ghsi brics report

8/2/2019 Ghsi Brics Report

http://slidepdf.com/reader/full/ghsi-brics-report 1/108

ShiftingParadigm

H h BriCS Ar

Rhapg Gba Hah

ad Dvp



AcknowleDGements

This report was developed by Global Health Strategies initiatives (GHSi), an international nonprotorganization advocating for improved access to health technologies and services in developingcountries. Our efforts engaged the expertise of our afliate, Global Health Strategies, an internationalconsultancy with ofces in New York, Delhi and Rio de Janeiro. This report comprises part of a larger

project focused on the intersections between major growth economies and global health efforts,supported by a grant from the Bill & Melinda Gates Foundation.

GHSi senior leadership, who advised the team throughout development of this report, includesDavid Gold and Victor Zonana (New York), Anjali Nayyar (Delhi) and Alex Menezes (Rio de Janeiro).

Brad Tytel, who directs GHSi’s work on growth economies and global health, led the development ofthe report. Katie Callahan managed the project and led editorial efforts.

Chandni Saxena supervised content development with an editorial team, including: Nidhi Dubey,

Chelsea Harris, Benjamin Humphrey, Chapal Mehra, Daniel Pawson, Jennifer Payne, Brian Wahl.

The research team included the following individuals, however contents do not necessarily reect theopinions of their respective institutions:

Brazil Carlos Passarelli, Senior Advisor, Treatment Advocacy, UNAIDSCristina Pimenta, Associate Professor, School of Biological Sciences, Veiga de Almeida University

Russia Kirill Danishevskiy, Assistant Professor, Postgraduate School of Health Management,Department of Public Health, Moscow Sechenov Medical Academy

India Sagri Singh, Independent Consultant, GHAR Consulting Inc.

China Guo Yan, Professor, School of Public Health, Peking University Health Science CenterJoan Kaufman, Distinguished Scientist and Senior Lecturer, Heller School for Social Policyand Management, Brandeis University and Lecturer in Global Health and Social Medicine,Harvard Medical School

South Africa Regina Osih, Independent Consultant, Public Health and Infectious DiseaseMatshidiso Masire, BridgingDialogue

Sridhar Venkatapuram, Wellcome Trust Fellow, London School of Hygiene & Tropical Medicine,

provided overall guidance.

We are extremely grateful to Amy Adelberger, Sanjaya Baru, Nicole Bates, Katherine Bliss, Xiaoqing LuBoynton, Deborah Brautigam, Martyn Davies, Steve Davis, Samu Dube, Jean Duffy, Ksenia Eroshina,Gabrielle Fitzgerald, Meenakshi Datta Ghosh, Dan Gwinnell, Yanzhong Huang, Suresh Jadhav, SalimKarim, Stephanie Lazar, Donna Lomangino, Ashok Malik, Dai Min, Steve Morrison, Rani D. Mullen,Adrianne Nickerson, Blessed Okole, Linda Patterson, Bin Pei, Pronob Sen, Nina Schwalbe, MarkusSteiner, Ian Temple, Vasiliy Vlassov and Tom Wheeler for their support and input.

© 2012 Global Health Strategies initiatives (GHSi)

[email protected]



tABle oF contents

Executive Summary 5

1. Introduction 13

2. Brazil 19

Brazil Overview 19

Brazil’s International Cooperation 21

Brazil’s Health Cooperation 24

Brazilian Innovation and Implications for Global Health 29

3. Russia 33

Russia Overview 33 Russia’s Foreign Assistance 35

Russia’s Health Assistance 37

Russian Innovation and Implications for Global Health 41

4. India 43

India Overview 43

India’s Foreign Assistance 45

India’s Health Assistance 49

Indian Innovation and Implications for Global Health 51

5. China 57

China Overview 57

China’s Foreign Assistance 59

China’s Health Assistance 62

Chinese Innovation and Implications for Global Health 66

6. South Africa 71

South Africa Overview 71

South Africa’s Foreign Assistance 73

South Africa’s Health Assistance and Impact 75 on Global Health Innovation

7. Beyond BRICS 79

8. Key Findings and Conclusions 85

Citations 93



2

Global Health Strategies initiatives

1997: Russia joinsG7, resulting increation o G8

2001: Under pressure rom Brazil, India andother developing countries, WTO member

states announce Doha Declaration toencourage ull use o TRIPS exibilities to

ensure access to essential medicines

2001: Indian manuacturer Cipla beginsoering high quality ARVs at raction o cost

o other manuacturers, increasing accessor millions o HIV/AIDS patients globally

2002: First Russian contributionto Global Fund

2002: India’s Shantha Biotech develops low-cost, high quality hepatitis B vaccine andreceives WHO prequalifcation; price alls

rom US$23 to less than US$1 per dose

Brazil pledges US$20 millionover 20 years to the

GAVI Alliance

Brazil spearheads eortsto establish UNITAID, an

innovative fnancing mechanismto increase access to essential

medicines and healthtechnologies

Russia commits to reimburseGlobal Fund or grants

received through 2010; totalcommitments to reach US$317

million by 2013

China commitsUS$37 million to combat

malaria in Arica at Forumon China-Arica Cooperation

Russia sets agenda orSt. Petersburg G8 meeting to

ensure discussion on combatting

inectious diseases globally

BRICS oreign ministersmeet or frst time as

geopolitical bloc

First Indian contributionto Global Fund; totalcommitments reach

US$10 million by 2012

2003: Using lessons learned rom 2003 SARSepidemic, China begins prioritizing disease

surveillance in Southeast Asia

2003: India, Brazil and South Arica establishthe IBSA trilateral to coordinate initiatives,

including those or health

2003: Brazil takes leadership role in elevatingtobacco control as a global health priority;

subsequently 168 countries sign ontoFramework Convention on Tobacco Control

2003: First Chinese contribution toGlobal Fund; total commitments reach


2003: India announces, going orward, it willonly accept bilateral assistance rom US, UK,

Germany, Japan, Russia and EU

2003: First South Arican contribution toGlobal Fund; total commitments reach


2004: South Arica launchesArican Renaissance and Cooperation

Fund, mechanism to channel itsdevelopment assistance

2005: India launches National Rural HealthMission, aiming to improve

health o its rural population

1993: Serum Institute

o India receivesWHO prequalifcation

or its measlesvaccine; India is frst

developing countryto receive WHOprequalifcation

1996: Brazil becomesfrst developing

country to guaranteeree ARV access to all

HIV/AIDS patients

key milestones oF BRics’ enGAGement in GloBAl HeAltH

1950–1965 2001–20051990s 20

1950: Chinalaunches international

assistance program

1955: Soviet Unionlaunches economic

and technicaldevelopment program

1960: Brazil establishesnational systemor international

cooperation

1964: India launchesInternational Technical

and Economic

Cooperation Programme,its cornerstone oreign

assistance program



ghsinit iat ives.org

Brazilian and South

Arican Ministers oForeign Aairs sign

onto Oslo MinisterialDeclaration, whichestablishes health

as key component ooreign policy

First South Aricancontribution to

the GAVI Alliance;pledges US$20 million

over 20 years

South Arica invited tojoin BRICs

CAPRISA, partiallyunded by South

Arican government,announces study

proving efcacy o ARV-based microbicide gels

to prevent HIV inectionamong women

China passes Japanto become 2nd largest

global economy

WHO announces China’s

SFDA complies withinternational vaccineregulation standards,

paving way orWHO prequalifcation

o Chinese-manuacturedvaccines

South Arica is frstcountry to announce

plans or national roll-outo GeneXpert, a state o

the art molecularTB diagnostic

India launchesDevelopment

AdministrationPartnership to oversee

international assistanceprogram

South Arica plans tolaunch its frst-ever

development agency,SADPA

China commitsadditional US$73

million or malariatreatment centers

and other acilitiesin Arica at Forum

on China-AricaCooperation

China commitsUS$124 billion or

domestic healthsector reorm

Russia releases conceptnote on internationalassistance priorities

and pledges tocontribute US$400-

US$500 million eachyear; commits to

eventually provideUN recommended

0.7% o GDP tointernational assistance

Serum Institute o India,in partnership with PATH

and WHO, launchesmeningitis A vaccine,

MenAriVac –frst vaccine designedspecifcally or Arica

Brazil begins providinginrastructure andcapacity building

support to ARV actoryin Mozambique –

Arica’s frst publicpharmaceutical acility

resulting rom South-South collaboration

First Russiancontribution to the GAVIAlliance; pledges US$80

million over 10 years

Brazil hosts WHO WorldConerence on Social

Determinants o Health

China releaseswhite paper on oreign

assistance program – frstpublic document on its

policies and approach

Russia hosts FirstGlobal Ministerial

Conerence on HealthyLiestyles and NCDs

At frst-ever BRICS HealthMinisters’ Meeting,

countries issue declarationhighlighting global public

health as joint priority

China’s MOST announcesUS$300 million partnership

with Gates Foundation tound R&D or global health

and agriculture products

Russia commits US$36million to support global

response to NCDs atUN Summit on Non-

Communicable Diseases

India removed romWHO list o polio-endemic countries

Russia and US signMOU to cooperate

on global eradicationo polio

China hostsministerial meeting

on drug-resistant

TB; World HealthAssembly later passes

MDR-TB resolution

2007 2010 2011 20122009



4


list oF AcRonyms

ABC Brazilian Agency for Cooperation

AMC Advanced Market Commitment

ARF African Renaissance and International Co-operation Fund

ARV Antiretroviral Drugs

AU African Union

CAPRISA Centre for the AIDS Program of Research in South Africa

CIS Commonwealth of Independent States

CNBG China National Biotec Group

DAC Development Assistance Committee

DFID UK Department for International Development

DST Department of Science and Technology (South Africa)

EPI Expanded Program on Immunization

FOCAC Forum on China-Africa Cooperation

GPEI Global Polio Eradication Initiative

GIZ German International Cooperation Agency

ICTC International Centre for Technical Cooperation on HIV/AIDS (Brazil)

IFFIm International Finance Facility for Immunization

MDR Multidrug-Resistant

MOFCOM Ministry of Commerce (China)

MOST Ministry of Science and Technology (China)

MRC Medical Research Council (South Africa)

NCD Non-Communicable Disease

NHI National Health Insurance (South Africa)

NRF National Research Foundation (South Africa)

NTD Neglected Tropical Disease

ODA Ofcial Development Assistance

OPV Oral Polio VaccinePAHO Pan-American Health Organization

PPD Partners in Population and Development

R&D Research and Development

SAARC South Asian Association for Regional Cooperation

SADC Southern African Development Community

SADPA South African Development Partnership Agency

SCO Shanghai Cooperation Organization

SFDA State Food and Drug Administration (China)

SII Serum Institute of India

TAC Treatment Action Campaign

TIA Technology Innovation Agency (South Africa)TRIPS Trade-Related Intellectual Property Rights

UNAIDS Joint United Nations Programme on HIV/AIDS

UNDP United Nations Development Programme

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

USAID US Agency for International Development

WHO World Health Organization

WTO World Trade Organization

XDR Extensively Drug-Resistant




gauge the true long-term impact of the BRICS oninternational development, there is no doubt thatit will continue to increase.

At the same time that BRICS foreign assistancespending has grown, funding for global health hasslowed as US and European donors struggle amid

increasing nancial constraints. Some Europeangovernments have cut assistance spendingdramatically. As a result, there is an urgent needfor new health resources and innovation. Theworld will undoubtedly look to the BRICS forgreater leadership in these areas.

This report presents ndings from a qualitativeand quantitative survey of present and futureefforts by Brazil, Russia, India, China and SouthAfrica to improve global health. It examines theseroles within the broader context of international

eXecUtiVe sUmmARy

The enormous and increasing inuence ofthe BRICS countries (Brazil, Russia, India,

China and South Africa) can be seen in manyareas including economics, politics and culture.The economies of the BRICS have expandedsignicantly, and in 2011 China overtook Japan tobecome the second largest global economy. Braziland India are now sixth and ninth, respectively.While growth in the BRICS has recently begun toslow, to date these countries have shown muchgreater resilience than the US and Europe in theface of the global nancial crisis.

Within this context, BRICS foreign assistancespending has been growing rapidly. Throughplatforms like the BRICS forum, these countriesare also exploring opportunities for more formalcollaboration among themselves and with otherdeveloping countries. While it is impossible to

$6,000

$5,000

$4,000

$3,000

$2,000

$1,000

$0

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: World Bank Open Data — Brazil — Russia — India — China — South Africa

.1 BRics ABsolUte GDP GRowtH oVeR time (USD Billions)



6


triangular cooperation.” They also committedto use the BRICS platform as “a forum ofcoordination, cooperation and consultation onrelevant matters related to global public health.”Other global leaders have in turn noted thesetrends, and some have urged the BRICS and other

emerging powers to nd new ways to contribute.In a report delivered to heads of government atthe 2011 G20 meeting, Bill Gates expressed hisexcitement at “the potential for these rapidlygrowing countries to form partnerships with poorcountries to advance development.”

There are notable differences between the waysthe BRICS approach foreign assistance and themethods of traditional donors. Each of the BRICShas made health advances over the past fewdecades, and policymakers feel this equips them

with unique perspective on improving healthoutcomes in developing countries. The BRICSemphasize “South-South” cooperation and theyfavor models anchored in domestic programsand their own political and social philosophies.These often include bilateral capacity buildingand infrastructure development, and draw directlyon lessons learned by BRICS policymakers inaddressing their own internal challenges. EachBRICS country also employs its own methods, andcontributes in unique ways:

BRAZIL

Brazil is the sixth largest economy (nominally) inthe world, posting 7.5% growth in 2010, thoughthis slowed to 2.8% in 2011. Brazil has used itsglobal leadership position to champion South-South collaboration, particularly with otherLusophone (Portuguese-speaking) countries. Itsapproach to international cooperation emphasizespartnership, capacity building and health careaccess. Brazil does not report annual gures, soits spending is difcult to quantify. Estimates forBrazil's international cooperation spending in2010 range from US$400 million to US$1.2 billion.It is clear that health is a strong focus of theseprograms, reecting a longstanding domesticcommitment to equity. The Brazilian governmentis also investing substantial resources indomestic research and development (R&D), withannual public investment increasing 13.5% eachyear from 2000-2010. This could accelerate thecountry’s ability to supply health technologiesglobally. Highlights of Brazil’s current andpotential contributions to global health include:

development and foreign assistance, thoughhealth remains the primary focus. This reportalso includes a brief look at other emergingpowers beyond the BRICS that have potential toimpact major global health issues. The goal wasto examine existing BRICS assistance programs

and contributions to health innovation in orderto identify opportunities for the BRICS andother emerging powers to expand upon theirachievements and increase their contributionsto improving health in the poorest countries.

BRics imPAct

on GloBAl HeAltH

The BRICS are in many ways still developingcountries, and they continue to face signicanthealth challenges of their own. So their interestand goals in supporting global health and

development efforts are tempered by domesticconcerns. Yet at the same time, these countrieshave all engaged in foreign assistance fordecades. BRICS foreign assistance spending isstill relatively small when compared to overallspending by the US and Western Europeancountries, but in recent years it has beenincreasing rapidly. From 2005 to 2010, Brazil’sassistance spending grew each year by around20.4%, India’s by around 10.8%, China’s byaround 23.9%, and South Africa’s by around 8%.Russia’s assistance increased substantially early

in the same period, before stabilizing at aroundUS$450 million per year.

Today, among the BRICS, China is by far thelargest contributor to foreign assistance, andSouth Africa is estimated to be the smallest bya signicant margin. Brazil and Russia prioritizehealth within their broader assistance agendas,while China, India and South Africa tend tofocus on other issue areas. Though their healthcommitments vary signicantly in both sizeand scope, each of the BRICS has contributedto global health through nancing, capacitybuilding, dramatically improved access toaffordable medicines, and development of newtools and strategies.

In this context, BRICS policymakers themselvesincreasingly recognize their potential to have evengreater global health impact. At a meeting in2011, BRICS Ministers of Health publicly declaredtheir commitment to “support and undertakeinclusive global public health cooperationprojects, including through South-South and




network of milk banks. To date, Brazil’s Ministryof Social Development and Hunger Alleviationhas implemented 23 Bolsa Família-inspiredprojects in more than 50 countries.

• Multilateral Financing: Brazil contributedUS$106.5 million to the World Health

Organization (WHO) and the Pan-AmericanHealth Organization (PAHO) between 2006 and2009, and pledged an additional US$20 millionover 20 years to the GAVI Alliance. The countryalso helped spearhead the founding of UNITAID,and has given the organization more thanUS$37 million since 2007.

• Tobacco Control: Brazil played a leadershiprole in negotiations for the 2005 Framework

• HIV/AIDS: In 1996, Brazil committed to provideuniversal access to ARV drugs for HIV patients— a goal many global policymakers thoughtwas impossible to achieve in a developingcountry. Brazil’s success in this area and inHIV prevention has signicantly inuenced the

global response to the epidemic. Brazil hasdrawn on these experiences to support HIV/AIDS programs in other countries, including aUS$21 million investment in building an ARVplant in Mozambique.

• Child Nutrition: Brazil is collaborating withother countries and international agencies tohelp implement local variations of successfulBrazilian initiatives, such as its Bolsa Famíliaconditional cash transfer program and its

.2 G7 Vs. BRics: estimAteD AnnUAl GRowtH oF

FoReiGn AssistAnce PRoGRAms (2005-2010)

AnD ABsolUte AssistAnce (2010) (%, USD)

Source: OECD; Institute of Applied Economic Research (IPEA) Report, 2011; Inter-PressService, "Brazil, Emerging South-South Donor"; The Economist, “Speak Softly and Carrya Blank Cheque”; Deauville Accountability Report G8 Commitments on Health and FoodSecurity, Ministry of Finance of Russian Federation, 2011; Union Budget and EconomicSurvey, Ministry of External Affairs, Ministry of Finance, Government of India; Government

of India ofcial; “The Dragon’s Gift: The Real Story of China in Africa,” D. Brautigam;World Bank Open Data; GHSi AnalysisNote: *Russia pledged to steady foreign assistance disbursements between US$400Mand US$500M

40%

30%

20%

10%

5%

4%

3%

2%

1%

$40B

$30B

$20B

$10B

$5B

$4B

$3B

$2B

$1B

- $10B

- $20B

-10%

-20%

0%

.30%

.20%

.10%

$300M

$200M

$100M

-.10%

-.20%

-.30%

BrazilUnitedStates

Japan Germany France UnitedKingdom

Canada Italy Russia* India China SouthAfrica

-3%

-4%

US$1.2B

$31.2B

$18.9B$14.4B $14.4B $13.4B

$5.2B

$3.2B

U S$400M U S$472M US$680M

US$3.9B

US$143M

Annual Growth(2005-2010)

Absolute ForeignAssistance (2010)

High Estimate,Absolute ForeignAssistance (2010)



8


— is to prepare Russia’s health care industryfor the global market.

INDIA

India has one of the fastest growing economies inthe world and the ninth largest GDP (nominally).

The country’s growth averaged 8.5% annuallyfrom 2005 to 2010, and although the rate slowedto 6.1% in the fourth quarter of 2011, Indianpolicymakers believe growth could go up againin 2013. This growth, combined with a largepopulation, energetic democracy and activeforeign policy, has helped expand India’s inuenceregionally and globally. India has increased itsforeign assistance budget, and total assistancegrew from an estimated US$443 million in 2004to US$680 million in 2010. Yet health has notbeen a strong focus of assistance programs,as the government has prioritized efforts toaddress signicant domestic health challenges.Meanwhile, India’s pharmaceutical industrycontinues to have enormous global impact, andthe country recently launched a US$1 billioninnovation fund to encourage greater R&Dfor problems aficting developing countries.Highlights of India’s current and potentialcontributions to global health include:

• Pharmaceutical and Vaccine Manufacturing: Indian manufacturers have played a criticalrole in driving down prices and improving access

to vaccines and HIV/AIDS treatments for millionsof people worldwide. This includes developingnew vaccines such as the MenAfriVac meningitisA vaccine, which was designed specically forAfrica’s Meningitis Belt. The Indian governmentand others are also increasingly investing inearly-stage R&D in order to generate innovativehealth technologies.

• Global Polio Eradication: In February 2012,India was ofcially removed from the list ofpolio endemic countries. India’s polio programwas almost entirely self-funded throughUS$1.49 billion in support to the globaleradication initiative over nine years, and thegovernment and partners mobilized millions ofpeople to assist in immunization campaigns.This important accomplishment has addedsignicant new momentum to global efforts toeradicate polio.

• E-Health: India is using its expertise ininformation technology to assist other countries

Convention on Tobacco Control, and itsaggressive domestic control program isconsidered a model for other countries.

