’s delegation was relatively small (two people working for Fiocruz and two following up the ARV factory), as was the case for India (only a small number of people working in the High Commission of which one followed up development cooperation). Furthermore some of them return to their countries of origin for considerable periods of time during the year. The number of medical experts (for example involved in the Chinese medical teams) carrying out the projects is higher – but still rather small. The limited number of personnel and presence could not only render the follow up of the projects difficult, but might also inhibit sustainable relationships with other development partners and national government officials. This remains however a hypothesis.

3.2 Discourse and objectives

As far as could be asserted, the discourse and objectives of the BICS in the health sector in Mozambique seemed to be in line with findings in other literature about the BICS involvement in development cooperation in general and in health specifically (see De Bruyn 2013a & b). This discourse focuses on issues such as equal partnerships, mutual benefit, solidarity, and the use of own appropriate expertise coming from addressing their own development challenges. Moreover, the countries do not consider themselves in a donor recipient relationship.

For some initiatives, the cooperation between Mozambique and Brazil, China and India seems a one way street without much involvement of the local governmental levels. Other, such as the INS support were praised for their participatory approach by government representatives. Future research has to further assess whether the discourse matches with the practice.

According to the representatives of the government, an important difference between the BICS (and especially Brazil and China) and the DAC-donors was the limited exigency of the former in terms of plans, evaluations, working groups.

3.3 Budget and financial resources

The countries do have in common that reliable data about budget and initiatives is hard to find. Consequently it is not yet possible to put exact figures on the financial commitments to health cooperation. Still, from the available information it seems that – apart from the ARV factory – budgets are not comparable to those of the DAC-donors

38

involved in health cooperation. One of the representatives of a DAC-donor argued that the credit lines of India and China for infrastructural projects might be a useful resource that enables the Mozambican government to build health infrastructure.

3.4 Modalities

According to the interviews with DAC-donors, a typical feature of the BICS’ approach is the emphasis on projects. These include small projects (such as medical teams, master courses) as well as flagship projects, such as the Pan-African e-network for India, and the ARV factory of Brazil. Furthermore, Brazil extents primarily technical assistance, while India and China also provide credit lines (although not in health it seems). Other important kinds of assistance include training and the delivery of equipment and drugs. Areas in which the BICS operate include communicable diseases (esp. HIV/AIDS and malaria) and public health. Still there might be an encompassing strategy behind these initiatives. For Brazil, the overarching strategy is structural cooperation. At first sight, the BICS seem to implement projects and programmes which they have carried out in other African countries. It remains a question whether this is indeed the case, and if so - whether the experiences and know-how is effective in the Mozambican context.

NGOs are virtually absent in the projects, while the private sector is an important actor. Most of the loans and grants is in the form of tied assistance, i.e. the equipment is delivered by Brazilian, Indian, South African or Chinese companies.

3.5 Collaboration and coordination with DAC-donors

There is almost a complete lack of coordination and communication between the BICS and the DAC donors in health cooperation in Mozambique. Only Brazil attends sporadically the Health Partners Group (HPG) 67 . The Indian and Brazilian representatives explained in the interview that they refrain from attending the HPG because they are not donors. In the interviews the DAC-donors critique the lack of coordination and consultation of the BICS because it might risk the effectivity of certain interventions in the health sector and makes collaboration difficult. There is indeed an interest of some DAC-donors to set up joint projects (especially with Brazil). They believe that the BICS can provide valuable expertise in certain domains68. Apart from Italy and USAID and CDC, some other DAC-donors do explore potential collaboration at the headquarters in their home countries. 3.6 Future research steps

This paper has reported the main findings of an exploratory fieldwork in Mozambique. Its main aim was to map the activities and presence of the BICS’ development cooperation in the health sector. In the next phases of this four year research project the data in this paper will be updated. In addition, the next research steps will explore the partnerships between the BICS and the national governmental actors as well as with other development partners in more depth. Attention will be given to the way these partnerships are started, developed and implemented and how and to what extent the discourse of equality, mutual benefits and own appropriate expertise is put into practice. The research will focus on a number of initiatives identified in this study, including the ARV and medicine factory and the strengthening of the INS, and the school feeding program, all involving the Brazil cooperation, the Pan-African e-Network of India, the medical teams or cataract programme of China, and the CSR initiatives of mining companies in the Tete province. These case studies will be supplemented with

67

Interview with representatives of DAC-donors and Fiocruz. 68

Interview with representatives of DAC-donors.

39

initiatives in the food and agriculture sector in Malawi (see De Bruyn 2014). From these insights lessons can be drawn for other development practitioners and policy experts.