RUSSIA

Since the fall of the Soviet Union, the Russian

economy has rebounded and it is currently ranked11th in the world in terms of nominal grossdomestic product (GDP). Russia has also retainedsignicant regional inuence in Eurasia. Thecountry has chosen to align its foreign assistanceprogram with policies established by Westerndonors through the Organisation for EconomicCo-operation and Development’s DevelopmentAssistance Committee (OECD-DAC). Overall,Russia now spends approximately US$400million to US$500 million each year on foreignassistance. Health is a priority, and between2006 and 2010, one-fourth of total assistancewas allocated for health projects. However themajority of this went to the Global Fund to FightAIDS, Tuberculosis and Malaria, which has givengrants to Russia. The country also provides moresupport to multilaterals than any of the otherBRICS, and is investing heavily in its domesticpharmaceutical industry. Highlights of Russia’scurrent and potential contributions to globalhealth include:

• Polio and Vaccine Funding: Russia prioritizespolio eradication in its region and has donated

US$33 million to the Global Polio EradicationInitiative. Russia is also the only BRICScontributor — and one of only six contributorstotal — to the GAVI Alliance’s Advanced MarketCommitment (AMC) for pneumococcal vaccines.It has committed US$80 million to the AMCfrom 2010 to 2019.

• Neglected Tropical Diseases (NTDs): Russiahas contributed US$21 million to NTDcontrol from 2009 to 2012. It is working withneighboring governments and some Africancountries to conduct NTD needs assessments.

• Malaria Control: Russia partners with theWorld Bank and WHO to strengthen malariacontrol and prevention programs in Zambiaand Mozambique.

• Pharmaceutical Investments: In 2011, Russiaannounced a US$4.4 billion investment inbuilding capacity for domestic pharmaceuticaland medical production and innovation. Thegoal of this program — known as Pharma 2020




and the distribution of Chinese-made anti-malarial drugs. In 2009, China committed anadditional US$73.2 million to support a varietyof malaria programs and medical facilitiesacross the African continent.

• Family Planning: China has been a leaderin producing low-cost family planningtechnologies, in support of its strict domesticpolicies. Since 2008, Family Health International(now FHI 360) has partnered with ShanghaiDahua Pharmaceutical Co. to accelerate globalaccess to Sino-implant (II), a low-cost injectablecontraceptive. By February 2012, more than halfa million units had been procured for global use.

• Investment in Health Innovation: ChineseR&D spending has grown by 20% every year forthe past decade and in 2009, China surpassed

Japan to become the world’s second-largestinvestor in R&D after the US. Among otherstrategies, China has invested US$1.3 billion inhealth-related R&D “mega projects” on diseaseprevention and drug development. In 2011, theChinese Ministry of Science and Technologyalso entered into a US$300 million partnershipwith the Bill & Melinda Gates Foundation thatfocuses in part on development of new healthtechnologies for resource-poor countries.

SOUTH AFRICA

South Africa is the most recent addition tothe BRICS. While its economy is signicantlysmaller than those of its counterparts, it is theonly African member of the BRICS Forum andof the G20. Currently, its nominal GDP ranks28th globally. South Africa’s foreign assistanceprogram is modest compared to the other BRICS,both because of its smaller economy and becausethe government is focused on the country’s owninternal health and development challenges.However, these domestic efforts have inuencedthe global response to several major healthissues. The South African government is alsostrategically investing in indigenous health R&Dthat targets domestic priorities. Highlights ofSouth Africa’s current and potential contributionsto global health include:

• HIV/AIDS: South Africa’s recent efforts tocombat HIV/AIDS have helped shape globalhealth research and policy, and its healthactivist community has provided inspiration and

in developing e-health platforms. This includesthe Pan-African Telemedicine and Tele-EducationNetwork, which links Western African hospitalsand universities with their Indian counterparts tofacilitate the sharing of best practices.

• Low-Cost Service Delivery: Indianorganizations have pioneered efforts to expandaccess to quality health services among thepoor. Aravind Eye Hospital, for example, is theworld’s largest ophthalmological organization,treating 2.4 million patients annually. It providesfree or very low-cost services to 65% ofpatients, deriving its revenues from those whoare able to pay. Aravind has provided technicalassistance in China and Egypt.

CHINA China is now the world's second largest economy

and boasts a GDP bigger than all its BRICScounterparts combined. The country has alsorapidly increased its foreign assistance spending,particularly in Africa. The Chinese governmentreports that it has committed a total of US$40.5billion in foreign assistance since 1950, andassistance budgets grew at an annual rate of29.4% between 2004 and 2009. In 2010 alone,China is estimated to have disbursed US$3.9billion. The majority of China’s assistanceis provided through bilateral channels. Thecountry is guided by a philosophy of “mutually-

benecial” development that it believes buildsself-sufciency in recipient countries and doesnot interfere in domestic politics. Health is only asmall focus of China’s overall assistance budget,but its government has consistently funded somespecic health programs. At the same time, thecountry is investing signicant resources andeffort in boosting the domestic pharmaceuticalindustry and expanding overall innovation.Highlights of China’s current and potentialcontributions to global health include:

• Medical Teams: Since 1963, China has senta reported 21,000 medical workers to provideservices in 69 countries. These teams also trainlocal medical staff to build capacity.

• Malaria Control: China has supported malariaprograms in Africa in some form for morethan 30 years, but these efforts have recentlyincreased. In 2006, China committed US$37.6million for 30 malaria and treatment centers



0


models for other countries. One key researchcontribution was the CAPRISA 004 study,designed and led by South African researchersand partially funded by the South Africangovernment. This study demonstrated proof ofconcept that a vaginal gel containing an ARV

could prevent HIV transmission in women.

• R&D Financing: South African investment inR&D has increased steadily, and was US$2.6billion in 2008. The government has set agoal of reaching 2% of GDP by 2018. A keyresource for translational health research isthe government-funded Technology InnovationAgency (TIA). Launched with an initial budgetof US$54 million, TIA currently supportsmultiple health R&D initiatives, including aDrug Discovery and Development Centre andseveral clinical trials.

• Tuberculosis (TB) Diagnostics: On WorldTB Day 2011, South Africa announced plansfor national roll-out of GeneXpert, a next-generation molecular TB diagnostic. This is byfar the strongest commitment that any countryhas made to molecular TB diagnostics. If thetool proves to have an impact, South Africa’sdecision could signicantly inuence adoptionin other high-burden countries.

• Vaccine Supply: South Africa’s largest vaccine

distributor, the Biovac Institute, hopes tobecome a full-edged manufacturer by2013. The institute, which is a public-privatepartnership, supplies all eight vaccines thatcomprise South Africa’s Expanded Programmeon Immunisation and also supplies vaccines toNamibia, Botswana and Swaziland.

BEYOND BRICS In addition to traditional donor governmentsand the BRICS, a number of other countries arealready having a signicant impact on globalhealth and development. Some of these countries

have robust foreign assistance programs, whileothers are driving innovation for affordable healthtechnologies. Highlights of these emergingpowers’ current or potential contributions toglobal health include:

• The Gulf States all contribute to global healthmultilaterals. This includes Saudi Arabia’sUS$53 million pledge and Kuwait’s $4.5 million

pledge to the Global Fund; and the Crown Princeof Abu Dhabi’s US$33 million pledge to the GAVIAlliance. Saudi Arabia, Kuwait and the UAE haveall also supported polio eradication efforts,particularly in Pakistan and Afghanistan.

• Turkey’s 2010 budget included US$68million toward basic health, water andsanitation assistance projects, includingsmall donations to polio eradication. Turkey’sgrowing pharmaceutical industry is also a

signicant potential exporter of generic drugs.

• Indonesia produces 15 WHO prequalied vaccinesthrough its state-owned vaccine company,Bio Farma. It has also been a leader in healthassistance policy among developing countries.

• Mexico provides bilateral development aidwithin Latin America, including some healthprojects, and it recently launched the MexicanInternational Development and CoordinationAgency. At the same time, the Carlos SlimHealth Institute, based in Mexico City, provides

signicant funding for health programsthroughout Central America.

• South Korea provided US$136 million inhealth assistance in 2010, and has contributedmoderately to several health multilaterals,including the Global Fund and the GAVI Alliance.The country has also helped develop vaccinestargeting diarrheal, respiratory and neglectedviral diseases through its International VaccineInstitute (IVI).

key FinDinGs

Our research has produced a number of keyndings that highlight some of the BRICS’current and potential impact on global health:

• The BRICS are all established providers

of foreign assistance; however their

contributions have increased signicantly

over the last ve years.

Our goal in this report is to examine

existing BRICS assistance programs

and health innovations to better

understand their impact and

opportunities going orward.




• Strengthening regional diseasesurveillance networks

• Helping to harmonize global

regulatory processes

conclUsions

All of the BRICS face signicant domestic healthand development challenges, but they areincreasingly engaging in global health. Thesecountries are also scaling up investments ininnovation and exploring cooperative mechanismsthat can benet developing countries. Thepotential benets of collaboration werehighlighted at the 2011 Ministers of Healthmeeting, where the BRICS declared theircommitment to work together on commonhealth challenges.

Importantly, Brazil, Russia, India and SouthAfrica all have or are launching centralassistance agencies. China’s assistanceprogram involves a variety of governmentagencies led by the Ministry of Commerce.However, in 2011 China released a white paperthat provided a formal, public overview of i tsapproach to international development. Asthe scale of China’s assistance efforts grow,a central aid agency could help maximize theimpact of its investments. Across the BRICS,better management systems, more coordination

across agencies, and increased monitoring andevaluation will likely be needed.

Like traditional donors, the BRICS have theirown motives for engaging in internationalassistance, and there are, to be sure, reasonableconcerns about the effectiveness of theirprograms. Yet these countries represent apotentially transformative source of new resourcesand innovation for global health and development.Their approaches will vary from those oftraditional donors, and will be shaped by their

own experiences, philosophies and interests.But over the long-term, the BRICS are sure to playan important role in helping to improve the healthand well-being of the world’s poorest countries.

• The BRICS are employing approaches to foreign

assistance that are different from traditional

donors and shaped by domestic experiences.

• As with Western donors, economic and

political interests are inuencing the BRICS

as they expand their development and healthassistance programs.

• Innovative domestic health programs and

policies in the BRICS are increasinglyinuencing health practices globally.

• The production of high-quality, lower-costhealth technologies by the BRICS is improving

access in resource-poor countries, and thegrowing investment in early-stage R&D by theBRICS could have a similar long-term impact.

• The BRICS have declared health collaboration

a priority, but they have not yet begun towork collectively to enhance the impact of

their assistance programs.

Overall, the BRICS are beginning to play animportant role in regional and global healththrough foreign assistance and other efforts.Notably, the production of low-cost drugs,diagnostics and vaccines by the BRICS willcontinue to provide signicant benets todeveloping countries. So too will the BRICS’increased investments in health innovation.

At the same time, there are a number of areaswhere more coordinated efforts by the BRICS couldhave even greater impact on global health. Thiscould be through assistance, innovation or increasedsupport for relevant partnerships and multilaterals.A few specic examples might include:

• Providing political and technical support to

accelerate access to life-saving vaccines

• Catalyzing access to innovativeTB tools and strategies

• Supporting efforts to eradicate polio

• Increasing leadership on NCDs andtobacco control

Sources and methodology for qualitative and quantitative findings can be found in the full report



2


BRics: FoReiGn AssistAnce AnD GloBAl HeAltH




1 INTRODUCTION

I n March 2012, the heads of government of Brazil, Russia, India, China and South Africa will

gather in New Delhi for the fourth annual BRICS Summit. Since 2001, when Jim O'Neill,

then Head of Global Economic Research at Goldman Sachs, coined the acronym “BRIC” to

refer to what he predicted would be the four fastest growing emerging economies, the term

has become common shorthand. The enormous — and still growing — inuence of the BRICS

can be seen in many areas including global economics, politics, development and culture.

At the same time, the BRICS have chosen to claimthe acronym for themselves to formalize theirafliation and increase their stature. The BRICsrst met exclusively in 2006, and the rst formal

annual summit took place in Russia in June 2009.

In late 2010, South Africa was invited to join thegroup — making the BRICs the BRICS.

Starting from their rst meeting, the governments

of the BRICS have expressed their interest in

1.1 BRics ABsolUte GDP GRowtH oVeR time (USD Billions)

$6,000

$5,000

$4,000

$3,000

$2,000

$1,000

$0

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: World Bank Open Data — Brazil — Russia — India — China — South Africa



4


engagement in global issues and doing so withdifferent goals, tactics and rationales than thoseof Western powers — which means their impactshould be considered on their own terms.

tHe BRics AnD GloBAl HeAltH

Alongside others, the global health communityhas been looking to the BRICS with an evolvingset of interests. Most of the BRICS, aside from

Russia, have traditionally been viewed as targetsfor global health assistance because they are stillconsidered developing countries. Large portionsof their populations live below the poverty line,they face signicant domestic health challenges,

building an alternative platform for cooperationon issues including health, economics, scienceand technology. This would build on each of theirlong-standing international ties, and it wouldseek to appeal to other developing countries thatmight see the BRICS as more equal partners. The

BRICS forum exemplies how these countries andothers like them are emerging as major actorsand asserting themselves on the global stage. Asan example, in February 2012, India proposed thatthe BRICS create a multilateral bank that wouldbe exclusively funded by developing nations andnance projects in those countries. Regardinghealth specically, the BRICS Ministers of Healthmet in July 2011 and declared their commitmentto collaboration on common health challenges,and to “support other countries in their efforts topromote health for all.”

Each of the BRICS faces its own domesticchallenges and collaboration among themhas been slowed by their political and culturaldifferences. Yet they are all increasing their

The BRICS Ministers o Health met

in July 2011 and declared their

commitment to collaboration on

common health challenges, and to

“support other countries in their

eorts to promote health or all.”

1.2 BRics economic AnD HUmAn DeVeloPment inDicAtoRs*

BRICSOther Leading

Economies

Indicator Year Brazil Russia India ChinaSouth

Africa

United

States

Japan

Population, total 2010 194,950,000 141,750,000 1,170,938,000 1,338,299,000 49,991,000 309,052,000 127,450,000

Reserves of ForeignCurrency and Gold and Rank

2011 US$357.9B7

US$513.0B5

US$345.8B8

US$3.2T1

US$50.3B38

US$132.4B20 (2010)

US$1.1T2 (2010)

Life expectancy (years) 2009 72.8 68.6 64.8 73.1 51.6 78.1 82.9

Literacy rate, adult total(% of people ages 15and above)

- 90.0(2008)

99.6(2009)

62.8(2006)

93.0(2009)

88.7(2007)

- -

GDP Per Capita, PPP(current US$)

2010 $11,200 $19,800 $3,600 $7,600 $10,600 $47,200 $33,800

Income inequality measuredby GINI coefcient** - 36.8

(2004)41.5

(2005)42.2

(2009)53.9

(2009)65.0

(2005)45.0

(2007)37.6

(2008)

CO2

emissions (kt) 2008 393,000 1,709,000 1,743,000 7,032,000 436,000 54,561,000 1,208,000

Mobile cellular subscriptions (per 100 people)

2009 90.0 162.5 45.4 56.1 94.2 89.3 90.1

Health expenditure percapita, PPP (constant 2005international $)

2009 $940 $1,040 $130 $310 $860 $7,400 $2,700

Source: World Bank Open Data; CIA World FactbookNote: *World Bank and CIA World Factbook indicators were used over local sources to allow for cross-country analysis;** The higher the GINI coefcient, the larger income inequality




developed countries. There is also excitementabout the role their public and private sectorscould play in producing the next generationof effective, low-cost health technologies

and strategies, with or without support frominternational partners.

This focus on the BRICS belies the fact that allve countries are already contributing to healthbeyond their borders, and have been doing sosince long before the term “BRICS” existed. Forexample, manufacturers in several BRICS —particularly India — have been a source of drugs,vaccines and diagnostics used in the poorestcountries; through policy and activism, Braziland South Africa have been highly inuential in

advancing the global response to HIV/AIDS; Chinahas been a signicant contributor to malaria

and all of them have received donor fundingfocused on helping them improve their healthindicators. Given the size of China and India’spopulations alone, improvements in the health

of the BRICS t the very denition of improvingglobal health.

With donor spending from the US and Europeslowing or declining, however, there is anurgent need for new global health resourcesand champions. A number of global healthprograms and institutions are facing majornancial shortfalls, as exemplied by the recentcancellation of the Global Fund to Fight AIDS,Tuberculosis and Malaria’s Round 11 funding.

With this in mind, international organizations havestarted looking to the BRICS as potential donorsand health innovators in their own right.

Just as the G20 — which includes all ve of theBRICS — is eclipsing the G8 as the premierforum for discussions on world affairs, there isa growing sense that BRICS governments canplay a greater role in improving health in less

BRICS Health Ministers’ Beijing Declaration

In July 2011, the Ministers of Health fromthe BRICS met in Beijing for the rst annualBRICS Health Ministers Meeting. At the

conclusion of the summit, they issued theBeijing Declaration, which emphasized theimportance of collaboration and innovationin public health across the BRICS and withother countries. In the declaration, the BRICScollectively committed to, among other things:

• Strengthen health systems and overcomebarriers to access for health technologiesthat combat infectious and non-communicable diseases, particularly HIV,TB, viral hepatitis and malaria

• Explore and promote technology transfersto strengthen innovation capacity andbenet public health in developing countries

• Work with international organizationsincluding WHO, the GAVI Alliance, UNAIDSand the Global Fund to increase access tomedicines and vaccines

BRICS-Initiated Development Bank

During a meeting of G20 nance ministers

in February 2012, India proposed setting up

a multilateral bank that would be exclusively

funded by developing nations and nanceprojects in those countries. This proposal is

currently under discussion and will likely be

addressed in more depth at the March BRICS

Summit. The idea for the bank builds on a

pledge BRICS leaders made at their 2011

Summit in China, where they promised to

“strengthen nancial cooperation among the

BRICS Development Banks." While details

are unavailable, the bank could follow the

model of other institutions, such as the

Islamic Development Bank, based in SaudiArabia, which fosters economic development

and social progress among its dues-paying

member countries — all of whom belong to

the Organisation of Islamic Cooperation.

International organizations have

started looking to the BRICS

as potential donors and health

innovators in their own right.



6


Yet some critics argue that they lackaccountability, do not coordinate withinternational efforts, and need better monitoringand evaluation. BRICS assistance is alsooften driven by mixed motives, slowed bycapacity challenges, and faced with unrealisticexpectations from many global stakeholders. In

this way, they may not be all that different fromthe very Western models they seek to replace.

control in Africa; and Russia is one of just sixnational donors to the GAVI Alliance’s AdvanceMarket Commitment (AMC).

The BRICS are also supporting health anddevelopment in different and sometimes lesstangible ways than what we expect of traditional

donor countries. The BRICS explicitly reject manymodels used by Western donors, and are insteadtrying to utilize innovative approaches to globalhealth engagement that are rooted in their owndomestic experiences. They are also inuenced bygeography and the history and connections theyshare with other developing countries.

Many of the BRICS’ global health anddevelopment efforts are having positive impact.

The BRICS explicitly reject many

models used by Western donors, and

are instead trying to utilize innovative

approaches to global health

engagement that are rooted in their

own domestic experiences.

1.3 G7 Vs. BRics: estimAteD AnnUAl GRowtH oF

FoReiGn AssistAnce PRoGRAms (2005-2010)

AnD ABsolUte AssistAnce (2010) (%, USD)

Source: OECD; Institute of Applied Economic Research (IPEA) Report, 2011; Inter-PressService, "Brazil, Emerging South-South Donor"; The Economist, “Speak Softly and Carrya Blank Cheque”; Deauville Accountability Report G8 Commitments on Health and FoodSecurity, Ministry of Finance of Russian Federation, 2011; Union Budget and EconomicSurvey, Ministry of External Affairs, Ministry of Finance, Government of India; Government

of India ofcial; “The Dragon’s Gift: The Real Story of China in Africa,” D. Brautigam;World Bank Open Data; GHSi AnalysisNote: *Russia pledged to steady foreign assistance disbursements between US$400Mand US$500M

40%

30%

20%

10%

5%

4%

3%

2%

1%

$40B

$30B

$20B

$10B

$5B

$4B

$3B

$2B

$1B

- $10B

- $20B

-10%

-20%

0%

.30%

.20%

.10%

$300M

$200M

$100M

-.10%

-.20%

-.30%

BrazilUnitedStates

Japan Germany France UnitedKingdom

Canada Italy Russia* India China SouthAfrica

-3%

-4%

US$1.2B

$31.2B

$18.9B$14.4B $14.4B $13.4B

$5.2B

$3.2B

U S$400M U S$472M US$680M

US$3.9B

US$143M

Annual Growth(2005-2010)

Absolute ForeignAssistance (2010)

High Estimate,Absolute ForeignAssistance (2010)




focus on presenting the priorities, policies andperspectives of the BRICS countries themselves.In examining the impact of the BRICS on healthoutside their borders, the report attempts to lookbeyond the denitions of development assistancethat have been commonly used by traditionaldonors. However, we do not measure the speciceffectiveness of individual approaches.

metHoDoloGy AnD

DeFinitions

Our methodology included a literature review, in-country interviews, and data analysis. The reportincludes both qualitative and quantitative ndingscollected through research in each individualcountry. Sources include international anddomestic primary and secondary sources, and keyin-country health and development experts. Whilethis approach has allowed us to take a broad and

tHe RePoRt

In our work in global health, the GHSi team andpartners have identied specic examples of waysthat the BRICS and other emerging powers haveindependently impacted key health challenges

in a variety of ways. And we have seen clearopportunities where BRICS country institutionscould apply their unique experiences andexpertise and have even greater positive effect.

Our goal in this report is to examine existingBRICS assistance programs and healthinnovations, to better understand their impactand opportunities going forward. We use theBRICS platform as an opportunity to look at theindividual and collective activities of these veprominent countries specically, while keeping

in mind the contributions of other emergingcountries, such as those in the G20, that are notgenerally recognized as donors.

The scope of this report is broad, and includesthe public sector and government spendingfor health assistance, as well as the privatesector, domestic innovation, and innovativepolicy and advocacy. Across all of this, we

The Global Fund and Round 11 Funding

Since the Global Fund to Fight AIDS,Tuberculosis and Malaria (Global Fund) wasfounded in 2002, it has disbursed nearly

US$16 billion in funding over ten rounds ofgrant-making and helped to provide diseaseprevention and treatment programs tomillions of people in developing countries.Nearly 3.3 million people in Africa alone nowhave access to ARV therapy for HIV/AIDSbecause of Global Fund grants.

In recent years, however, the Global Fundhas faced a serious funding shortfall as manytraditional donors have scaled back supportin the face of the global nancial crisis andallegations of mismanagement. During its2010 fundraising, the Global Fund obtainedUS$11.7 billion in new commitments, US$1.3billion short of its minimum projected budget.In 2011, the Global Fund Board announced thecancellation of the Round 11 funding cycle —effectively cutting off new grants until 2014. Inaddition, the Board announced that fundingfor upper-middle-income countries includingBrazil, Russia, China and Mexico would be

limited going forward.

OECD

The Organisation for Economic Co-operationand Development (OECD) is an internationalorganization comprised of 34 countries

that acts as a forum for global economicanalysis and policy formation. The OECD'sDevelopment Assistance Committee (DAC)provides a venue for the largest aid donors,including governments and multilateralorganizations, to discuss approaches todevelopment assistance. The DAC also sets anofcial denition for development assistanceand tracks aid ows from Member States.None of the BRICS are OECD members,although Russia is currently in discussionsfor membership and Brazil, China, India and

South Africa have all been offered “enhancedengagement” status. This allows forheightened involvement in OECD activitiesand could lead to future membership.




8


numbers are our own estimates. They are basedon these resources and existing trends.

RePoRt stRUctURe

The body of the report is divided into six chapters.Each of the rst ve chapters is focused on oneof the BRICS. This is followed by one chapter thatprovides a snapshot of other emerging powersthat are not generally seen as donors but whosepublic or private sectors are engaged in notablehealth activities: the Gulf States, Indonesia,Mexico, South Korea and Turkey. Each sectionexplores key implications of the countries’involvement in the eld of global health. This is

followed by our conclusions.

Given the enormity of this topic and limitations indata, our ndings are not intended to be denitive.However, while each of the BRICS faces its ownchallenges and exhibits its own motives andcontradictions, they are all having signicantimpact on the global health landscape. As theBRICS’ role in global health continues to expand,so will their inuence.

exible look at the BRICS and global health, wehave been limited by challenges accessing datathat is not publicly available.

At the same time, because each of the BRICSperceives health assistance and foreign assistancedifferently — as aid, assistance, or cooperation— each section denes assistance based on thatcountry’s own approach. These denitions typicallyinclude capacity building, technical assistance,preferential loans and other mechanisms.

NOTE ON ASSISTANCE-RELATED DATA: Thenumbers we use to quantify foreign assistancespending by the BRICS and other countries

are based on publicly-available resources andgrounded in the denitions of "assistance"used by individual countries — whethertraditional aid provider or member of theBRICS. For G7 country historic aid gureswe relied on OECD data. For BRICS foreignassistance gures we relied on in-countrysources and, when necessary, selectinternational publications as well as our best judgement. As noted in individual gures, a few

1.4 BRics AnD key HeAltH mUltilAteRAls: totAl PleDGes

AnD AssistAnce ReceiVeD (USD Millions)

Source: Global Fund, GAVI All iance, UNITAIDNote: Health Multilateral Launches: GAVI Alliance - 2000, Global Fund - 2002, UNITAID - 2006;*Brazil, Russia and South Africa were never eligible for GAVI Alliance support (based on GNIper capita requirements) and China graduated from eligibility in 2006;**UNITAID does not have distribution programs. Rather it supports partner programs,including Global Fund, WHO, Clinton Foundation;†South Africa has committed to supporting UNITAID in the future; Data accurate as of17 March 2012

$400

$200

-$200

-$400

-$600

-$800

-$1,000

$50

$40

$30

$20

$10

$0

Brazil*

Russia*

India China*

South Africa*†

Global Fund

GAVI Alliance

UNITAID**

A s s i s t a n c e

P l e d g e d

( U S D M

i l l i o n s

)

A s s i s t a n c e R e c e i v e d

( U S D

M i l l i o n s

)



ghsinit iat ives.orgghsinit iat ives.org

Adecade after coining the term “BRIC,” Goldman Sachs economist Jim O’Neill remarked

that Brazil’s growth had surprisingly overshadowed its counterparts and exceeded all

economic projections. His observation highlights the signicant economic and sociopolitical

changes that have transformed Brazil from a regional to global power with dramatic

speed.1 After decades of political and economic instability, Brazil entered the 21st century

as a vibrant democracy and the economic engine of Latin America. At the same time,

Brazil’s political leaders are looking outward and actively pursuing an inuential role in

regional and international affairs as a “champion” of the Global South. Brazil’s approach to

international cooperation is heavily inuenced by its progressive domestic social policies,

including a strong emphasis on equity and access to health care and development.

economic lAnDscAPe

Brazil is currently the world’s sixth largesteconomy and the second largest among theBRICS. Economists project Brazil will surpassFrance to become the world’s fth largesteconomy by 2016.2, 3 Much of the country’seconomic success can be traced to the scaland social policies of the last two presidents:Fernando Henrique Cardoso and Luiz Inácio Lulada Silva (Lula). Lula in particular is considered tobe one of the most successful national leadersin recent decades. Brazil’s GDP per capita (PPP)more than doubled since 1990 to US$11,220in 2010. Sound economic policy and a robustdomestic market also enabled Brazil to be one ofthe rst emerging market economies to recoverfrom the recent global nancial crisis. WhileBrazil’s economy contracted 0.6% in 2009, Brazilposted 2.7% growth in 2011.4

Brazil’s economy is largely fueled by manufacturingand natural resources — primarily oil, timberand minerals. Industry comprises 28% of thecountry’s gross domestic product (GDP) andagriculture accounts for 6%.5 The country is alsoan appealing destination for foreign investmentdue to its growing middle class, abundant naturalresources and high interest rates.6, 7 A substantialamount of this is from China, which invested atleast US$12 billion in Brazil in 2010 — largely in

extractive industries — and continues to rampup investment in this and other sectors.8 Brazilhas also dedicated signicant resources towarddeveloping its domestic science and technologysector, with the goal of becoming a leading sourcefor innovation.

Despite all of this progress, Brazil still facesserious domestic challenges. Infrastructure gapsand social inequality could undercut continued



20


progress, and the World Bank currently ranksBrazil as the 13th most unequal country globallyby the Gini index. The Brazilian government hasbeen investing in a range of social programs,including increases in the minimum wage andconditional cash transfer programs. These

have helped lift 28 million Brazilians out ofsevere poverty over the past ten years. However,increased innovation is needed to ensuresustained growth and wider access to the benetsof this growth.9

Domestic Politics

AnD FoReiGn AFFAiRs

After 20 years of military dictatorship, Braziltransitioned to a fragile democracy in 1984. Whileinitial governments struggled to achieve political

and social stability, Brazil today is a muchstronger and vibrant democracy under PresidentDilma Rousseff. As Lula’s chosen successor, sheis broadly popular and has continued many of thepolicies of the previous administration.10

Globally, Brazil’s economic wealth and geopoliticalinuence have given it an increasingly importantvoice in international affairs. Brazil is a memberof the G20, the World Trade Organization (WTO),the Union of South American Nations (UNASUR)and the Mercosur community. The country will

also host the 2012 United Nations Conference onSustainable Development (Rio+20), the 2014 FIFAWorld Cup and the 2016 Olympic Games. Brazilplayed visible roles within the WTO and the WorldHealth Organization (WHO) around intellectualproperty (IP) regulations and patent laws. At thesame time, in May 2007, the Organisation forEconomic Cooperation and Development (OECD)offered Brazil — along with China, India andSouth Africa — the opportunity for “enhanced

engagement.” This is widely understood ascreating a path for Brazil to ofcially join theOECD in the near future.11

In terms of South-South cooperation, Brazil

prioritizes foreign relations and economicpartnerships with Latin American countries andother Lusophone countries, including those inAfrica. However, the government has also soughtto position itself as a leading voice for the broaderGlobal South. In addition to the BRICS forum,Brazil also engages in direct dialogue with Indiaand South Africa through the India-Brazil-SouthAfrica (IBSA) trilateral framework.

Domestic HeAltH lAnDscAPe

Brazil’s domestic health indicators have improvedin recent decades, due in part to its sustainedfocus on health care access. Brazil’s approach tohealth care places heavy emphasis on reducingsocioeconomic disparities and this is reectedin its universal health care system, the UniedHealth System (SUS). The Brazilian constitutionrecognizes health as a citizen’s right and state’sduty; the SUS is structured around this principle

Brazil prioritizes oreign relations

and economic partnerships with

Latin American countries and other

Lusophone countries, including

those in Arica. However, the

government has also sought to

position itsel as a leading voice or

the broader Global South.

IBSA

Established in 2003, the India-Brazil-SouthAfrica Dialogue Forum (IBSA) is a coordinatingmechanism for South-South cooperation

across the three member states — which areunited by the fact that they are all emerging“multiethnic and multicultural democracies.”IBSA organizes annual heads of state summits,and each country donates US$1 millionannually to the “IBSA Fund” to supportprojects aimed at ghting hunger, poverty anddisease. The goal is to build ties together andfacilitate partnerships with less-developedcountries. IBSA also has 16 working groupsfocused on areas of mutual interest andpotential cooperation. Health is one of IBSA’smajor focus areas, and its efforts aim toaddress shared disease priorities including TB,HIV /AIDS and malaria, particularly throughinnovation and R&D.




burden of non-communicable diseases (NCDs).NCDs now account for 74% of the causes ofmortality (Figure 2.1). Approximately 40% of theadult population has high blood pressure andmore than 7 million Brazilians are diabetic.18,19 This shifting disease burden is likely to strain

Brazil’s health infrastructure in the years tocome — and is already impacting programmaticpriorities of the SUS.

Braz’ iraa

cpra

Brazil’s approach to “international cooperation”— which is how the government prefers to dene

its foreign assistance — is rooted in the country’sbelief in horizontal cooperation and is shaped inlarge part by policymakers’ commitment to socialequity. Through its international cooperationefforts, Brazil has sought to pass along

and guarantees universal access to primary,secondary and tertiary care. Nearly 80% ofBrazil’s population receives health care in thepublic sector through the SUS, although coveragerates and service quality vary widely acrossdifferent regions.12,13,14 In 2010, the government’s

expenditure on health care — US$734 per capita— represented 9% of Brazil’s GDP.15

Brazil is recognized by health activists worldwidefor its commitment to providing universalantiretroviral (ARV) drug access to Brazilians livingwith HIV and for its emphasis on HIV prevention.The country has maintained a national adult HIV/AIDS prevalence rate close to 0.61% since 2000.16 Brazil also prioritizes domestic production ofessential medicines and health technologiesas a means to increase and sustain access.

Many vaccines are produced domestically andimmunization rates are very high, with measlescoverage alone near 99%.17

Like other emerging economies undergoingsimilar demographic shifts, Brazil faces a growing

2.1 BRAzil leADinG cAUses oF DeAtH, 2008

COMMUNICABLE DISEASES AND

MATERNAL AND CHILD HEALTH CONDITIONS

Respiratory Infections

Other

Perinatal Conditions

HIV/AIDS

TB

NON-COMMUNICABLE DISEASES

Cardiovascular Diseases

Cancers

All Other Non-Communicable Diseases

Respiratory Diseases

Diabetes

INJURIES

Injuries

Source: WHO Global Burden of Disease, 2008

TOTAL: 1.2 million deathS



22


ability to facilitate funding and relationshipswith partner countries is somewhat limited.24 This means that, increasingly, a broader groupof government agencies and institutions directlynance and implement Brazil’s internationalcooperation programs.25 While this allows

for some exibility around the formation andstructure of partnerships, programs still tend tocoincide with the country’s foreign policy.

In approach, Brazil’s international cooperationagenda aligns with the country’s longstandingstated commitment to South-South cooperation,mutual benet and shared experiences amongdeveloping countries. Brazil’s policy is to provide“demand-driven” assistance, tailored to the needsand contexts of recipients, often as a response toa request for assistance. The country also draws

upon best practices from domestic initiativesand seeks to export models and experiencesthat have proven successful at home.26 Brazil’sgovernment openly rejects the top-down, donor-driven assistance models that it associates withtraditional donors, as well as the denitions

achievements and lessons learned in tackling itsdomestic priorities, such as HIV/AIDS control andpoverty elimination. At the same time, Brazil’scooperation strategies echo its foreign policypriorities, which include the country’s aspirationsto become a Global South leader and to obtaina United Nations (UN) Security Council seat.20,21 In expanding its network of partner countriesthrough cooperation, Brazil has been able toproactively expand its global inuence.22

tRenDs in inteRnAtionAl

cooPeRAtion

Brazil’s initial cooperation efforts date backto the 1950s. During that decade, the countrystarted to establish links with Africa and LatinAmerica through a limited number of initiativesand technical assistance programs, bolstering

its inuence in those regions. In 1960, Brazilestablished a national system for internationalcooperation to better integrate the assistanceit both received and provided into its nationaldevelopment agenda. In 1987, the governmentestablished the Brazilian Agency for Cooperation(ABC), housed within the Ministry of ForeignAffairs, in order to formalize alignment ofthe country’s foreign policy priorities andtechnical cooperation activities.22 As the ofcialcoordinating body for Brazilian internationalcooperation, ABC’s mandate is to articulate theactivities undertaken by different governmentsectors in the context of Brazil’s foreign affairs.23

Despite this, Brazil’s institutional framework forinternational cooperation is relatively ad hoc andrequires improved coordination. Because it isguided by the Ministry’s broader foreign policyagenda and relatively restricted budget, ABC’s

Brazil’s approach to “international

cooperation” — which is how the

government preers to dene its

oreign assistance — is rooted in

the country’s belie in horizontal

cooperation and is shaped in large part by policymakers’ commitment

to social equity.

Source: Brazilian Technical Cooperation for Development,Overseas Development Institute, 2010Note: *Breakdown as outlined by ABC

2.2 BRAzil inteRnAtionAl

cooPeRAtion* By sectoR,

2005-2009 (%)

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0

Health

Social Development

Energy

Public Administration

Public Security

Environment

Education

Other

Agriculture




cURRent inteRnAtionAl

cooPeRAtion PRoGRAm

Today, Brazil is both a recipient of foreignassistance and a donor. However, the foreignassistance it receives has steadily decreased overthe last decade. In 2009, the country receivedUS$338 million in assistance.32 In 2010 Brazil gavean estimated total of between US$400 million andUS$1.2 billion. (Figure 2.3). Anecdotal evidencesuggests that the actual gure is closer to thehigh estimate. However, the range of estimatesis quite large because Brazil does not report to

the OECD Development Assistance Committee(DAC) and available government data does notcomprehensively track aid ows across agencies.33

Brazil’s international cooperation programcurrently prioritizes Lusophone countries —Angola, Cape Verde, East Timor, Guinea-Bissau,Mozambique and São Tomé and Príncipe — andcountries in Latin America and the Caribbean

used by the OECD. That said, Brazil’s approach to

international cooperation values good governanceand respect for human rights.27,28

Brazil’s top international cooperation prioritiesinclude agriculture, education and health,29 andthe country emphasizes technical support —specically capacity building, knowledge transferand infrastructure development (Figure 2.2).Brazil also favors trilateral cooperation, settingit apart from the other BRICS, which generallyprefer to supply assistance through bilateralor multilateral channels. Under this approach,

Brazil partners with a developed country ormultilateral agency on a program in a developingcountry, leveraging the partner’s expertise andnancial capital to enhance program outcomes.30 This triangulation also creates cost-sharingmechanisms that allow cooperation programsto bypass federal laws that restrict how publicresources can be spent. For instance, thetransfer of nancial aid abroad is prohibited.31

2.3 estimAteD BRAzil FUnDinG FoR inteRnAtionAl

DeVeloPment cooPeRAtion (USD Millions)

$1,200

$1,000

$500

$400

$300

$200

$100

$02005 2006 2007 2008 2009 2010

Source: Institute of Applied Economic Research (IPEA) Report, 2011; Inter-Press Service, "Brazil, Emerging South-South Donor"; The Economist, "Speak Softly and Carry a BlankCheque"; World Bank Dataset; GHSi AnalysisNote: The IPEA report provides analysis of the cooperation activities of 65 federalgovernment ministries and related entities involved in Brazil’s development cooperation;USD:BRL currency conversions based on IMF annual average exchange rates

High Estimate

Low Estimate



24


Braz’ Hah

cpra

Funding for global health efforts comprises one-

sixth of Brazil’s total international cooperationoutlays.37 As in the country’s broader assistanceprogram, most of its health activities take the formof technical assistance and focus on Lusophonecountries, South America and the Caribbean.These programs are funded and managed througha combination of bilateral and multilateralchannels, although Brazil also increasinglyengages in trilateral health cooperation. WhileBrazil is expanding its support for health in poorercountries, its greatest contributions to globalhealth are arguably its leadership on policy and

access issues affecting the Global South.

region (Figure 2.4). In 2009, 50% of ABC’sbudget went to programs in Africa and 23%went to development efforts in South America.Mozambique, East Timor, Guinea-Bissau andHaiti are the largest recipients.34 Haiti remainsa top priority. Brazil leads the UN Stabilization

Mission in Haiti and it increased its nancialcontributions to the country — totaling US$350million to date — in the aftermath of the January2010 earthquake.35

Brazil is one of the few assistance providersunscathed by the recent global nancial crisis,and its prole and commitments to foreignassistance are likely to continue increasing.ABC’s spending has tripled since 2008.36

2.4 BRAzil tecHnicAl cooPeRAtion

By ReGion, 2005–2009 (%)

Source: Institute of Applied Economic Research (IPEA) Report, 2011Note: Technical cooperation represents one piece of total Brazilian cooperation outlined in the IPEA report;USD:BRL currency conversions based on IMF annual average exchange rates

Latin America and Caribbean

AfricaUnspecied

International Organizations

Oceania

Europe

North America

Asia

North Africa and Middle East




HeAltH cooPeRAtion

PRioRities

Brazil’s health cooperation priorities aredetermined by its overall foreign policypriorities, health-specic expertise and theneeds of partnering countries.44,45,46,47 Programspredominantly focus on HIV/AIDS, nutrition,access to medicines and capacity building —all areas of perceived strength — with funding

channeled through a combination of bilateral,multilateral and trilateral mechanisms.

HIV/AIDS AND ACCESS TO MEDICINES

Health cooperation around the prevention andtreatment of HIV/AIDS — and access to medicinesmore broadly — builds on Brazil’s successes intackling its own HIV epidemic. In 1996, underpressure from domestic AIDS activists, theBrazilian government guaranteed universalaccess to state-of-the-art ARV treatment for allcitizens with HIV.48 To achieve this goal, Brazil

promoted the local production of generic ARVdrugs and importation of brand-name ARVs andincreased pressure on pharmaceuticals andWestern countries to lower the cost of existingHIV/AIDS medicines. Combined with aggressiveHIV prevention programming, this cut Brazil’sAIDS mortality in half between 1996 and 2002.49

At the time of Brazil’s commitment, many globalpolicymakers doubted the feasibility of providinguniversal access to ARV treatment in a developingcountry with limited resources.50 Yet Brazil’s

success upended this conventional wisdom, andthe program has become a source of great pride.As a result, other developing countries havesought Brazil’s cooperation and counsel on theirown HIV/AIDS and ARV policies.

International Cooperation Program: In 2002,Brazil formed bilateral partnerships with Bolivia,Paraguay and other developing countries to

tRenDs in HeAltH

cooPeRAtion

Health is currently one of Brazil’s top-threefocus areas for international cooperation.38 Approximately 35% of ABC’s cooperation activities

are health-related, and this represents only aportion of Brazil’s overall commitments, which arespread across multiple government agencies.39

Health has been a pillar of Brazil’s internationalcooperation program since the program'sinception in the 1960s.40 Much of this focusstems from the country’s domestic commitmentto improving health equity and access. Brazil’s1988 Federal Constitution established the rightof all citizens to health and government-providedhealth services. This right was formalized with the

creation of the SUS, Brazil’s universal health caresystem. The SUS is built upon a core philosophyof availability and access, and while quality ofcare continues to vary widely across regions andtypes of services, other developing countries seeBrazil’s domestic health achievements as a modelfor success in resource-limited settings.41 SUSemployees are used to working in challengingenvironments and are thus valuable sources ofknowledge in technical cooperation initiatives withdeveloping countries.