41

APPENDIX: INTERVIEW LIST Name Function Organisation Date

Geraldina Langa Ministry of Health, Department of Planning and Cooperation

27/3/2013

Chanvo Salvador Lucas Daca Daca

Bilateral relationships responsible

Ministry of Health, Department of Planning and Cooperation

7/11/2013

Ilesh Jani General Director Ministry of Health, National Health Institute

29/3/2013 & 12/11/2013

Dr Joao Alexandre Public Health infrastructure, Consultant

Ministry of Health 26/3/2013

Dr Mazivila Adj. Director Ministry of Health, Department of Planning and Cooperation

27/3/2013 & 8/11/2013

Dr Felisbela Gaspar Director Ministry of Health ,Institute of Traditional medicine

13/11/2013

Dr Quinesh Vice Director Ministry of Health 12/11/2013

Dr Mariano Ophalmologist Central Hospital of Maputo 12/11/2013

Patricia David e Silva Health Partners Group Coordinator

Health Partners Group 4/11/2013

Emanuele Capobianco Chief of Health and Nutrition

UNICEF 19/3/2013

Lisa Kurbiel Senior Social Policy Specialist

UNICEF 25/3/2013 & 4/11/2013

Lola Castro Representative and country director

WFP 28/3/2013

Ilaria Martinatto Programme Officer WFP 14/11/2013

Eva De Carvalho Malaria Specialist WHO Phone call

Dr Daniel Kertesz Representative WHO Mozambique 20/3/2013

Marco Gerritsen First Secretary Health & HIV/AIDS

Embassy the Netherlands 19/3/2013

Rui Alvaro Serra da Costa Reis

Mozambique representant

Agència Catalana de Cooperació al Desenvelopument

21/3/2013

CláudioVolpe Dr. Vincenzo Oddo Giulion Borgnolo

Health consultant Deputy director

Italian Embassy, Development Office

26/3/2013

Kirsten Havemann Counsellor (health) Royal Danish Embassy 19/3/2013 & 5/11/2013

Etelvina Mahanjane DFID 25/3/2013

Jonas Chambule Irish Aid 28/3/2013

Eric Korsten Assessor para gestão de Recursos Humanos em saúde/Chefe de projeto

Projeto de Apoio à Formação e Gestão de Recursos Humanos no setor de Saúde

BTC 25/3/2013

Mark Deneer Chief of Cooperation Belgian Embassy 26/3/2013

Antoon Delie Chief of Cooperation Belgian Embassy 30/10/2013

Dr Claudia Herlt Programme director, multisectoral programme HIV

GIZ 27/3/2013

Eliane Moser

Stuart Lane

Senior Development Officer

Chef of Cooperation

Canada 12/11/2013

Geert Haghebaert Attaché EU – Delegation to the Republic of Mozambique

29/3/2013

Alyssa Leggoe Integrated Health Office Chief

USAID 27/3/2013

42

Mindy Hochgesang CDC 28/3/2013 & 8/11/2013

James Colbourn Senior Malaria advisor CDC 8/11/2013

Alfredo E. Vergara CDC 6/11/2013

Simões Victorino Consultant Health, Education and Good Governance

JICA 27/3/2013

Paulo Joppert Ministro-conselheiro Brazilian Embassy 14/11/2013

Jose Luiz Telles Coordinator Fiocruz 5/11/2013

Lícia de Oliveira

Coordinator of the Project on Implementation of ARV Factory in Mozambique

Fiocruz/Farmanguinhos 20/3/2013 & 11/11/2013

Francisco Le Francisco Taegino

ARV Factory in Mozambique, Technical Support International Advisor

Fiocruz/Farmanguinhos 20/3/2013

José Luiz Bellini Leite General coordinator Embrapa 31/10/2013

Eduardo Munhequete Occupational Health manager

VALE 15/11/2013

S. Balanchandran Second Secretary High Commission of India 28/3/2013 & 30/10/2013

Ayay Lal Project engineer TCIL 8/11/2013

Manoj Gupta Country Head Jindal Africa 6/11/2013

K. Sunderaresan General Manager Operations

Dr Agarwal’s Eye Hospital 1/11/2013

Pu Renyao Surgeon Hand (orthopedist)

Central Hospital Maputo 7/11/2013

Brian Ritter Conselheiro High Commission of South Africa

1/11/2013

Luis Massalambane Labo Marketing Officer Department Trade and Industry, Rep. of South Africa

1/11/2013

Natacha Bobin Programme Director PSI 7/11/2013

Jean-Luc Anglade Chef of Mission MSF 7/11/2013

David Wood National Director Malaria consortium Phone call

Sally Griffin Coordinator NAIMA+ 20/3/2013

Lise Ellyin Clinton Foundation 22/3/2013

Beatrice Crahay National Director International Centre for Reproductive Health

28/3/2013

Alex Shankland Researcher IDS 26/3/2013

Sigrid Eckman Researcher Independent consultant 28/3/2013

Natalia Fingermann Researcher University of São Paulo 22/3/2013

Sergio Chichava Researcher IESE 5/11/2013

Adriana Abdenur General coordinator BRICS policy Centre 14/11/2013

Isabel Diogo Researcher Brazil 6/11/2013

Lu Yang Researcher LSE 5/11/2013

43

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http://www.focac.org/eng/zxxx/t954620.htm