Brazil’s focus on health extends to its overallforeign policy agenda. The country’s healthcooperation strategy is supported by both theMinistry of Health and the Ministry of ForeignAffairs. This arrangement has enabled health tobe integrated into Brazil’s broader foreign policyobjectives and programs with an emphasis onhorizontal partnerships, local capacity buildingthrough human capital and infrastructuredevelopment, and regional coordination.42 In2006, Brazilian policymakers took this model tothe UN, where they spearheaded efforts to make

health an ofcial cornerstone of foreign policyfor all countries. This resulted in the 2007 OsloMinisterial Declaration, signed by the Ministersof Foreign Affairs of Brazil, France, Indonesia,Norway, Senegal, South Africa and Thailand.The declaration calls on governments to fullyintegrate global health into their foreign policiesand to recognize the fundamental role of healthin international relations.43

At the time o Brazil’s commitment to

universal access to ARVs, many global

policymakers doubted its easibility

in a developing country with limited

resources. Yet Brazil’s success upended

this conventional wisdom.



26


Bolsa Família: Bolsa Família is a centralcomponent of Brazil’s broader Fome Zero/ZeroHunger federal assistance program. It encouragesfamilies to meet specic health and developmentbenchmarks, such as immunizing infants andenrolling children in school, in exchange for cash

payments and nutrition subsidies. Since 2005,Brazil’s Ministry of Social Development and HungerAlleviation (MDS) has implemented 23 BolsaFamília-inspired technical cooperation projectsin more than 50 countries, with support from theWorld Bank, the UK Department for InternationalDevelopment (DFID) and others. In 2008, followingsuccessful pilot programs in Ghana, MDS, DFIDand the United Nations Development Programme(UNDP) International Poverty Centre launchedthe Africa-Brazil Cooperation Program on SocialDevelopment, with a goal of systematizing Brazil-Africa cooperation around nutrition and socialdevelopment more broadly.55

Brazilian Network of Human Milk Banks: Brazil’sNetwork of Human Milk Banks is the largest of itskind in the world, with nearly 200 banks collecting140,000 liters of breast milk per year. The milkbanks promote breastfeeding to improve infantnutrition and seek to prevent mother-to-childtransmission of HIV.56 Brazil began expandingits milk bank network in 2003. In 2005, followingthe successful replication of Brazil’s model inVenezuela, Uruguay, Argentina, Ecuador andCuba, Brazil helped establish the Latin AmericanNetwork of Human Milk Banks.57 Fiocruz — afederally funded health research institute — isalso overseeing efforts to establish milk banksacross the Community of Portuguese LanguageCountries (CPLP) and in other African countries.58 As of 2011, the Brazilian government had signedagreements with Mozambique, Cape Verdeand Angola to implement milk banks, providetechnical training, and purchase equipment within

two years.59

CApACITY BUILDINg AND

INFRASTRUCTURE DEVELOpMENT

Brazil uses technical health cooperation to buildcapacity in partner countries, with a stated goalof fostering local ownership, reciprocity andsustainable development.60

donate treatments and transfer technologiesand best practices for national HIV/AIDS and“access to ARV” programs. The second phaseof the program — supported by UNAIDS andUNICEF — began in 2005 and focused on Bolivia,Paraguay, Nicaragua, Guinea-Bissau, Cape Verde,

East Timor and São Tomé and Príncipe. Thesepartnerships aim to demonstrate the feasibilityand cost-effectiveness of Brazil’s ARV policies inlow-income countries.51

International Centre for Technical Cooperation

on HIV/AIDS (ICTC): In 2005, Brazil and UNAIDSfounded ICTC within the Ministry of Health’s STD/AIDS Department in Brasília. Informed by Brazil’sdomestic progress against HIV/AIDS, ICTC hasserved as a South-South technical resource onHIV/AIDS-related issues. As of 2011, ICTC had

collaborations with 19 countries in South America,Africa and the Caribbean.52 In addition to Brazil,ICTC has received support from European donoragencies and multilaterals.53

Mozambique ARV Factory: Brazil is currentlysupporting the development of a US$21 million ARVfactory in Mozambique. Once complete, the facilitywill have the capacity to produce 226 million ARVtablets and 145 million units of other medicinesannually for domestic supply and provision toother African countries. The goal is to reduce

Mozambique’s donor dependence and to increasehealth partnership opportunities within Africa. TheOswaldo Cruz Foundation (Fiocruz) is leading theinitiative. Several other Brazilian institutions areinvolved, providing equipment and training staff.Despite the fact that the project timeline has beenextended by several years, initial production isexpected late in 2012 and full technology transferis slated for completion by 2014.54

NUTRITION

In recent years, Brazil has had great success in

reducing domestic poverty rates and child hungerthrough programs like Bolsa Família and itsNetwork of Human Milk Banks. Many developingcountries view Brazil as a global leader innutrition policy and programming, and Brazilcollaborates with several of them to implementlocal versions of successful initiatives.




Related Intellectual Property Rights (TRIPS) tofacilitate lower-cost production and distributionof essential medicines in developing countries.At the 2004 International AIDS Conference inBangkok, Brazil worked with other countries toestablish the International Technical CooperationNetwork, which conducts joint activities toleverage TRIPS exibilities and the 2001 DohaDeclaration. The Network ofcial launched at the2005 World Health Assembly.64,65

Framework Convention on Tobacco Control

(FCTC): Brazil’s strong domestic tobaccocontrol program has allowed it to assume aglobal leadership role in this area, and thecountry played a prominent role in negotiationsaround the FCTC. WHO recruited the country tospearhead the Tobacco Free Initiative and chairthe Intergovernmental Negotiating Body for theagreement. Brazil’s support for the FCTC wascritical to its 2005 enactment, because it helpedcounter industry arguments that tobacco controlwas largely a “rst world issue.”66 In December2011, President Dilma Rousseff signed newtobacco control legislation, increasing taxes ontobacco products and making Brazil the world’slargest smoke-free country. Brazil’s Ministryof Agriculture is providing technical assistanceand agricultural extension services to help

Emergency Care Units: Following the January2010 earthquake in Haiti, Brazil has beenworking to help rehabilitate the country’s healthsystem through equipment donations, diseasesurveillance support and professional training forHaitian medical personnel.61

Integrated Health Care Networks: With supportfrom the German International Cooperation

Agency (GIZ), the Brazilian Ministry of Healthand ABC are in discussions to help buildintegrated health care networks similar to theSUS in Paraguay and Uruguay. This effort willbe implemented in stages, beginning with pilotprojects in each country.62

HEALTH pOLICY LEADERSHIp

Brazil has been a vocal advocate for specicglobal health policies, with signicant impact onthe health of developing countries and the actionsof key international organizations.63 This health

diplomacy has been most notable around IP rightsand tobacco control.

Intellectual Property Rights: Since the late1990s, Brazil’s Ministries of Health and ForeignAffairs have defended the country’s aggressivestance on access to medicines — and ARVs inparticular — at the WTO and the UN. Brazil hasremained an advocate for exibilities in Trade-

WTO TRIPS Agreement

The Agreement on Trade Related Aspects of Intellectual Property Rights, or TRIPS, is a 1995World Trade Organization (WTO) agreement on intellectual property rights that strengthenedpatent protections in many Member Countries. Among other things, the agreement

provided patented pharmaceutical drugs, including HIV/AIDS drugs, with greater protectionagainst generic production. To address the negative effects of TRIPS on access to medicines indeveloping countries, the WTO issued the Doha Declaration of 2001, emphasizing that TRIPSshould be interpreted in light of the importance of access to medicine for all. TRIPS also includesseveral “exibilities,” including compulsory licensing, parallel importation, limits on dataprotection, public health emergencies and other exceptions.

Brazil has been one of the most prominent supporters of the compulsory license exibility, andthe country has successfully invoked the possibility of using it in negotiations to lower the pricefor patented ARVs. To date, Brazil has issued only one license for an ARV drug. India recentlyissued its rst license for a cancer drug, and Thailand has issued several licenses for ARVsand cancer and heart disease medicines. The pharmaceutical industry has strongly opposed

compulsory licensing in middle-income nations, pointing to the high costs of R&D and theirdiscounted prices in developing markets.



28


the Americas. Between 2006 and 2009, Brazilgave a combined total of US$106.5 million tothese agencies.69 In 2006, Brazil pledged US$20million over 20 years to the International FinanceFacility for Immunisation (IFFIm), one of the GAVIAlliance's funding mechanisms, indicating global

immunizations is a priority issue.

Brazil’s most prominent multilateral effort isUNITAID, launched in 2006 by the governments ofBrazil, France, Chile, Norway and the UK. UNITAIDleverages an innovative funding mechanismbased on airline fees and other donor supportto facilitate sustained, global access to essentialmedicines. Brazil has contributed US$10 millionto UNITAID annually since 2007. UNITAID usesits resources to build and shape markets forhealth commodities, helping to reduce the cost of

medicines for priority diseases — namely TB, HIV/AIDS and malaria — and increase the supply ofdrugs and diagnostics for low- and middle-income countries.70

farmers who are currently dependent on tobaccosales diversify away from tobacco crops. Thiscomprehensive approach to tobacco control is seenas a model for other countries.67

Union of South American Nations (UNASUR)

Pharmaceutical Policies: Brazil and otherSouth American countries are using UNASURas a platform to collectively negotiate withpharmaceutical companies on fair drug, technology,vaccine and medical equipment pricing.68

cooPeRAtion witH

HeAltH mUltilAteRAls

Brazil provides nancial and technical supportto a number of multilateral health organizations.These include the Global Fund, the GAVI Alliance

and various UN agencies (Figure 2.5). Of these,Brazil’s most signicant nancial contributionsare to WHO and the Pan-American HealthOrganization (PAHO), WHO’s regional branch in

2.5 BRAzil contRiBUtions to key

HeAltH mUltilAteRAls, 2006-2009 (USD Millions)

Source: Institute of Applied Economic Research (IPEA) Report, 2011; UNICEF; UNITAID; UNAIDS; the GAVI AllianceNote: Brazil pledged US$20 million over 20 years to the GAVI Alliance in 2006 and was approved in 2011 to begincontributions; USD:BRL currency conversions based on IMF annual average exchange rates

$90

$80

$70

$60

$50

$40

$30

$20

$10

$0.8

$0.6$0.4

$0.2

$0

UNAIDS

UNFPA

WHO

WHO/PAHO

UNICEF

UNITAID




of these products are still in the early stages ofdevelopment and primarily target the domesticmarket, they could have implications for theglobal health market in the near future.

Brazil’s total public investment in science and

technology has been steadily increasing, growingfrom approximately US$3.6 billion in 2000 toUS$12.8 billion in 2010 — an annual growth rateof 13.5%.74 Innovation is a priority for PresidentDilma Rousseff, who launched an economicstimulus package in 2011 to expand governmentsupport and incentives for R&D.75,76 The BrazilianDevelopment Bank’s (BNDES) Profarmainnovation program is a key model, providingpreferential nancing conditions to public andprivate companies that invest in R&D capacityfor the health sector.77

These broad investments in the country’sR&D capacity have enabled increased supportfor specic programs that align with global healthpriorities. As an example, Brazil was the 4thlargest funder of neglected disease researchin 2008, with an investment that year ofUS$36.8 million.78

pUBLIC SECTOR INVESTMENT

IN HEALTH RESEARCH

At the federal level, Brazil’s public research

nancing is channeled through a number ofagencies that support both the public and privatesectors. In addition to BNDES, which funds theprivate sector and major infrastructure projects,some select agencies include:

The National Council of Scientic and

Technological Development, and the Brazilian

Innovation Agency for Research and Projects

Funding (FINEP), both of which are linked to theMinistry of Science, Technology and Innovation.79

The National Council of Scientic andTechnological Development supportsresearch programs through theme-specicrequests for proposals.80

The Coordination for the Improvement of

Higher Education Personnel, an agency withinthe Ministry of Education, funds academic

In 2011, the Brazilian government declined asecond phase grant from the Global FundMalaria Project on the grounds that it couldindependently nance the project activities.The government recommended that the GlobalFund use funds earmarked for Brazil to help

other developing countries with greater healthand development needs.

Braza iva

ad ipa fr

Gba Hah

In recent years, the Brazilian government has

taken signicant steps to build the country’sbiotechnology sector and develop its faculty forhealth innovation. Currently the public sector,including academic and government-sponsoredinstitutions, is responsible for the majority ofBrazil’s health research.71 While the privatesector has traditionally been weak in this area,policymakers have come to recognize keyshortcomings in Brazil’s capacity to translatedomestic research into new health products.As a result, they are increasingly looking to theprivate sector as a key partner in strengthening

the country’s product development pipeline.72 The majority of Brazil’s present R&D is aimedat domestic health priorities.73 However, manyof these issues are also critical global healthchallenges. As Brazil’s competencies in healthresearch and innovation grow, its products andexpertise may play a greater global role.

key tRenDs in

HeAltH innoVAtion

Much like the other BRICS, Brazil has scaled up

investments in and capacity for public, privateand academic R&D in an effort to transitionfrom manufacturer to innovator. Historically,much of Brazil’s health manufacturing focusedon production of key supplies for the healthsystem. Today, Brazil’s R&D pipeline is morerobust and includes vaccines, diagnostics andreagents, drugs and therapeutics. While many



30


in Brazil totaled approximately US$750 millionbetween 2002 and 2010, with 68% coming fromagencies outside of the Ministry of Health.88

THE ROLE OF THE pRIVATE SECTOR

Brazil’s private sector has traditionally relied on

partnerships with public institutions to accesstechnical know-how and research expertise.89 However, Brazil’s government is implementinga range of measures to further strengthenthe country’s innovation infrastructure. Theseefforts are directed at both the public andprivate sectors, and include laws passed in2005 and 2006 that formally foster cross-sectorrelationships and facilitate the sharing ofintellectual property and resources.90

Currently, the private sector’s role in Brazilian

health innovation is small. However, as a resultof government and private investment, itsability to contribute to health R&D and productdevelopment is increasing. BNDES and FINEPhave provided signicant direct nancial supportto private biotechnology and pharmaceuticalcompanies, which are building in-house programsand partnerships.91 In addition, the growth ofBrazil’s generics market over the last decadehas provided companies with enough revenue tostart establishing R&D portfolios. Between 2000and 2009, the country’s domestic pharmaceutical

market grew substantially, to approximatelyUS$16 billion per year. This makes Brazil LatinAmerica’s leading pharmaceutical market andhas helped attract other sources of investmentthat are further building the private sector’scapacity for production and innovation.92

HeAltH innoVAtion AnD

GloBAl HeAltH cAse stUDies

BRAZIL’S pUBLIC SECTOR

MANUFACTURERS

Brazil’s large, government-linked health nonprotmanufacturers — which focus on both R&D andthe production of health products for the SUS— are unique among the BRICS.93 These publicmanufacturers provide the majority of affordablevaccines, drugs and diagnostics used by theBrazilian government and are a key component ofthe country’s health innovation system.

research through scholarships and fellowshipsand provides support to senior scientists andinternational research programs.81

The Department of Science and Technology

(DECIT) invests in ministry priorities for health

innovation and also helps coordinate innovationfunding from other federal and state agenciesthat targets Brazil’s health goals.82

The Ministry of Health’s Secretariat for Science

and Technology and Strategic Supplies (SCTIE),which is home to DECIT, is increasingly focusedon priorities that could support both nationaland global needs, in alignment with Brazil’sinternational cooperation efforts. In addition toits research investment, SCTIE also providesdirect funding to increase R&D capacity of

manufacturers that provide diagnostics, drugsand vaccines to the SUS.83,84

At the state level, government-funded ResearchFunding Foundations (FAPs) provide directsupport to local research organizations,focusing on the strengths and priorities of eachstate.85 Virtually all Brazilian states have FAPs,whose budgets are usually proportional tostate tax revenue. Together, the FAPs provideapproximately US$1 billion in total funding per

year, although the state of São Paulo fronts closeto 40% of this.86

Both Brazil’s federal and state agencies haveincreased their investments over the past eightyears. DECIT’s budget alone has grown fromapproximately US$2.78 million when it wasfounded in 2000 to around US$40 million in2009.87 DECIT has also played a catalytic roleamong federal and state funders by leadingthe development of national health researchstrategies that have been endorsed by other

funding agencies. Public health research funding

Brazil’s large, government-linked

health nonprot manuacturers —

which ocus on both R&D and the

production o health products or the

SUS — are unique among the BRICS.




infrastructure, including labs, schools of publichealth and research institutes. For example,Fiocruz’s international ofce in Maputo,Mozambique, is responsible for implementingthe ARV manufacturing project, as well ascooperation activities in other African countries.98

Bio-Manguinhos — Fiocruz’s ImmunobiologicalTechnology Institute — is Latin America’sleading producer of vaccines and diagnostics forinfectious and parasitic diseases. It is capableof producing 200 million doses of vaccines peryear, including immunizations against measles,polio, diphtheria, tetanus, MMR and yellowfever. It is the world’s largest producer of yellowfever vaccine. Bio-Manguinhos also developsand manufactures diagnostic kits for HIV/AIDS,Chagas and leishmaniasis, among others. While

these products primarily support the domesticmarket, it also supplies products directly to PAHOand UNICEF for distribution to other countries.Bio-Manguinhos' yellow fever vaccine andpolysaccharide meningococcal A and C vaccineshave WHO prequalication and have beenexported to more than 60 countries.99,100

In addition, Fiocruz recently launched the Centerfor Technological Development in Health (CTDS),which aims to mobilize public sector resources forresearch while capitalizing on the private sector’s

comparative advantage in product development.CTDS was founded in response to acknowledgedgaps in translational activities that link Brazilianhealth innovation to product development.101 CDTS also has a number of notable partnershipswith international organizations, including a2007 agreement with the private biotechnologycompany Genzyme to facilitate drug R&D for17 neglected diseases and collaborations withthe Drugs for Neglected Diseases initiative andMedicines for Malaria Venture.102

Butantan: Butantan, afliated with theSecretariat of Health of the State of São Paulo,is another prominent public health research andmanufacturing institution. Established as theFederal Seropathy Institute in the early 1900s,its original mandate — like Fiocruz’s — was tohelp lead Brazil’s ght against bubonic plague.Butantan began producing vaccines in the 1940s

In the specic case of vaccines, two institutionsalone — Fiocruz’s Bio-Manguinhos and Butantan— comprise 89% of all vaccine sales to theBrazilian Ministry of Health and supply almost

100% of the routine vaccines covered by theNational Immunization Program.94 They aresupported by public investment and work in closecoordination with the Ministry of Health. Bothare currently investing in enhanced productioncapacity, and their goals include potentiallyplaying a larger international role in supplyingaffordable vaccines.

Fiocruz: The Brazilian government foundedFiocruz, based in Rio de Janeiro, in 1900 tooversee the country’s campaign against bubonic

plague.95 Since then, Fiocruz’s work — distributedacross multiple units with specic expertise —has expanded dramatically. Today the institutionis a national and regional leader in health R&D;production of vaccines, reagents, drugs anddiagnostics; human resource training; informationsharing; quality control; and implementation ofsocial programs.96 Fiocruz prioritizes technologytransfers to increase its in-house researchand manufacturing capacity. These includepartnerships with the private sector to strengthenits vaccine manufacturing capacity, such asone established in 1985 with the multinationalpharmaceutical company GlaxoSmithKline.97

Fiocruz works closely with the Ministry ofHealth and ABC to execute regional andinternational cooperation activities. Much of thiswork leverages Fiocruz’s technical expertiseto help other governments strengthen health

The Brazilian government ounded

Fiocruz, based in Rio de Janeiro,

in 1900 to oversee the country’s

campaign against bubonic plague...

Today the institution is a national

and regional leader in health R&D; production o vaccines, reagents,

drugs and diagnostics; human

resource training; inormation

sharing; quality control; and

implementation o social programs.




32


the Brazilian government announced a renewedcommitment to produce benznidazole — anantiparasitic medication — and provide it to othercountries where Chagas remains endemic.Brazil has been producing benznidazolesince 2008, but global supplies of the active

pharmaceutical ingredient have fallen andexisting stocks have been depleted.105

The announcement, championed by the BrazilianMinistry of Health, will make Brazil the world’ssole producer of benznidazole going forward.Nortec Química, a private company based in Riode Janeiro, will produce the active pharmaceuticalingredient in benznidazole through a tech transferfrom Roche. Laboratório Farmacêutico doEstado de Pernambuco (LAFEPE), a public drugmanufacturer in the state of Pernambuco, will then

manufacture the drug to supply global markets.Brazil aims to produce 3.2 million benznidazolepills per year. Médecins Sans Frontières and PAHOwill help distribute the drug in endemic countriessuch as Bolivia and Paraguay.106

and is now a domestic leader in vaccine innovationand production. Its current portfolio of vaccinesincludes diphtheria-pertussis-tetanus (DPT),inuenza, hepatitis B, and a neonatal immunizationto protect newborns against tuberculosis (TB). Itconducts basic and applied biomedical research

in other elds including molecular biology,immunology and epidemiology.103

While Butantan’s main focus is access tomedicines domestically, it is also involvedin research that has global implications.Butantan is developing a low-cost rotavirusvaccine in partnership with the US NIH andPzer. The vaccine is currently in clinical trialsbut if successful it is expected to cost betweenUS$1 and US$2 per dose, as compared to thecurrent GAVI Alliance price of US$2.50 per dose.

Butantan is also working on vaccines againstpneumonia and dengue.104

pUBLIC-pRIVATE pARTNERSHIpS

Benznidazole: In December 2011, although thedomestic burden of Chagas disease is declining,




R ussia is unique among the BRICS in that it is re-ascending, rather than ascending, to the

status of global economic and political power. As a successor state of the former Soviet

Union, Russia was once one of the most powerful nations in the world. While it faced signicant

economic challenges — including a 40% GDP contraction and the rise of corruption and

oligarchy — following the Soviet Union’s collapse, it has rebounded to what the World Bank

calls “unprecedented macroeconomic stability.”1 Russia has been the only BRICS member of

the G8 since 1997, at the same time building partnerships with the emerging economies. It

is also increasingly protective of its traditional sphere of inuence in Eurasia. Russia’s long-

term growth, however, is threatened by structural issues, and recent demonstrations have

highlighted its political challenges and impacted its reputation for stability.

economic lAnDscAPe

Russia currently has the 11th largest economy bynominal GDP, and it holds the fth largest foreignexchange reserves. While the move from plannedto market economy plunged Russia into chaosin the 1990s, it has enjoyed economic growthaveraging 5% annually from 1998 to 2010.2,3 GDPper capita (PPP) has increased nearly three-foldsince 2000 to US$19,800 in 2010, anda large portion of Russia’s population is now

middle class.4,5

Russia is home to the world’s largest mineral andenergy reserves, and these commodities largelydrive its economy. The country has consistentlybeen one of the biggest oil and gas exporters, andpolitical unrest in North Africa and the MiddleEast, combined with a move away from nuclearpower following the Japan Fukushima disaster,

3 RUSSIA

have only increased its output. In 2011, oil exportsreturned for the rst time to Soviet Union levels.6 Russia is also a signicant exporter of steel andprimary aluminum. While commodities havefueled Russia’s economic success, they are alsovulnerable to global boom and bust cycles. As aresult, since 2007, Moscow has been working todiversify into high-tech sectors.7

While Russia’s economy is growing fasterthan most of its Western European and G8

counterparts, it still faces serious challenges.Russia was among the countries hardest hitby the global nancial crisis, and while it issteadily recovering — growth in 2010 was 4%(down from 8.5% in 2007) and is expectedto stabilize in this range — it still needs tomanage the budget decit it built up duringthat period.8 Rebounding oil prices have helped,but ination, high expenditures and volatile



34


and Friendly Cooperation in 2001, which outlineda 20-year strategic vision for their relationship.At present, they are actively working to increasetheir economic ties.11


Russia’s health indicators dropped precipitouslyfollowing the collapse of the Soviet Union, andwhile the situation has since improved, Russiadoes not enjoy the same health standards asother countries in the G8. A Russian born todaycan expect to live 68.6 years, up from 64.4 in1994. Maternal, under-5 and infant mortalityrates have been cut in half since 1990.12,13 Thatsaid, life expectancy continues to lag behindthe US and Western Europe, neighboringUkraine and Georgia, and Brazil and China.

Like most countries, Russia’s health issuesdisproportionately impact the poor.14

Russia has high burdens of NCDs that farexceed other countries of its economicstanding. Cardiovascular disease causes 61%of all deaths within the country, and rates areamong the highest in the world (Figure 3.1). 15 This is compounded by high levels of alcoholconsumption. While Russia has a relatively smallburden of infectious diseases, rates of HIV/AIDSand TB are high among at-risk populations,

including intravenous drug users and prisoners.16 Russia’s prisons have become a notorious sourceof drug-resistant TB.17

To address infectious diseases, the governmentcommitted US$600 million for HIV/AIDS in2012, doubling the 2010 budget.18 However, theprogram has drawn criticism due to its lack offocus on prevention and unwillingness to fundneedle exchange. This is hugely problematic asintravenous drug use is the main mode of HIVtransmission in Russia.19,20

The Russian government has taken note oflagging health indicators and is working toreverse these trends. At US$1,038, Russiacurrently leads the BRICS in health expenditureper capita — though this still falls short incomparison to the US and Western Europe.21 Since 1991, the government has also beenattempting to move to a more decentralized

commodity markets continue to pose problems.Unlike the other BRICS, Russia is struggling tomanage a shrinking population. However, like itscounterparts, it must also overcome economicand political corruption, increasing disparitybetween rich and poor, and the need to raise

capital for non-energy sectors.9

Domestic Politics

AnD FoReiGn AFFAiRs

In March 2012, Vladimir Putin was electedPresident of Russia for a third time after termlimits required him to step down in 2008. Putin’sre-election was expected, but opposition groupshave staged a series of protests in recent monthsdemanding political reform. It is still unclear howthis will impact domestic politics moving forward.

Russia’s geopolitical inuence has uctuatedin parallel with its economy and post-Sovietrecovery. In 1997, Russia was invited to join theG7 — transforming it into the G8. It is also aninuential member of the G20, was conrmed asa member of the WTO in December 2011, and isin the process of joining the OECD. Russia alsoassumed the Soviet Union’s place as one of theve permanent members of the UN SecurityCouncil. Russian foreign policy is currently drivenby a desire to be viewed as one of the non-Western

powers of the world.10

In recent years, Russia has had mixed butgenerally cordial relationships with the US, theEU and its immediate neighbors — althoughtensions sometimes are. This has been evidentin recent disagreements over the response torevolutions in the Middle East and North Africaand with Russia’s war with Georgia in 2008. Whilethey do not always align politically, the EU iscurrently Russia’s largest trade partner. Russiaalso plays a key role in regional fora, including the

Commonwealth of Independent States (CIS) andthe Eurasian Economic Community (EurAsEC).

Russia also enjoys a friendly rapport with theother BRICS. It has a longstanding relationshipwith India dating back to the Soviet Union, andit has actively engaged China since the 1990s.Russia and China enacted border demarcations in1991 and signed the Treaty of Good-Neighborliness




Ministry of Finance reports indicate it currentlyprovides an estimated US$400 to US$500 millioneach year to other countries, which is lessthan Brazil, India and China. The country takes

a traditional, vertical approach to assistanceand is in the process of joining the OECD. Thisshould lead to more transparent reporting onits assistance program. It also sets Russia apartfrom other BRICS, which tend to favor horizontal“cooperation” programs.24

tRenDs in FoReiGn AssistAnce

The historical roots of Russia’s internationalassistance program lie in the Soviet Union. Drivenby the Cold War, the Soviet Union launched aneconomic and technical development programin 1955 that focused on “neutralist” countries —including many in Southeast Asia, South Asiaand Africa.

The Soviet Union used economic, military anddevelopment aid as a political tool to improve itsglobal standing in developing countries. In 1961,Russia provided about US$1 billion, and by 1986that gure had grown to US$26 billion.25 After the

health care system. In recent years, thegovernment redoubled efforts to modernizehealth care in the country.22 In 2005, then-President Vladimir Putin earmarked US$28

billion through 2013 for the “National HealthCare Project,” which focuses on reinvigoratingRussia’s health care infrastructure and workforce,particularly in outlying regions. Its ultimate aimis to increase life expectancy.23 The Pharma 2020policy was launched in parallel to increase thecountry’s capacity to domestically producepharmaceuticals and innovative biotechnology.

Rua’ Frg

Aa

With the collapse of the Soviet Union, Russiawent from being one of the largest sources ofinternational assistance in the world to being anet aid recipient in the 1990s. It became a re-emerging donor in the 2000s. While the countrydoes not publicly report ofcial assistance gures,

3.1 RUssiA leADinG cAUses oF DeAtH, 2008

COMMUNICABLE DISEASES ANDMATERNAL AND CHILD HEALTH CONDITIONS

HIV/AIDS

Other

TB



Cancers



INJURIES

Injuries





36


the aid agendas of the OECD-DAC countries.30,31 In January 2007, Russia released an InternationalDevelopment Assistance (IDA) Concept Note thatlaid out the factors driving its growing program.These include maintaining an agreeable globalenvironment for itself and ensuring stability in

neighboring states, with global poverty reductionas the cornerstone for its efforts.

With these IDA goals in mind, a large portion ofRussia’s foreign assistance goes to its neighbors.Priorities include education and infectiousdisease control.32 Russia is also increasinglyproviding assistance to countries in other regions— most notably Africa — but it has yet to lay out aformal engagement strategy.33

When the Russian government launched itscurrent assistance program in 2004, it pledged

to contribute US$400 to US$500 million per year.Thus far, it appears to have met this commitment.Russia actually exceeded its goal in 2009, whenit provided approximately US$785 million in

Soviet Union broke up, there was a sharp reversal.Russia received a total of US$20.4 billion in aidfrom Western donors between 1990 and 2004.26

As Russia’s economy rebounded, the assistanceit received dropped dramatically. Today the

country no longer receives any ofcial bilateralassistance, although a few domestic non-governmental organizations (NGOs) still getinternational funding. Many UN agencies maintaina presence in Moscow and are involved in healthpolicy discussions.27 While Russia had beenforgiving Soviet-era debt for Highly Indebted PoorCountries, it truly re-emerged as a donor in 2004with an eye toward its 2006 G8 presidency.28,29

cURRent FoReiGn

AssistAnce PRoGRAm

Russia is currently the only G8 country withassistance policies and regulations but no formaldenition for ofcial development assistance(ODA). However, the country is aligning itself with

3.2 RUssiA totAl inteRnAtionAl

AnD HeAltH AssistAnce (USD Millions)

$900

$800

$700

$600

$500

$400

$300

$200

$100

$02006 2007 2008 2009* 2010**

All Other Sector Assistance

Health Assistance

Source: Deauville Accountability Report, G8 Commitments on Healthand Food Security, Ministry of Finance of Russia, 2011Note: *Marked increase in 2009 a result of emergency funds tostabilize Kyrgyzstan during the global nancial crisis**2010 health gures designated “preliminary” by Ministry of Finance




aid. This was driven by emergency economicsupport for Kyrgyzstan in the wake of the globalnancial crisis (Figure 3.2). Russia has pledged toeventually contribute the UN-recommended 0.7%of GNI in international assistance.34,35

Like several other BRICS, Russia does not havea central aid agency. Instead, all assistanceprograms are overseen by a group of governmentbodies, including the Ministry of Finance, the

Ministry of Foreign Affairs and the Ministryfor Affairs of Civil Defence, Emergencies andDisasters Relief.36,37 As a result, programmanagement is often ad hoc. The Russiangovernment is working to improve its internalcapacity, and ministries are working closely withthe World Bank and UN to develop a more formalassistance architecture. The government wasexpected to launch a central agency for bilateralforeign assistance — RUSAID — in June 2012,but talks are currently on hold.38,39

In the meantime, the Russian government

prefers to provide assistance throughmultilateral aid channels. Policymakers believethat multilateral agencies provide nancialcontrols, established delivery mechanisms, andopportunities for coordination and harmonization,as well as technical support. Key partnerorganizations include UN funds and agencies,nancing mechanisms like the Global Fund,G8 international initiatives, the World Bankand the International Monetary Fund. Russiaalso maintains some trilateral partnershipswith multilateral agencies, but direct bilateralactivities are currently limited.40,41

Rua’ Hah

Aa

Between 2006 and 2010, Russia contributed a

total of US$444 million — or one-fourth of itstotal international assistance funding — to health(Figure 3.3).42 Historically, the majority of Russia’shealth assistance has been channeled throughmultilateral institutions. This still holds true,although the percentage is declining. Russia’ssupport for global health multilaterals includingthe Global Fund, the GAVI Alliance, the GlobalPolio Eradication Initiative (GPEI) and many UNhealth agencies is signicantly greater than manyof its BRICS counterparts.

mAjoR tRenDs in

HeAltH AssistAnce

Russia’s focus on health assistance began withthe re-emergence of its foreign assistanceprogram in the early 2000s and is grounded inthe country’s Soviet-era successes combatingcommunicable diseases.43 Since 2007, Russia’s

Source: ODA, Forming a New CollaborationParadigm, M. Larionova

3.3 RUssiA inteRnAtionAl

AssistAnce By sectoR,

2006-2010 (USD Millions)

$1,800

$1,600

$1,400

$1,200

$1,000

$800

$600

$400

$200

$0

Health

Education

Energy

Agriculture

Other

Russia is currently the only G8 country

with assistance policies and regulations

but no ormal denition or ocial

development assistance. However, the

country is aligning itsel with the aid

agendas o the OECD-DAC countries.



38


total assistance funding has uctuated becauseof the global nancial crisis and, as a result,health assistance has constituted anywhere from15% to 50% of spending. However, in absoluteterms, health assistance funding has remainedrelatively consistent at between US$80 andUS$130 million annually (Figure 3.2).44 Russia’stotal assistance budget is expected to stabilizeover the next few years at around US$400 toUS$500 million per year, and health assistance

will likely remain a key component of thecountry’s international efforts.

Russia’s health assistance policies are relativelyopaque, and many key decisions are likelymade at the highest levels of government.45

While Russia funnels a large majority of healthassistance through multilateral institutions, itincreasingly engages in trilateral partnershipswith multilaterals and developing countries. Italso provides limited bilateral health assistance,particularly within the CIS region.

In 2006, Russia put infectious diseases on theagenda for the G8 meeting in St. Petersburg.Since then, its bilateral programs have generallyfocused on infectious diseases and diseasesurveillance. The Russian government is alsostarting to take a more visible role in global effortsto address NCDs. Russia hosted the First GlobalMinisterial Conference on Healthy Lifestyles andNCDs in April 2011, and both Prime MinisterVladimir Putin and WHO Director-GeneralMargaret Chan attended. In addition, Russia has

committed US$36 million to support the globalNCD response.46 While NCDs are a domestichealth priority, it is unclear whether the countrywill be able to play a viable global leadership rolein this area, given its own high burden.47

Russia’s support or global health

multilaterals including the Global

Fund, the GAVI Alliance, GPEI and

many UN agencies is signicantly

greater than the majority o its

BRICS counterparts.

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%2006 2007 2008 2009 2010

$10M

$78.4M

$57.4M

$85.7M

$5.5M

3.4 RUssiA GloBAl FUnD AssistAnce As PARt oF

All otHeR HeAltH AssistAnce (%, USD Millions)

% Assistance to Global Fund

% All Other Health Assistance

Assistance to Global Fund, in USD Millions

Source: Global Fund; Deauville Accountability Report,G8 Commitments on Health and Food Security,Ministry of Finance of Russia, 2011




but signicantly less than many G8 peers (Figure3.5). Russia is the only BRICS contributor — andone of only six contributors total — to the GAVIAlliance's Advanced Market Commitment (AMC)

for pneumococcal vaccines. The country hascommitted US$80 million to the AMC from 2010to 2019, or US$8 million per year. Russiahas also provided small amounts of funding —with totals ranging from US$1.6 million toUS$13 million from 2006 to 2010 — to UNhealth organizations, including UNICEF, theUnited Nations Population Fund (UNFPA)and the Joint United Nations Programme onHIV/AIDS (UNAIDS).

Aside from India, Russia is the only BRICS

contributor to the GPEI, having donated a totalof US$33 million between 2003 and 2012. TheRussian government views polio eradicationin the region as a major priority, and in 2009,the US Department of Health and HumanServices and the Russian Ministry of Health andSocial Development signed a memorandum ofunderstanding to strengthen collective effortsaround polio eradication. This included disease

AssistAnce to


The Russian government prefers to work within

the G8 and UN frameworks for foreign assistance,and this extends to health assistance. From2006 to 2009, an overwhelming majority ofRussia’s health assistance was channeled to theGlobal Fund. In 2006, the country announced itwould reimburse the Global Fund for projects inRussia. The Global Fund then received between44% and 82% of Russia’s health assistancefunding annually until it became a net donor in2010 (Figure 3.4). The country has pledged anadditional US$20 million per year for the Fund’sThird Replenishment period from 2011 to 2013,

which means that the organization will continueto receive a signicant portion of Russia’sestimated US$80 to US$130 million annual healthassistance budget. The pledge brings Russia’stotal commitments to the Global Fund to date toUS$317 million.48

Beyond the Global Fund, Russia gives more tomost health multilaterals than the other BRICS

3.5 RUssiA contRiBUtions to

key HeAltH mUltilAteRAls, 2006-2010 (USD Millions)

Source: Global Fund; GPEI; the GAVI Alliance; UNICEF; UNAIDS; UNFPANote: *Russia’s assistance to GAVI AMC only began in 2010 and by 2012 had reached US$24 million

$250

$200

$150

$100

$50

$25

$20

$15

$10

$5

$0

UNFPA

GAVI AMC*

GLOBAL

FUND

GPEI

UNICEF

UNAIDS



40


DISEASE AND ANTI-EpIDEMIC

SURVEILLANCE

Russian-funded disease surveillance systemsare designed to benet both recipient countriesand Russia itself. Russian assistance generallyfocuses on strengthening surveillance capacity in

neighboring countries and training large teamsof specialists on diagnostics and surveillance,particularly for inuenza. Disease surveillanceprograms have received the largest percentage ofRussia’s bilateral health assistance funding, withtotal commitments of more than US$100 millionfrom 2006 to 2010.54

NEgLECTED TROpICAL DISEASES (NTDS)

Between 2009 and 2012, Russia contributed atleast US$21 million to NTD control in neighboringCIS states and some African countries. Russian-

funded programs have focused on capacitybuilding, training and the development ofinnovations for the surveillance, diagnosis andprevention of NTDs, including leishmaniasis,schistosomiasis and blinding trachoma.Russia has also worked with CIS and Africangovernments on NTD needs assessments.

tRilAteRAl AssistAnce

FoR HeAltH

Russia has supported some trilateral assistance

programs, emphasizing partnerships withglobal health multilaterals over those with othercountries or regional bodies. Russian policymakersbelieve that partnerships with multilaterals allowRussia to play a more active role in projects, whilestill aligning with established foreign assistanceframeworks. Although annual contributions totrilateral health programs are impossible toquantify, it appears that these programs havefocused on malaria control in Africa, and HIV/AIDSand surveillance in CIS countries.

MALARIARussia has worked with the World Bank and WHOto support the Bank’s Malaria Booster Programand strengthen disease control and preventionin Zambia and Mozambique. Russia is alsoworking with these partners to strengthen humanresources and to create a cadre of malaria expertsin Africa, the Middle East and the CIS region.

surveillance, immunization campaigns, technicalassistance and advocacy. In 2010, a polio outbreakin neighboring Tajikistan spread to Russia, andthe country lost its polio-free WHO certication.As a result, President Dmitry Medvedev calledfor greater engagement on polio efforts in Russia

and Central Asia.

BilAteRAl AssistAnce

FoR HeAltH

Russia provides limited amounts of bilateralhealth assistance, focusing nearly exclusivelyon the CIS region. Because Russia does notreport all bilateral assistance disbursements,it is difcult to determine year-to-year gures.However, Russia is estimated to have committeda total of at least US$168 million to bilateralhealth projects from 2006 to 2013.49

Russia’s bilateral health assistance has focusedprimarily on infectious diseases — particularlyHIV/AIDS, disease and anti-epidemic surveillanceand, to a lesser extent, neglected tropicaldiseases (NTDs).

INFECTIOUS DISEASES AND HIV/AIDS

The Russian government’s focus on HIV/AIDS inthe region partly stems from a desire to preventthe disease from spreading across bordersinto Russia via infected migrant workers and

other channels. However, historically, migrantworkers in Russia are more likely to contractcommunicable diseases in the country andcarry them home.50 HIV/AIDS programs fundedthrough bilateral assistance include vaccine andmicrobicide research, education, the developmentof HIV/AIDS country strategies and treatmentand screening.51,52 The Russian government hasalso worked to get HIV/AIDS on the agendasof regional intergovernmental organizations,including the Shanghai Cooperation Organization(SCO) and the EurAsEC. While Russia’s domestic

HIV/AIDS program has been criticized for itspromotion of abstinence and lack of harm-reduction programs for the most at-riskpopulations, it does not appear that these policieshave inuenced programs it funds throughmultilaterals or in other countries.53




In 2007, government funding for health R&Dwas a relatively low US$300 million, althoughexpenditures are increasing. Following its 2006G8 presidency, Russia committed to expand itssupport for HIV/AIDS treatment and preventionresearch, investing US$38.2 million in HIV/AIDS

vaccine programs.57,58

In addition, Russia’s academic institutions areconsidered valuable “centers for knowledge andscience” by CIS countries, which use them fortraining and scientic information.59 Russianmedical schools alone provide training to nearly20,000 foreign students annually, most of whomcome from the CIS and Asia.60 Neighbors alsolook to Russian institutions for support on diseasesurveillance — their help was critical in containingthe 2010 polio outbreak in Tajikistan — and as

potential partners for research collaborations.61 Russia’s public and academic sectors have thepotential to make more substantive contributionson a global scale, but there are signicant hurdles,including lack of regulatory and IP policies andlanguage barriers.62

Russia’s private health technology sector is small,with limited capacity for innovation. The country’sdomestic biopharmaceutical and medicalequipment industries are worth approximatelyUS$6.7 billion and US$900 million annually,

respectively, but 70% of their products targetthe domestic health care system.63,64 In 2007,Russian pharmaceutical exports made up lessthan 0.04% of global sales.65 Private companiesmostly produce older technologies, such as basicantibiotics and x-ray machines, and have fewR&D facilities. There are also relatively fewongoing clinical trials in Russia.66,67 As a result,Russia relies on imports for its advancedmedical technologies.68

Quality control is also a major challenge in

the private sector, and only 10% of Russia’s600 pharmaceutical companies follow GoodManufacturing Practice (GMP).69 With theimplementation of the Pharma 2020 strategy,Russia hopes to signicantly strengthen itscapacity to produce and export high-qualityhealth-care products.