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Russo, G. & Shankland, A. (2014), “Brazil’s engagement in health co-operation: what can it contribute to the global health debate” in Health Policy and Planning, Vol. 29, No. 2, pp. 266-270 Sotero, P. (2009), ‘Brazil as an emerging donor. Huge potential and growing pains’ in Development Outreach, Vol. 11, No. 1, pp. 18-22 South Africa High Commission in Lilongwe (2013), Communication South-Africa – Malawi relations, South Africa High Commission, Lilongwe Stolte, C., (2012), Brazil in Africa: Just Another BRICS Country Seeking Resources?, http://www.chathamhouse.org/publications/papers/view/186957?mkt_tok=3RkMMJWWfF9wsRohv63AZKXonjHpfsX76O4lXqSxlMI%2F0ER3fOvrPUfGjI4FTcVkI%2FqLAzICFpZo2FFcH%2FaQZA%3D%3D, consulted on 17/7/2013. Stratsis Incite (2011a), ‘India Goes Seeking Coal in Mozambique’ in Stratsis Incite, 14/1/2011, http://stratsisincite.wordpress.com/tag/india-in-africa/, consulted on 17/7/2013. Stratsis Incite (2011b), ‘Indian drug firms use South Africa as entry way into rest of Africa’ in Stratsis Incite 1/6/2011, http://stratsisincite.wordpress.com/2011/06/01/indian-drug-firms-use-south-africa-as-entry-way-into-rest-of-africa/, consulted on 17/7/2013. Stratsis Incite (2012), ‘India plans to invest more in African gas and oil sector’ in Stratsis Incite, 9/1/2012, http://stratsisincite.wordpress.com/2012/01/09/india-plans-to-invest-more-in-african-gas-and-oil-sector/, consulted on 17/7/2013. Timmermans, N. and Vinyals, L. (2012), Monitoring of EU Education and Health Expenditure in Developing Countries, European Commission, Brussels Tomlinson, B. (2013), The Role of NGOs and Their Relationships with Donors and Governments Delivering Aid: A Research Paper on the Current Trends and Issues, UNDP-China. Vlaamse Regering (2009), Landenstrategienota II voor de Ontwikkelignssamenwerking tussen de Regering van Mozambique en de Regering van Vlaanderen, Vlaamse Regering, Brussel Waning, B., Diedrichsen,E. & Moon,S. (2010), ‘A lifeline to treatment: the role of Indian generic manufacturers in supplying antiretroviral medicines to developing countries’ in Journal of the International AIDS Society, Vol. 13, No.1, pp. 35. WHO (2009), WHO Country Cooperation Strategy 2009-2013. Mozambique, WHO, Brazzavile Xinhua (2013), ‘China to provide Mozambique with medical equipment for central hospital’ in Xinhua, 19/2/2013, http://www.globaltimes.cn/content/762510.shtml, consulted on 17/7/2013.

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PARTNERS

Het Leuven Centre for Global Governance Studies

(www.globalgovernancestudies.eu) coördineert de derde generatie van het

Steunpunt “Buitenlands beleid, internationaal ondernemen en ontwikkelingssamenwerking” voor de Vlaamse Regering. Een Steunpunt heeft als doel de wetenschappelijke ondersteuning van Vlaams beleid.

Het project brengt 17 promotoren en 10 junior onderzoekers (waarvan acht doctoraatsstudenten) samen. Het Steunpunt doet aan (a) dataverzameling en -analyse, (b) korte termijn beleidsondersteunend wetenschappelijk onderzoek, (c) fundamenteel wetenschappelijk onderzoek en (d) wetenschappelijke dienstverlening.

We werken samen met een aantal partners: het Antwerp Centre for Institutions and Multilevel Politics, de Vlerick Leuven Gent Management School en H.U.Brussel. Binnen de KU Leuven maken ook collega’s verbonden aan de Faculteit Economie, het Instituut voor Internationaal en Europees Beleid, de Onderzoekseenheid Internationaal en Buitenlands Recht, het Instituut voor Internationaal Recht, het Instituut voor Europees Recht en HIVA - Onderzoeksinstituut voor Arbeid en Samenleving deel uit van het project.

Het onderzoek is verdeeld over vier thematische pijlers: (i) Internationaal en Europees Recht; (ii) Internationaal en Europees Beleid; (iii) Internationaal Ondernemen; en (iv) Ontwikkelingssamenwerking.

Bezoek onze website voor meer informatie: www.steunpuntiv.eu

http://www.globalgovernancestudies.eu/

http://www.steunpuntiv.eu/

brazil, india, china and south africa in the health sector in

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