HIV/AIDS AND SURVEILLANCE

Russia has worked with the Global Fund andUNAIDS to co-sponsor three meetings ofthe Eastern Europe and Central Asia AIDSConference. The Russian government also signeda memorandum of understanding with WHO to

help strengthen surveillance and lab capacity inthe CIS and in Africa.

Rua iva

ad ipa fr

Gba Hah

Russia’s most signicant contributions to global

health innovation have emerged from its publicand academic sectors. Under the Soviet Union,Russia built signicant institutional capacityfor combating infectious diseases. Today, theseinstitutions are considered a regional resource bymany CIS countries. At the same time, Russia’sprivate health care technology sector — includingits biopharmaceutical and medical equipmentindustries — is small. It relies on externalmarkets for raw materials and possessesextremely limited R&D capabilities. To addressthis, the Russian government recently injected

US$4.4 billion into the sector as part of anambitious plan to signicantly increase domesticcapacity for health production and innovation.This plan, known as Pharma 2020, could impactRussia’s future contributions in this area.

key tRenDs in

HeAltH innoVAtion

The Russian government’s health R&D programbuilds off of work done under the Soviet Union,when publicly funded research focused on

infectious diseases and tropical medicine.55,56

Oneof the Soviet Union’s best-known contributions inthis area is its 1959 role as host of the rst clinicaltrial for oral polio vaccine (OPV). Thousands ofRussian children participated, and the SovietUnion subsequently became the rst countryto develop, produce and use the vaccine formass immunization.




42


Stage 1 (2009-2012): Develop domestic infrastructurefor production and R&D. The government isconstructing ten major “innovation centers” andpharmaceutical clusters across the country.

Stage 2 (2013-2017): Transition local

consumption from internationally to domesticallyproduced generics, with the end goal of makingRussia independent of exports.

Stage 3 (2018-2020): Begin developing innovativedrugs for patent; expand to global market.

The Pharma 2020 program is supportingdevelopment of 57 new drugs to combat a varietyof diseases ranging from hepatitis B to multiplesclerosis, which could reach the market in thefuture.73 In addition, a number of multinational

pharmaceutical companies, including AstraZenecaand Novartis, have made signicant long-terminvestments through the program. AstraZenecais currently constructing the rst full-cyclepharmaceutical production facility in Russia.74

While the nal outcomes of Pharma 2020remain to be seen, opinions are mixed. Someexperts believe that the government is being tooambitious and that it will take even more timeand resources to accomplish the plan’s goals.75 However, greater Russian pharmaceutical

manufacturing and innovation capacity couldtranslate into new opportunities to supportglobal health programs.

HeAltH innoVAtion AnD

GloBAl HeAltH cAse stUDies

pHARMA 2020

In March 2011, Prime Minister Vladimir Putinlaunched the Pharma 2020 strategy, committing

more than US$4.4 billion to build capacity fordomestic production and innovation in Russia’spharmaceutical and medical industries.70 Multinational pharmaceutical companies areexpected to commit an additional US$1 billionin investments.71 The Pharma 2020 strategy ismeant to complement the Health 2020 initiative,which launched in 2005 with a goal of improvingdomestic health indicators. However, a centralcomponent of Pharma 2020 is to prepare Russia’shealth care industry for the global market.

Pharma 2020 has three broad goals to beachieved by 2020: 1) Increase local production by50% to ensure domestic access to drugs — bothessential medicines and those that combat rarediseases; 2) Ensure that a majority (60%) of allproducts produced are innovative and; 3) ReachUS$100 million in exports.

To accomplish these goals, Pharma 2020directs US$850 million toward improving humanresources and domestic infrastructure, US$900million toward ensuring all manufacturers

transition to GMP, and US$2.7 billion towardbuilding R&D capacity for innovative products.72 The plan is being implemented in three stages:




I ndia has one of the fastest growing economies in the world, and by 2050 it is expected

to have the third largest economy — behind only China and the United States. Economic

growth combined with a large population and vibrant parliamentary democracy has

bolstered India’s political inuence both regionally and globally. However, India is still

home to large pockets of poverty and signicant health challenges. There are alsomarked economic disparities between different regions as well as urban and rural areas.

Corruption and weak infrastructure present additional challenges. The Indian government

increasingly recognizes the need to invest heavily in programs and initiatives that it hopes

will sustain the country’s rapid upward trajectory and ensure what experts refer to as

“inclusive growth.”1

economic lAnDscAPe

India currently has the ninth largest economyby nominal GDP, and GDP growth rates haveaveraged more than 7% from 1998 to 2010 and8.5% since 2005 to 2010.2 Indian GDP per capita(PPP) more than doubled since 2000 to US$3,600in 2010, helping to build a large and growingmiddle class.3 In addition, the government hasrecently launched several ambitious programsthat aim to lift hundreds of millions more peopleout of extreme poverty.

India’s economic success is largely due to theeconomic reforms of the early 1990s, whichreduced direct tax rates, increased the role ofprivate sector enterprises, and lightened heavygovernment restrictions in critical areas likeforeign direct investment.4 Growth has beensustained by the country’s skilled servicesindustry and 480 million-strong workforce, whichis second only to China. Services comprise 55% ofthe total economy, with industry and agriculturemaking up 26% and 19%, respectively. While the

country was affected by the global nancial crisis,India’s GDP did not contract, but instead growthslowed to 5%. GDP growth returned to between

7% and 8% through the end of the decade, largelydue to domestic demand.5,6

India’s continued growth is not withoutchallenges. Despite the country’s economicstrength, some economists question whetherIndia will soon feel the effects of slowdowns inthe rest of the world.7 The fourth quarter of2011’s growth rate, 6.1%, was the slowest ratein almost three years.8 That said, the country'sMarch 2012 Economic Survey predicts thatIndia's growth will rebound to 7.6% and 8.6%

in 2013 and 2014, respectively.9

India’s strict investment and labor lawscontinue to create roadblocks in the privatesector. In January 2012, the Indian governmentcompromised on an effort to relax foreigninvestment policies and instead reversed long-standing ownership limits on single-brand foreigncompanies. These policies had required foreign



44


also worked to strengthen links with the US andEuropean countries. Despite a difcult history,India has sought to increase positive politicalties with China — its largest trade partner withbilateral transactions worth US$60 billion in 2010.However, India remains wary of China, not leastbecause of its close relationship with India’s long-standing rival, Pakistan.14

Domestic HeAltH sitUAtion

India is home to some of the most advancedhealth care facilities in the world and boasts oneof the largest medical tourism industries globally.Yet at the same time, millions of India’s poorestpeople lack access to basic health care and 43% ofthe country’s children are malnourished.15 Whilehealth indicators are improving, the contradictionsare stark. At 64.8 years, life expectancy is at anall-time high; however, it is still lower than other

countries with similar economic standing.16

Indiaalso has some of the highest global burdensof infectious diseases and maternal, neonataland child health problems. HIV/AIDS and TB kill460,000 Indians annually, while childhood clusterdiseases account for 220,000 deaths, the most ofall the BRICS (Figure 4.1).17

There have, however, been areas of signicantprogress. In February 2012, Indian surpassedone year without detecting a single case ofwild poliovirus and was removed from the list

of polio-endemic countries. Just three yearsearlier, India had more polio cases than any othercountry in the world. India’s success on poliowas mainly funded by the Indian governmentitself, which contributed US$1.49 billion since2003, and it involved mass mobilization of localfrontline health workers across the country. TheIndian government has also taken initial stepsto introduce the ve-in-one pentavalent vaccine,

companies to have an Indian partner with a51% ownership stake to operate in the country.10 At the same time, ination — which reached 11%during the rst half of 2010 but declined to 6.7%in January 2012 — continues to pose a threat,particularly to India’s 250 million farmers.11,12

These issues are compounded by slow progresson infrastructure, corruption and povertyreduction, and limited job opportunities comparedto the size of the labor market.

Domestic Politics

AnD FoReiGn AFFAiRs

India boasts the world’s most populousdemocracy and a vibrant political culture, with sixrecognized national parties alongside numerousstate and regional parties. While two major

national parties dominate the country’s politics,neither is generally able to form a governmentwithout forging often contentious allianceswith regional parties. The current governmentis a coalition, the United Progressive Alliance,led by the left-leaning Congress party. PrimeMinister Manmohan Singh is the only primeminister to return to power for a second termsince India’s rst, Jawaharlal Nehru. Yet despitethis, his government has found it difcult to passlegislation due to coalition politics and a series ofcorruption scandals.

While India’s domestic politics are unpredictable,the country’s size and economic growth haveincreased its global inuence. India is anoutspoken member of the G20 and participates inother multilateral groups including the WTO andthe SCO. India also has a long-standing interestin joining the UN Security Council as a permanentmember and it has frequently put forward Indiancandidates for leadership positions of majorinternational institutions.

The Indian government is working openly toexpand its global presence and to forge strategicpartnerships with other countries. These rangefrom immediate neighbors to traditional andnew global powers.13 India has strong bilateralrelationships with Afghanistan and Bangladeshand follows a “Look East” policy, emphasizingties with the Association of Southeast AsianNations (ASEAN) countries. The government has

In February 2012, Indian surpassed

one year without detecting a single

case o wild poliovirus and was

removed rom the list o polio-

endemic countries. Just three years

earlier, India had more polio casesthan any other country in the world.




issues, continue to be a problem. The 2012-2013Union Budget also increases focus on a numberof key health areas, including immunization,rural health and human resources for health.

It formally launches the National Urban HealthMission, which aims to improve the health of thepoor living in India’s urban slums.21 Health willbe a major component of India’s 12th ve-yearplan, which will be submitted in 2012 and will layout the strategic vision for the country. The planincludes a commitment to increase governmenthealth expenditures to 2.5% of GDP by 2017 andto move toward universal health care.22

ida’ FrgAa

As its economy and international prole havegrown, India has substantially increased boththe size and scope of its foreign assistanceprogram. Since 2005, it has committed to support

which would protect children from diphtheria,pertussis, tetanus, hepatitis B, and Haemophilus

influenzae type b.

Beyond infectious diseases, India also facesa mounting burden of NCDs, which wereresponsible for 53% of all deaths in the countryin 2008.18 Cardiovascular disease is currentlythe nation’s leading killer and diabetes ratesare increasing — India had 51 million cases in2010, up from 32 million in 2000.19 India’s NCDchallenges are driven by an aging population,changes in eating habits, and genetic factors,which impact the entire country at allincome levels.20

While health care administration is a state-levelissue in India, successive national governmentshave been increasing their investment in thehealth sector. The National Rural Health Mission(NRHM) was launched in 2005 to strengthenhealth infrastructure and ensure functional healthsystems for India’s enormous rural population.The program has made signicant progress,but inadequate human resources, among other

4.1 inDiA leADinG cAUses oF DeAtH, 2008


Diarrheal Diseases



Other

TB

Childhood Cluster Diseases

HIV/AIDS





Cancers

INJURIES

Injuries





46


Japan, Germany, Russia and the EU — thoughother donors were welcome to continue theirassistance through NGOs and multilateralagencies. That same year, India began repayingdebt to 15 countries, the World Bank and theAsian Development Bank.25 Today, foreign

assistance to India constitutes just 0.3% of thecountry’s GDP, and the shift to net donor couldcome within a few years.26

Indian policymakers do not view the countryas a “donor” in the traditional sense. Instead,policymakers see India’s assistance program asan expression of soft power centered on South-South solidarity, technical capacity building andsustainability.27 They also emphasize that, unlikeWestern donor programs, Indian assistance is“demand-driven” and “reactive.” The country

does not put out formal requests for proposals;instead, recipients approach India for supportas they deem necessary.28 At the same time,however, India appears to be taking a moreproactive approach to foreign assistance in aneffort to counteract Chinese inuence.

cURRent FoReiGn

AssistAnce PRoGRAm

Because India views foreign assistance as anextension of foreign policy, its program is largely

under the jurisdiction of the Ministry of ExternalAffairs (MEA). The MEA works with the Ministryof Finance on assistance-related budget issues.The Ministry of Trade and Commerce alsoparticipates around private sector support andthe Prime Minister’s Ofce has discretionaryfunds that may be directed toward assistanceprograms.29 Other ministries also play smallerroles. The government is currently working tobetter coordinate its international assistance,and in early 2012 it launched the DevelopmentAdministration Partnership within the MEA to

increase efciency in the administration of itsprogram. It is also in the process of launching acentral assistance agency.30

India does not systematically report foreignassistance gures, and what is reported is notcomprehensive. This makes it difcult to quantifyannual commitments or disbursements. However,in recent years the national budget has included

projects in nearly 80 countries. India uses foreignassistance as a diplomatic tool to build goodwillthrough horizontal cooperation, secure accessto natural resources, open new markets for itsdomestic industries, and counterbalance China’sgrowing inuence. India openly rejects Western

denitions and approaches, as well as the terms“donor” and “aid,” preferring to view its effortsas a form of South-South partnership. WhileIndia does not have a unied approach to foreignassistance, it is working to increase efciencieswithin its current programs. The Indiangovernment is also in the process of establishinga central agency to oversee the country’sdevelopment assistance activities.

tRenDs in

FoReiGn AssistAnce

India’s foreign assistance program traces its rootsto the 1950s, when Prime Minister JawaharlalNehru rst committed funds to Nepal andMyanmar (then Burma). India’s early assistanceefforts focused on building local capacity in keyneighboring countries to help foster pro-Indiasentiments.23 In 1964, the country launched itscornerstone Indian Technical and EconomicCooperation (ITEC) initiative, which trained civilservants from developing countries. Yet despitethese early programs, India continued to receive

far more foreign assistance than it disbursed.Between 1951 and 1992, India accepted a totalof US$55 billion in foreign aid — making it theworld’s largest recipient.24

In recent years, the Indian government hassought to move the country from net aid recipientto foreign assistance provider. In 2003, Indiaannounced that it would continue to acceptbilateral assistance from only the US, the UK,

Indian policymakers do not view the country as a “donor”

in the traditional sense. Instead,

policymakers see India’s assistance

program as an expression o sot

power centered on South-South

solidarity, technical capacity building

and sustainability.




nance institutions like the African and AsianDevelopment Banks. In 2009, India committedUS$1.4 billion to these types of organizations.32

In terms of geographic focus, the majority ofIndia’s assistance continues to go to neighborsincluding Bhutan and Nepal in order to buildgoodwill in the region (Figure 4.3).33 In recentyears, India has also attempted to build a stablerelationship with Afghanistan. As a result, itsassistance to Afghanistan — including bilateralactivities and lines of credit — now totals upwardof US$1 billion, making India the country’sfth largest donor.34 India has historic tiesto Afghanistan and Afghan President Hamid

Karzai was educated in India through the ITECprogram. Yet the recent exponential growth inIndian assistance to Afghanistan is also drivenby regional politics, including India’s strainedrelationship with Pakistan.

India is currently shifting toward a moreeconomically driven assistance program focusedon accessing natural resources and developing

more assistance-related numbers, and from whatdata are publicly available it is clear that fundingis increasing. Total Indian foreign assistance grew

at an estimated 7.4% annually between 2004and 2010, from approximately US$443 million toUS$680 million over this period (Figure 4.2).

Indian foreign assistance typically includestechnical cooperation, grants, contributionsto international organizations, soft loans, andExport-Import (EXIM) Bank lines of credit withsubsidized interest rates. Lines of credit aredesigned to be repaid by recipient countries withthe Ministry of Commerce covering the differencebetween actual and subsidized rates.31 The

vast majority of these resources are channeledthrough bilateral programs (Figure 4.2). Indianpolicymakers believe bilateral approaches bestalign with the country’s demand-driven, horizontalphilosophy and allow for innovative programming,including public and private sector involvement.However, India has on occasion providedvery large contributions to multilaterals forassistance programs, particularly international

4.2 inDiA inteRnAtionAl

AssistAnce commitments (USD Millions)

2004-2005 2 005-2006 2006-2007 2007-2008 2 008-2009 2009-2010* 2010-2011

$2,000

$1,600

$1,200

$800

$600

$400

$200

$0

Multilateral Assistance

Bilateral Assistance

Source: Union Budget and Economic Survey, Ministry of External Affairs, Ministry ofFinance, Government of India; Government of India ofcial interview; GHSi analysisNote: *Marked spike in 2009-2010 a result of Ministry of Finance investment ininternational nancial institutions



48


Indian assistance often takes the form of supportfor high-cost infrastructure projects, includingconstruction and power generation, as well aslower-cost projects in information technology

(IT). Assistance in Africa also tends to focus onbuilding the capacity of local civil servants andmanagers working in state-owned enterprises.39 A majority of these projects also benet India.Lines of credit are typically linked to Indian goodsand services and many private companies andstate-run enterprises collaborate on projects.40,41 When projects are in neighboring countries, Indiaalso receives infrastructure benets; for example,hydroelectric plants constructed in Bhutanprovide India with a steady source of electricity.42

new markets for its growing industries.35,36 TheIndian government has signicantly increasedforeign assistance to Africa through bothtechnical cooperation and nancial support,

and in 2011 Prime Minister Singh announced aUS$5 billion line of credit to help fund economicdevelopment on the African continent.37 TheConfederation of Indian Industries (CII) alsoorganizes an annual meeting known as theCII-EXIM Bank Conclave on India Africa ProjectPartnership to strengthened bilateral andmultilateral relationships across the continent.India has increased its engagement with LatinAmerica as well, though to a lesser degree.38

Source: Union Budget and Economic Survey, Ministry of External Affairs, Ministry of Finance,Government of India; Government of India ofcial interview; GHSi analysisNote: *Does not account for total lines of credit, which would signicantly increase assistance gures,especially for Afghanistan and African nations; USD:INR currency conversion based on IMF annual average exchange rates

4.3 toP 10 ReciPients oF inDiAn

BilAteRAl commitments, 2004-2010

BhutanAfghanistan*

Other Developing Countries

Nepal

Sri Lanka

Maldives

African Nations

Myanmar

Bangladesh

Mongolia




are proving to be of interest to other developingcountries. The number of Indian health assistanceprojects appears to be growing as these countriesincreasingly understand India’s strengths in thearea.46 Since India provides reactive, demand-driven health assistance, recipient requests are

guiding the country’s programs, which tend toemphasize knowledge sharing, capacity buildingand infrastructure strengthening.

Indian policymakers believe the scope of thecountry’s health assistance program will continueto expand as recipient countries become moreaware of its “[experiences] in tropical medicineand infectious diseases and [its capacity in]public health initiatives, training and R&D.”47 Policymakers are also interested in ndingopportunities to leverage India’s robust private

health sector and civil society in future healthassistance efforts.48


FoR HeAltH

In line with its broader assistance strategy, Indiaprefers bilateral health assistance to multilateralprograms. Since 2009, India has committed atleast US$100 million to bilateral health projects innearly 20 countries in South Asia, Southeast Asiaand Africa. Afghanistan appears to have received

the most health assistance, both in terms ofabsolute cost and range of projects.49

India’s bilateral health assistance includes arelatively large number of projects that arelower in cost than comparable projects in othersectors. The majority of health projects fundedby India have budgets between US$20,000 andUS$3 million, while infrastructure projects —energy and sanitation, for example — may reachhundreds of millions of dollars.50 As noted, Indiaprovides health assistance in areas of relative

strength, including infrastructure, IT and training.These activities all focus on building capacitywithin recipient countries.

HEALTH INFRASTRUCTURE

The bulk of India’s health assistance comes in thearea of infrastructure development. The countryhas helped construct or improve hospitals andclinics in the majority of its immediate neighbors,

ida’ Hah

Aa

Global health assistance makes up only a small

portion of India’s overall foreign assistanceprogram, but it appears to be growing.43 Activitiespredominantly include lower-cost bilateralprojects focused on infrastructure, humanresources, capacity building and education. Indianpolicymakers have expressed expectations thatIndia’s engagement in health will expand asother developing countries learn more about itssuccesses in the area.

mAjoR tRenDs in

HeAltH AssistAnce

Despite substantial economic growth, Indiacontinues to face major health challenges. Withthis in mind, the Indian government is dedicatingsignicant resources toward developinginnovative programs and strategies to improvehealth domestically. Priorities currently includeinfrastructure strengthening and capacitybuilding at the secondary and tertiary levels,providing access to and incentivizing maternaland child health care, and NCD preventionand management.44 The 2012-2013 Union Budget

also sharpens the focus on vaccine productionand access to services for India's rural andurban poor.45

With its attention focused on domestic issues,India’s global health assistance is limited whencompared to assistance for other sectors. However,efforts to improve health domestically are providinga range of lessons learned and best-practices that

Indian policymakers believe the

scope o the country’s healthassistance program will continue

to expand as recipient countries

become more aware o its

“[experiences] in tropical medicine

and inectious diseases and [its

capacity in] public health initiatives,

training and R&D.



50


practices. India has also committed to providesimilar support in Bhutan, Nepal and Afghanistanthrough a South Asian Association for RegionalCooperation (SAARC) initiative.53

CApACITY BUILDINg AND EDUCATION

India is well known for having a large, educatedcadre of health care professionals. Recognizingthis, other developing countries have approachedIndia for help in strengthening their own healthcare workforces. India has established medicalcolleges and provided faculty support in a numberof countries, particularly Bhutan and Nepal.54

MEDICAL MISSIONS

While Indian support for medical missions appearsto be small, the country has assisted humanitarianprograms for a number of years in ve cities

in Afghanistan: Kabul, Herat, Mazar-e-Sharif,Kandahar and Jalalabad. Through this program,

as well as countries throughout Africa. Recipientcountries also consistently approach India formedical supplies, and the government has donateda range of medicines, diagnostics, ambulances andother equipment to support their health response.Construction projects tend to have budgets ranging

from US$200,000 to US$3 million, while donationsare generally worth below US$1 million.51

HEALTH IT

India’s IT sector has a very strong reputation, andcountries have approached the government forsupport in developing e-health platforms. Theseprojects are often classied as IT assistance, butthey have had direct impact on health in recipientcountries.52 One of India’s most signicant projectsis the Pan-Africa Telemedicine and Tele-EducationNetwork, where hospitals and universities

throughout Western Africa are being linked withcounterparts in India to facilitate sharing best

4.4 inDiA contRiBUtions to key


Source: GPEI; UNICEF; UNFPA; Global FundNote: *India contibutes funds to the GPEI for its domestic polio eradication program;it contributed US$300,000 toward GPEI broadly in 2006

$800

$700

$600

$25

$20

$15

$10

$5

$0

GPEI*

UNICEF

GLOBAL

FUND

UNFPA




same time, the Indian government increasinglyrecognizes the potential for innovation toaccelerate efforts to address its own health-carechallenges. The government has announcedseveral ambitious plans to catalyze scienticinnovation in the public and private sectors in the

hopes of producing new health tools. When andif these approaches become available, they couldprovide additional, low-cost options for addressinghealth challenges in the poorest countries.

key tRenDs in

HeAltH innoVAtion

India’s private drug and vaccine manufacturershave revolutionized health in developing countriesby expanding access to generic products. Thesecompanies are able to tap into India’s large pool of

highly educated scientists, medical practitionersand IT professionals. They are also increasinglyinvesting in new early R&D programs.

While India’s most visible impact on global healthcontinues to be through low-cost manufacturing,the country has also produced a range ofinnovative approaches to health service delivery

India has deployed 15 health-care providersand enough free medicines to treat 360,000 ofAfghanistan’s poorest patients annually.55 Indiahas also sent medical missions to Africa.56

mUltilAteRAl AnD tRilAteRAl

AssistAnce FoR HeAltH

Due to its preference for bilateral programs andlimited overall assistance budget, Indian supportfor health multilateral organizations is small.The notable exception is the GPEI, which Indiauses as a mechanism to fund its own domesticeradication efforts. Between 2006 and 2010, Indiagave the GPEI US$781 million, which the GPEIthen used to fund programs inside the country(Figure 4.4). India has contributed a total ofUS$1.49 billion to the GPEI since 2003.57 It has

also made small contributions to the Global Fund,UNICEF and UNFPA.

India is involved in several relatively smalltrilateral health partnerships. In 2002, Indiapledged to provide 1 million metric tons ofhigh-protein biscuits — worth US$100 million— to support the World Food Programme’sSchool Feeding initiative in Afghanistan. India’scontribution is helping to provide nutritioussnacks for two million school-going children overa number of years.58 India has also supported

some trilateral health efforts through IBSA,including a number of infectious disease R&Dcollaborations with Brazil and South Africa.Finally, policymakers believe that India could playa role in increasing the emphasis on health withinregional institutions like SAARC.59

ida iva

ad ipa fr

Gba Hah

To date, India’s most signicant contributionsto global health innovation have come from itsrobust private sector. Indian biopharmaceuticalcompanies have had enormous impact bydramatically driving down prices for HIV/AIDStreatments and vaccines for leading causes ofchildhood morbidity and mortality. Yet at the

Council of Scientic and Industrial

Research

The Council of Scientic and IndustrialResearch (CSIR) is an autonomousgovernment body funded primarilyby the Indian Ministry of Science andTechnology. Founded in 1942, CSIR is oneof India’s premier industrial researchand development organizations with 39laboratories and eld stations across thecountry. Among several key focus areas,CSIR is heavily involved in biotechnologyresearch to address global health issues.The agency played an important role in thedevelopment of alternative and cheapertechniques for manufacturing ARVs to treatHIV/AIDS, which were then transferredto Cipla. CSIR has also developed novelantibiotics for TB, and it recently establishedan Open Source Drug Discovery initiative tospur development of other novel therapies.



52


BRICS. IBSA has facilitated partnerships onHIV vaccine and TB research, and the Mumbai-based drug manufacturer Lupin Ltd. haspartnered with Farmanguinhos and the BrazilianMinistry of Health to support the introduction ofa four-in-one combination TB drug. Under thedeal, Lupin will provide a technology transferthat will help Farmanguinhos establish its local

manufacturing facility.65

key HeAltH innoVAtion

cAse stUDies

gENERIC ARV MANUFACTURINg

Indian manufacturers currently provide 80% ofall donor-funded HIV therapies in developingcountries — drugs used by millions of patients.66 In 2001, the Mumbai-based drug manufacturerCipla began producing triple-therapy ARVs ata cost of US$350 per patient per year, which

was one-thirteenth of the standard price atthe time. Ranbaxy, a Gurgaon-based drugmanufacturer, quickly followed Cipla’s entryinto the ARV drug market.67

Not only did these producers impact globalprices, they also created simplied ARV treatmentregimens for people living in poor countries.Cipla’s new drug combined three different ARVsinto a single tablet, which reduced the numberof pills taken each day. Fixed-dose combinations(FDCs) like these make taking medications more

convenient, and are believed to help improvetreatment adherence, thereby reducing drugresistance. While ARV FDCs had been developedbefore, Cipla’s product was unique becauseit combined three ARVs that were licensed bythree separate pharmaceutical companies. Thenew FDCs were also heat-resistant enough foruse in developing countries where appropriaterefrigeration can be scarce.68 As a result, HIV/

that have become models for programs in othercountries. The TB Research Centre in Chennai,for example, conducted many of the initial studiesthat laid the groundwork for the developmentof directly observed treatment short-course(DOTS) — the preferred global TB treatment

strategy. More recently, telemedicine providers inIndia have helped make access to health adviceeasier for people in developing countries.60,61 In March 2012, India also pledged to increasescientic collaboration with African nationsaround a number of key areas, including capacitybuilding, science and technology innovation fordevelopment, knowledge transfer and adoption.62

Some of these programs have been supportedby other donors, and overall, India still facesenormous health delivery challenges. Yet the factthat India is tackling these issues at the same

time as other countries has enabled its successesto provide immediate templates.

In the public sector, Indian policymakers areincreasingly emphasizing the need for innovationsto ensure all Indians have access to appropriatehealth services. Much of India’s governmenthealth research funding is directed to the nearly40 biomedical research centers that comprisethe Indian Council of Medical Research and theDepartment of Biotechnology (DBT). The latterhas been central in encouraging health innovationacross the country, including new vaccinesfor rotavirus. The Department of Science andTechnology (DST) and the Council for Scienticand Industrial Research (CSIR) also conductsignicant health research.

The Indian government’s increased investments inhealth research coincide with the launch in 2010of what policymakers have declared the “Decadeof Innovation.”63 That year, the Indian governmentestablished the National Innovation Council (NIC),which is charged with developing a roadmapfor innovation in the country in several areas,including health. In conjunction with the NIC, thegovernment also plans to launch a US$1 billion“India Inclusive Innovation Fund” by July 2012to encourage innovative solutions for problemsaficting the poorest in the country.64

In addition, there have been examples of publicand private innovation partnerships with other

Indian companies manuacture

between 60% and 80% o all

vaccines procured by UN agencies,

making India by ar the

largest provider o aordable,

high-quality vaccinesor developing countries.




of foreign direct investment (FDI) in Indianpharmaceutical companies, because many believeit will have an impact on accessibility to drugswithin the country.71

In the meantime, Cipla recently partnered with a

Ugandan manufacturer to further reduce the costof treatment and address some of the transportchallenges that impede drug delivery in Africa.72 In addition to improving drug access and buildinglocal capacity, South-South collaborations like thisone could help bypass increased restrictions on IP.

INDIA’S VACCINE INDUSTRY

Eight manufacturers in India currently produce72 WHO prequalied vaccines — more thanare produced in any other country (Figure 4.5).In addition, Indian companies manufacture

between 60% and 80% of all vaccines procured byUN agencies, making India by far the largestprovider of affordable, high-quality vaccines fordeveloping countries.73

Revenues in India’s vaccine industry wereestimated to be approximately US$900 millionin 2011. They are expected to grow by 23% from2011 to 2012.74 However, funders are increasinglyvigilant about the quality of vaccines produced inIndia.75 WHO recently delisted several vaccinesfrom Panacea Biotec and Bharat Biotech after

routine inspections of their manufacturingfacilities unearthed quality control issues.

India began producing innovative vaccines morethan a century ago. The world’s rst plaguevaccine was developed in Mumbai in 1897, andan indigenous cholera vaccine was developedin Kolkata. Indian public institutes soon beganproducing biological products for domestic use,including DTP, MMR, tetanus toxoid and snakeantivenin.76 In the years following independence,a handful of private vaccine manufacturers,

including the Serum Institute of India (SII) andBiologicals E Ltd., began producing vaccines fordomestic programs. Beginning in the 1980s, SIIbegan engaging with international agencies —including WHO, PAHO and the UN — to discussproviding vaccines for global use.77 In the decadethat followed, Indian vaccine manufacturersemerged internationally, and SII is currently thelargest provider of vaccines by dose worldwide.78

AIDS patients living in developing countriesreceived access to better medicines than manypeople living in high-income countries.69 Sincethen, prices have continued to drop in parallelwith production and delivery costs, while stillproving protable for Indian companies.

Alongside a number of other actors, Indian

ARV manufacturers also helped spur effortsto challenge the IP rules preventing access togeneric drugs, beginning with the 2001 DohaDeclaration on the Trade-Related Aspects ofIntellectual Property Rights Agreement (TRIPS)and Public Health. These IP challenges havedramatically inuenced global health policy, butwhile they have improved health access, manycore issues remain unresolved. Since 2011, globalAIDS activists have been protesting a free tradeagreement currently under discussion betweenIndia and the EU that could strengthen IPregulations on HIV drugs and undercut access toARVs. Meanwhile, in March 2012, India issued itsrst-ever compulsory license for a cancer drug.Many experts believe this move could open thedoor to compulsory licenses for a variety of life-saving drugs from both India and other developingcountries.70 In addition, Indian policymakers arealso currently debating the appropriate levels

WHO Prequalication

WHO created the prequalication process

in 2001 to ensure that medicines, vaccinesand diagnostics procured by UN agencies

meet acceptable standards of quality, safetyand efciency. To achieve prequalicationstatus, manufacturers must submit data on

their product and an inspection team must

verify that the manufacturing site complieswith WHO practices. Medicines, vaccines

and diagnostics that pass these tests are

added to a list that multilateral organizations,such as UNICEF and the World Bank, use

to guide procurement. Additionally, many

developing countries use the prequalication

lists as proxies for national regulatoryapproval processes.



54


A, which is endemic in the “Meningitis Belt” alongthe southern edge of the Sahara Desert fromSenegal to Ethiopia. In addition to Burkina Faso,MenAfriVac has been introduced in Niger andMali. During the 2009-2010 meningitis season,there were more than 10,000 meningitis A cases

in these three countries. Following introduction ofthe new vaccine, the 2010-2011 season saw onlyeight cases.80

A number of Indian vaccine companies alsohave novel vaccines in the pipeline for diseasesincluding rotavirus, pneumococcus and humanpapillomavirus (HPV) — all vaccines that havebeen limited in their introduction in developingcountries. Several of these companies havereceived technical or nancial support in theirresearch from the Indian government and

international organizations including the GAVIAlliance, PATH, International Vaccine Institute(IVI) and the Gates Foundation. As the Indianvaccine sector has matured and evolved, somecompanies — including Shantha — have been

Indian manufacturers have also developed anumber of innovations that have helped expandvaccine supply and push down prices. Before 1990,only multinational vaccine companies producedrecombinant hepatitis B vaccines, and the averageprice was US$23 per dose. Shantha Biotech,

based in Hyderabad, developed a novel process formanufacturing the vaccine, thus creating India’srst indigenous recombinant product. The price isnow less than US$1 per dose. WHO prequaliedShantha’s vaccine in 2002 and it is now availablefor procurement by UN agencies for use in otherdeveloping countries.79

Global health organizations also increasinglyturn to Indian manufacturers to proactivelyimprove vaccine access in poor countries. InDecember 2010, MenAfriVac, the rst vaccine

designed specically for Africa, was launchedin Burkina Faso. MenAfriVac was developed bya collaboration between SII, PATH and WHO,with funding from the Gates Foundation. Theinexpensive vaccine protects against meningitis

Source: World Health OrganizationNote: *Data accurate as of 11 March 2012

Number of Prequalified Vaccines

0 10 20 30 40 50 60 70 80

Russia

Germany

Cuba

Brazil

Bulgaria

South Korea

Italy

USA

Indonesia

France

Belgium

India

4.5 toP 10 coUntRies witH wHo PReqUAliFieD VAccines, 2012*

TOTAL # OF WHO PREUALIFIED VACCINES: 213




2.4 million outpatients and organizing morethan 1,000 screening camps annually.82 Theorganization employs a unique business modelthat allows it to deliver quality services to allpatients — no matter their income level — whileremaining protable. Aravind provides free or

extremely low-cost services to nearly 65% of itspatients, and derives its revenue from those whoare able to pay.83 Aravind also ensures that itscare providers are able to maintain high patientvolumes through detailed program management,and it now manufactures its own intraocularlenses at signicantly lower costs than othersuppliers. Beyond India’s borders, Aravind hasprovided technical assistance to institutionsin China and Egypt in an effort to strengtheninnovative eye care in those countries.

Another example of frugal innovation is India’sprivate hospitals. Many of India’s leading privatehospitals have traditionally catered to the rich andto medical tourists. Yet managers at these healthproviders have begun proactively identifying waysto cut costs and deliver services to a larger cross-section of India’s population — expanding theirmarket while beneting poor populations. TheApollo Hospitals chain is planning to expand intoless-populated areas in India and cut costs forpatients through lower overheads and reducedtravel to larger cities.84 Apollo’s administrativecosts are already on average 7% of the patient’sbill, compared to an average of 25% in the US.85

Finally, many health providers in India arecollaborating with the IT and telecommunicationssectors to deliver services to low-resourcesettings. The Indian Space Research Organization(ISRO) is working in several states across India toinitiate telemedicine centers that serve those inhard-to-reach areas. The centers link with severalspecialty hospitals to provide tailored healthadvice to patients. The Pan-African e-Networkpartnership between the Indian government andthe African Union (AU) is looking to implementsimilar models that will link patients andpractitioners in India and Africa. The UniqueIdentication Authority of India (UIDAI) also seesseveral opportunities for improving access to avariety of health services, including immunizationand maternal health.

acquired by large multinationals. At the sametime, the industry acknowledges that new trade

agreements and IP regulations threaten the long-term viability of Indian vaccine manufacturersunless they continue to build up their internalR&D capacity.

LOw-COST SERVICE DELIVERY

India is often noted as a source of what expertscall “frugal innovation” — the ability to do morewith less.81 Business leaders and health providersin India have applied this concept to severalaspects of health services, with active supportfrom the IT sector and growing mobile phone

industry. These cost-cutting approaches haveexpanded access to quality health services amongsome of the poorest people in India, and arestarting to be applied globally.

Aravind Eye Hospital has been providing low-cost vision care in India for more than 30 years.It is currently the largest ophthalmologicalorganization in the world, treating approximately

Unique Identication Authority of India

In 2010, India formally launched aninitiative to provide every citizen with a12-digit identication number (UID). The

Unique Identication Authority of India(UIDAI) is charged with issuing the UIDnumbers and maintaining a database ofresidents containing biometric data andother information. To date, more than 110million UID numbers have been issued,with signicant implications for health.Linking UID information with hospitalor medical facility records could informpublic health program managers of theprevalence of various routine diseaseconditions and prepare the health systemto respond to unforeseen epidemics. TheUIDAI is planning to partner with RashtriyaSwasthya Bima Yojana (RSBY) — anothergovernment program aimed at providinginsurance to those living below the povertyline — to improve efciency in terms ofhealth insurance.




56


Research Initiative provides small and mediumbiotechnology companies with funding for proof-of-concept research and late-stage productdevelopment. To date, the program has resultedin the commercialization of a recombinant folliclestimulating hormone, the development of a

silk protein lm for burn victims, and an autodispenser for diagnostic applications.89,90 TheBiotechnology Industry Partnership Programmeprovides funding to companies on a cost-sharingbasis with a particular focus on developingtechnologies to address the country’s pressingdevelopment priorities.91 The program also aimsto build indigenous IP.

At the same time, DBT has signicantlysupported new vaccine innovations in India. A liveattenuated oral rotavirus vaccine — developed

through a unique partnership between theDBT, Bharat Biotech, the Society for AppliedStudies, the National Institute of Immunology,the Translational Health Sciences TechnologyInstitute, the Indian Institute of Science, andthe All India Institute of Medical Sciences — iscurrently in Phase III clinical trials. PATH, theUS Centers for Disease Control (CDC), the USNational Institutes of Health (NIH), StanfordUniversity and the Gates Foundation are providingtechnical expertise and program funding. Underthe partnership, Bharat Biotech will provide thevaccine to the Indian government’s NationalImmunization Program at US$1 per dose. Ifclinical trials continue to go well, the vaccinecould be available as soon as 2014.92,93

gOVERNMENT OF INDIA,

DEpARTMENT OF BIOTECHNOLOgY (DBT)

The DBT is a key hub for Indian health innovation.DBT’s mandate covers health, agriculture,environment and animal science. However,health is a core component of DBT’s activities

and accounted for a signicant proportion of theorganization’s US$180 million annual budget in2009 and 2010.86 The agency also collaborateswith institutions in countries around the world,including SAARC and ASEAN countries. Many ofthese projects focus on R&D and capacity buildingbetween countries.

The DBT was established in 1996 as a division ofthe Ministry of Science and Technology, with aninitial focus on strengthening advanced degreetraining in the biological sciences. This work

continues today, and the department recentlyannounced an initiative to build academiccapacity in the biosciences through six newresearch institutions and long-term partnershipswith leading national universities and researchcenters.87 Yet the agency has expanded itsactivities by engaging the private sector ininnovation, including helping to establish innovativebiotechnology research and incubation parks tosupport new biotechnology companies. Theseresearch parks received more than US$600,000 in2009 and 2010 from the DBT.88

In addition, two agship programs providefunding for businesses with signicant innovationpotential. The Small Business Innovation




economic lAnDscAPe

Starting in the late 1970s, after decades ofrelative political and economic isolation, theChinese government began to move the countryaway from a centrally planned economy toward amore market-oriented system — albeit one withstrong government controls. This shift spurred

rapid economic and social transformations thathave continued ever since.5

China’s growth over the past three decades hassupported the largest reduction in poverty and thefastest increase in national income ever seen inany country.6 Much of this is owed to governmentinvestment in infrastructure and industry, with an

eye toward establishing an export-driven economy.Exports of goods and services now account for30% of the country’s GDP — and in 2010 Chinabecame the world’s largest exporter, surpassingGermany.7,8 China’s massive population and cheaplabor have been an advantage in this regard,helping to fuel enormous industrial capacity,and since 1980 approximately 200 million rural

laborers and their dependents have relocated tourban areas to nd work in factories and otherindustries.9 However, new labor force entrantsare expected to decline substantially as a result ofChina’s “one-child” policy and an aging population,and wages and expectations are rising.10 This coulderase many of the current economic benets ofChina’s enormous labor pool.

C hina holds signicant power among the BRICS and globally. In 2010, after more than

30 years of sustained economic growth, China eclipsed Japan to become the world’s

second largest economy.1 The country’s GDP has increased by an average rate of 10% since

1980, and it now boasts an economy larger than all of its BRICS counterparts combined. 2,3

Export-driven growth has helped China build enormous foreign currency reserves, and it

has allowed the government to make massive investments in infrastructure, industry and,

increasingly, innovation. The country’s political and military power is growing and China

holds a permanent seat on the UN Security Council.4 China also commands strong inuence

among low- and middle-income countries, and has established important economic ties in

regions throughout the world. Yet when measured by per capita indicators, China remains

a developing country, and it faces challenges including a massive population, shifting

demographics and politics, high levels of income inequality and slowing growth.

5 CHINA



58


China has also sought to establish strong bilateraltrade and development ties in Africa, SoutheastAsia and Latin America, and it has convenedregular cooperative meetings such as the Forumon China-Africa Cooperation (FOCAC). China’srising global stature has led to some criticismof its policies on trade, currency exchange andhuman rights. In response to these concerns, theChinese government emphasizes its belief thatChina remains a developing country, and that itis inappropriate for any country to intervene inanother’s domestic affairs.17,18


Like other BRICS, China still faces a large burdenof infectious diseases, including TB, hepatitis andHIV/AIDS.19 TB — including drug-resistant TB —is the country’s top infectious killer, and China ishome to around one-third of all hepatitis B carriers

worldwide.20 HIV/AIDS prevalence rates remainrelatively low (around 0.1%), due in partto a series of aggressive HIV/AIDS prevention andtreatment programs initiated in 2003.21,22 However,China recently released data showing that HIV/AIDScases had increased by 45% over 2006 levels.23

As China’s economy has grown, chronic NCDshave become more common. NCDs constituted83% of deaths in 2008 (Figure 5.1), up from 58.2%of deaths during 1973 to 1975, and the burdencontinues to grow.24 Hypertension, diabetes and

obesity are all major concerns, particularly inurban settings.25 China is also the world’s largestconsumer and producer of tobacco, and thecountry is home to one out of every four tobacco-related deaths worldwide.26

Access to basic health care remains a criticalchallenge for China’s population. China boastsworld-class medical facilities in its major

More recently, China’s government has begunto emphasize domestic consumption to balancerising income levels, shifting demographics andreduced growth in international demand. China’sdependence on exports was highlighted duringthe global nancial crisis, which threatened

the manufacturing sector.11,12 Yet the country’seconomy showed signicant resilience. In 2012,the Chinese government cut its annual economicgrowth target for the rst time in eight years, butgovernment stimulus funds and policy changeshave so far helped offset turbulent movementsof capital.13 Threats to continued growth remain,but China’s strength stands out in comparisonto the struggling economies of the traditionalpowerhouses of the G8. In 2011, European leaderswent so far as to ask the Chinese government toconsider investing in measures to shore up the

EU economy.14

Domestic Politics

AnD FoReiGn AFFAiRs

China is a socialist country led by the ChineseCommunist Party. For the past decade, leadersincluding President Hu Jintao and Premier WenJiabao have led the country’s economic andgeopolitical ascendance. However, in 2012, theParty leadership will undergo a transition forthe rst time in ten years. While the handover of

power is expected to be smooth, it comes at anuncertain time for the global economy and amidwide-reaching social change within China.15

As a result of its massive economic inuence,China has begun to play an increasingly assertiveand outspoken role in international affairs. Thecountry has become a vocal presence at G20discussions — particularly since the onset of theglobal nancial crisis. China is also a prominentmember of many multilateral institutions,and a key partner in regional organizations

including ASEAN and the Asia-Pacic EconomicCooperation Forum.16

China’s growth over the past three

decades has supported the largest

reduction in poverty and the astest

increase in national income ever

seen in any country.

In 2009, China’s leaders committed

an unprecedented US$124 billion

or health sector reorm over three

years. This initiative aims to improve

inrastructure and human resources

capacity across the health system,

and ensure health insurance or the

whole population.




cha’ Frg

Aa

China has a long history of providing foreignassistance. Since 1950, the country hascommitted various forms of aid to more than160 countries and 30 international organizations.31 Yet China’s foreign assistance programs haveexpanded in parallel to the country’s enormouseconomic growth. While China does not publiclyreport annual assistance gures, it appearsthat Chinese aid is rapidly increasing and thegovernment disbursed an estimated US$3.9billion in 2010 (Figure 5.2).32 China’s approach

to foreign assistance is driven by a commitmentto South-South cooperation through mutuallybenecial economic development, infrastructureand trade projects, and non-interference in thedomestic affairs of other countries. The statedgoal is to help recipient countries strengthentheir capacity for self-development, and itappears to reect China’s own recent historyand current experiences.

cities, but health care infrastructure variessubstantially across regions and income levels— and migrant workers often have difcultyin accessing care. In the early 1980s, the

government moved to reduce spending onhealth and to privatize health care.27 This wasparticularly damaging in rural communities,which found themselves with little access tohealth insurance or consistent health services.28 These trends continued until the 2003 SARSoutbreak exposed critical shortcomingsin China’s health care system, laying thegroundwork for reforms.29

In 2009, China’s leaders committed anunprecedented US$124 billion for health sector

reform over three years. This initiative aims toimprove infrastructure and human resourcescapacity across the health system, and to ensurehealth insurance for the whole population.30

5.1 cHinA leADinG cAUses oF DeAtH, 2008

COMMUNICABLE DISEASES AND MATERNALAND CHILD HEALTH CONDITIONS



TB

All Other

HIV/AIDS



Cancers



Diabetes

INJURIES

Injuries





60


it to promote trade and mutually benecialdevelopment projects in recipient countries.37 Today, China sees itself as a leader among

developing countries and prides itself on itsphilosophy and commitment to South-Southcooperation and self-sustaining economicdevelopment. The government views this asbeing in direct contrast to the Western donorapproach. China also explicitly rejects Westernmodels of assistance that impose political andsocioeconomic conditions on recipients.38 WhileChina does invest heavily in countries where ithas strategic economic and political interests,it maintains a policy of noninterference in theinternal affairs of other countries.39

cURRent FoReiGn

AssistAnce PRoGRAm

China releases very little information about annualor country-level foreign assistance and untilrecently, China had never announced a formaldevelopment assistance policy.40 At the Global Aid

tRenDs in

FoReiGn AssistAnce

Since the 1950s, China has prioritized foreignassistance as a tool for geopolitical engagement.33 At its start, China’s foreign assistance programtargeted socialist neighbors in support of theirsecurity and socioeconomic development. Inthe 1960s, China began looking beyond itsneighbors, particularly to Africa.34 Under MaoZedong, the Chinese government felt it was thestate’s obligation to help post-colonial regimesmodernize.35 However, foreign assistance alsoallowed China to build strategic relationshipswith “non-aligned” states during the Cold War,

and helped China to compete with Taiwan fordiplomatic recognition.36

As the Chinese government implementedeconomic reforms in the 1980s and 1990s,policymakers began to explore new approachesto foreign assistance. China began to emphasizethe economic aspects of assistance and use

$4,500

$4,000

$3,500

$3,000

$2,500

$2,000

$1,500

$1,000

$500

$02000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010*

Ofcial External Assistance

EXIM Bank Concessional Loans

Source: “The Dragon’s Gift: The Real Storyof China in Africa,” D. Brautigam, 2009; GHSi AnalysisNote: *GHSi estimate

5.2 cHinA oFFiciAl FoReiGn AssistAnce (USD Millions)




that Chinese foreign assistance totaled aroundUS$25 billion in 2007 alone.45 However, theseestimates include Chinese economic investmentsthat are not dened as assistance by the Chinesegovernment. While China employs a differentapproach to assistance than many Western

donors, its policymakers draw a clear distinctionbetween what they consider to be trade orforeign direct investment and what they considerassistance. The latter is solely comprised ofgrants, interest-free loans and concessional loansto other developing countries.46

The majority of China’s foreign assistance isprovided through bilateral channels and focusesheavily on infrastructure — a developmentpriority that many traditional donors have movedon from in favor of social programs.47,48 Based on

cumulative gures, the largest share of Chineseassistance since 1950 — about 41% — has beenallocated through grants, which are focusedon infrastructure projects such as schools andhospitals and humanitarian aid. Interest-free andconcessional loans have generally focused on heavyinfrastructure projects including transportation andenergy, and industrial development.49

Geographically, Chinese foreign assistancefocuses on Africa and East and Southeast Asia,and the government reports that nearly 80% of

Effectiveness Forum in 2011, China declared “theprinciple of transparency…should not be seen as astandard for South-South Cooperation.”41

However, that same year, China released a whitepaper on foreign assistance highlighting thegovernment’s overall policies and programs,including cumulative funding totals from 1950-2009, regional focus and management.42 Accordingto this document, China has given a total ofUS$40.5 billion in cumulative foreign assistance

since 1950, and assistance increased at an annualrate of 29.4% between 2004 and 2009.43

China’s white paper portrays the country’sforeign assistance very differently than manyexternal theories about its program. Prior tothe white paper’s release, some China scholarsbelieved that the country’s foreign assistance —particularly in Africa — had grown so large thatit was on par with the US and the World Bank. 44 A 2008 study by New York University’s WagnerGraduate School of Public Service estimated

Today, China sees itsel as a leader

among developing countries and

prides itsel on its philosophy

and commitment to South-South

cooperation and sel-sustaining

economic development.

5.3 cHinA FoReiGn AssistAnce By ReGion, 2009

Africa

Asia

Latin American and the CaribbeanOthers

Oceania

Europe

Source: China’s Foreign Aid, State Councilof the People’s Republic of China, 2011



62


decision-making and implementation. To enhanceinter-agency coordination, MOFCOM recentlylaunched a collaboration mechanism to enabledevelopment of strategic assistance policiesacross government bodies.55 As its assistancespending continues to grow, China could likely

benet from having a dedicated developmentagency for their work in Africa and other areas.

cha’ Hah

Aa

Funding for health comprises a limited amountof China’s total foreign assistance spending.However, based on domestic experiences,

Chinese policymakers recognize health care as abuilding block for poverty alleviation throughoutthe Global South.56 With this in mind, China hasemployed health assistance as a soft powertool to engage other developing countries,particularly in Africa.57 This assistance is providedlargely through bilateral channels and focuseson health infrastructure, human resourcesdevelopment and, increasingly, malaria control.At the policy level, China has played a critical roleadvancing regional discussions around publichealth preparedness and disease surveillance,

particularly around inuenza and emerginginfectious diseases.

mAjoR tRenDs in

HeAltH AssistAnce

China’s initial work in global health was drivenby the same ideological factors that guided thecountry’s early foreign assistance program. In1963, China sent a medical team abroad to Algeriato provide services in the aftermath of the country’swar of independence.58 This was the rst time

China deployed medical professionals overseas.However, since then, international medical teamshave become a consistent component in China’sforeign assistance program — and a source ofpride for the Chinese government.

More recently, China’s leadership has come tosee global health engagement as a “mutuallybenecial” tool similar to other areas of foreign

funds through 2009 went to these regions (Figure5.3). In Africa, China provides some level ofassistance to 48 of the 54 states on the continent.50 Although originally propelled by political andsocial interests, in recent years China’s assistanceprograms in Africa have been largely driven byeconomic development concerns. In 2000, Chinashowcased its growing commitment to Africaby launching FOCAC. The Forum’s aim is tocoordinate and promote economic collaborationacross the continent, and it holds major summits

with heads of government every three years.51 FOCAC helps China engage African partnerson key economic and political priorities. TheChinese government has also strategically usedFOCAC summits to announce foreign assistancecommitments to the region that build goodwill.

These types of approaches have led to somecriticism that China is tying its assistance todomestic economic interests. As part of China’sphilosophy of mutually benecial developmentprojects, the government often requires recipients

to source procurement from Chinese rms. Itappears that China has, at times, also requiredChinese labor to be used on infrastructuredevelopment projects.52 However, these policiesare not unique to China. US regulations oftenrequire that aid programs use Americantechnologies and food supplies.53 While opinionsdiffer, Chinese policymakers view its approach asa straightforward way to create win-win programsand build more equal development partnerships.

China does not currently have a central agency for

foreign assistance and its programs are overseenby a number of government ministries. TheMinistry of Commerce (MOFCOM) is the primarycoordinating body, responsible for the formulationof assistance policies, regulations and projectmanagement.54 MOFCOM works closely withthe Ministry of Foreign Affairs, the Ministry ofFinance, the Ministry of Health (MOH), provincialgovernments and the Export-Import Bank on

Based on domestic experiences,

Chinese policymakers recognize

health care as a building block or

poverty alleviation throughout the

Global South.




traditional Chinese medicine for centuries.By improving access to Cotecxin, the Chinesegovernment could help African communities

combat malaria while bolstering the Chinesepharmaceutical industry. In 1996, all Chinesemedical teams were required to use Cotecxin.62

China has also played a prominent role in South-South cooperation around reproductive health.In 1997, China joined Partners in Population andDevelopment (PPD), an initiative launched at the1993 International Conference on Populationand Development to facilitate South-Southpartnerships.63 Since joining PPD, China hashosted a number of conferences, consultations

and trainings on family planning and reproductivehealth. The Chinese government — in coordinationwith provincial family planning committees — hasalso donated reproductive health technologies andhelped to build family planning clinics, particularlyin Africa.64,65 While some of China’s domesticreproductive health policies have met withsignicant criticism, the country does not seek toimpose any policies on recipient countries.

assistance. By helping to improve health indeveloping countries, Chinese policymakersfeel they can have health impact and help build

political and economic alliances. This approachhas led some experts to argue that Chinesehealth assistance is often driven by an interestin securing access to natural resources andeconomic markets.59 Yet Chinese policymakers dofeel that their country has resources and criticalexpertise to share with other, poorer countriesgiven its perceived domestic success in improvinghealth care with limited resources.60

An example of China’s complex approach toassistance is malaria. China has in the last two

decades prioritized malaria treatment within itshealth assistance programs. Malaria is also akey policy platform of the FOCAC.61 China hassupported malaria programs in some form formore than 30 years, but these efforts increasedafter 1993 when the WHO approved Cotecxin,an artimesinin-based antimalarial medicine.Artimesinin, a key antimalarial, is derived froma native-Chinese plant and has been used in

Source: China Health Aid to Africa, Liu Peilong, Guo Yan, Li Anshan, Ding Xuhong, Yang Haomin, 2011Note: *Additional commitments made in 2009 for malaria activities across all categories; USD:RMB currency conversionbased on IMF annual average exchange rates

0 $50 $100 $150 $200 $250 $300 $350

Additional Commitments*

Medical Equipment and Drugs

Human Resources for Health

30 Malaria Prevention andTreatment Centers

30 Hospitals

Chinese Medical Teams

5.4 estimAteD cHinese HeAltH AssistAnce

to AFRicA 2007-2011 (USD Millions)

TOTAL: US$757.1M



64


and treatment within the FOCAC framework.72 Atthe 2006 FOCAC Summit, the Chinese governmentannounced US$37.6 million in grants for 30malaria treatment centers and antimalarials. In2009, China announced an additional US$73.2million to support malaria programs and other

facilities across the continent.73 The exact currentstatus of many of these projects is unclear, butthey do not appear to be integrated with any otherglobal malaria programs.

HEALTH INFRASTRUCTURE

Infrastructure is a key component of all Chineseforeign assistance — including health efforts. Bythe end of 2009, China had provided assistanceto build more than 100 hospitals and clinics indeveloping countries, primarily in Africa.74 Chinahas also helped to supply many developing

country health clinics and hospitals with drugs,medical equipment and reproductive healthcommodities. To help ensure sustainableproduction of medicines, China has also fundedthe construction of pharmaceutical factories inMali, Tanzania and Ethiopia through its healthassistance activities.75

HUMAN RESOURCES FOR HEALTH

China has long expressed its commitment toimproving developing countries’ health careworkforces through training and scholarships.

China provides on-the-ground training programsthrough Chinese Medical Teams or otherinitiatives. However, China has also traditionallyprovided scholarships for students fromdeveloping countries to study in China.76 Theseshort-term training courses allow health carepersonnel to gain further expertise in topicssuch as family planning, malaria treatment andprevention, and traditional Chinese medicine.In the lead up to the 2015 MDG deadline, Chinahas emphasized human resources training as acritical area. In 2008, Chinese premier Wen Jiabaoannounced a ve-year program to train 1,000health care practitioners across Africa.77

AssistAnce to


China has traditionally provided health assistancethrough bilateral channels, providing limitedsupport to global health multilaterals. However


FoR HeAltH

The majority of Chinese health assistanceis provided through bilateral channels andis focused primarily on Africa. The Chinese

government does not release annual reports onits programs, so it is difcult to quantify annualhealth assistance. However, it is estimated thatChina committed approximately US$757.1 millionin health assistance to Africa between 2007and 2011 (Figure 5.4). Chinese bilateral healthassistance has also traditionally fallen into a fewmajor categories:

CHINESE MEDICAL TEAMS

Chinese medical teams have been a criticalelement of Chinese health assistance since

the 1960s. Medical teams are typically madeup of 15-25 physicians, laboratory techniciansand assistants who provide free medical care

in recipient countries. They are often sent to

communities that lack access to health careand provide services to the community and train

local medical staff to build capacity.66,67 China

also deploys medical teams to assist in disaster

relief efforts; they were among the rst medicalaid teams to arrive after the 2003 earthquakes

in Algeria and Iran, and after the 2005 tsunami

in Southeast Asia.68 Through 2009, the Chinese

government reports sending more than 21,000medical workers to 69 countries worldwide.69,70

MALARIA SUppORT

As noted, China supports a variety of malariaprograms in Africa and in 2005 it pledged toincrease this assistance.71 Based on its ownexperience in combating the disease — as wellas its interest in promoting artemisinin therapies— China developed programs for malaria control

At the 2006 FOCAC Summit, the

Chinese government announced

US$37.6 million in grants or

30 malaria treatment centers

and antimalarials. In 2009, China

announced an additional US$73.2

million to support malaria

programs and other acilities

across the continent.




income countries.81 Importantly, the Chinesegovernment announced it would use domesticresources to cover Global Fund commitments— a decision lauded by UNAIDS and otherinternational HIV/AIDS groups. It is still unclear

whether the Global Fund’s new policies aroundmiddle-income countries will impact China’sdonations to the organization.82

In recent years, China has also increasedits commitments to WHO, particularly sinceMargaret Chan became Director-General. Dr.Chan served as Hong Kong’s Director of Healthduring the 2003 SARS outbreak, and the Chinesegovernment strongly supported her candidacyfor Director-General in 2006.83 The governmentcommitted US$8 million to her campaign, which

included an intense three months of canvassingand relationship building with various UNofcials.84,85 In January 2012, WHO’s ExecutiveBoard nominated Dr. Chan for a second term,which is now pending approval by the WorldHealth Assembly.86

Over the last decade, China has alsodemonstrated leadership within regionalorganizations around public health and disease

it has consistently supported UNICEF, WHO andmost visibly, the Global Fund (Figure 5.5).

In 2003, China began to build a strongrelationship with the Global Fund — as both a

recipient and, to a much smaller extent, a donor.Since then, China has received US$587 millionfrom the Fund, making it one of the largestrecipients of grants. Over the same period, it hasdonated US$20 million.78 In 2011, China doubledits steady US$2 million commitment and pledgedto further increase its annual commitment in2012 and 2013.79 China has also been active onthe Fund’s board.

Recently, however, China’s engagement with theFund has been overshadowed by controversy.

In 2011, the Fund froze payments to Chinadue to nancial irregularities and concernsthat disbursements were not being channeledappropriately to civil society organizations.80 It became an opportunity for critics to arguethat China was too rich to deserve additionalsupport. Although funds were reinstated a fewmonths later, China was cut off again in 2012when — facing severe funding shortfalls — theGlobal Fund cancelled future grants to middle-

5.5 cHinA contRiBUtions to key


Source: UNICEF; UNFPA; UNAIDS; Global Fund

$30

$25

$20

$15

$10

$5

$0

UNICEF

GLOBAL

FUND

UNAIDS

UNFPA



66


In terms of health specically, Chinese public andprivate vaccine manufacturers are widely expectedto begin entering the global market soon,further reducing prices and improving accessin developing countries.94 This impact couldextend to other health care technologies such as

diagnostics and family planning commodities.While government investments prioritize domesticneeds, a number of international organizationsare working with Chinese institutions to directtheir research toward tools and strategies thatcould benet other developing countries.95 To besuccessful, however, these institutions will needto overcome lingering concerns about the qualityof their products, as well as signicant culturaland systemic barriers that have often kept themfrom pursuing international markets.96

key tRenDs inHeAltH innoVAtion

The Chinese government is the largest sourceof domestic funding for science and technology.Over the last decade, the government has rapidlyincreased its investments in R&D through bothpublic and private entities .97 Government R&Dspending has grown by 20% every year for thepast decade and in 2009, China surpassedJapan to become the world’s second-largestinvestor in R&D after the US (Figure 5.6). In

2012, government expenditures on science andtechnology are expected to reach US$36.1 billion,a 12.4% increase on 2011 spending.98 AlthoughR&D budgets are soaring, the government hasalso emphasized the need for scientic capacitybuilding, specically around innovation. In2011, Chinese Premier Wen Jiabao announcedthat the central government was aware of thecountry’s “insufcient scientic and technologicalinnovation capabilities,” adding that the Chineseeconomy needs to be put on a path of internallydriven growth, “driven by innovation.”99

To accomplish this goal, China has, among otherstrategies, developed 16 "mega projects" in 11focus areas. Two of these "mega projects" focuson health specically:

1) Control and prevention of infectious diseases

2) Drug innovation and development100

surveillance.87 After the SARS epidemic,China began to strengthen collaboration withcountries across Asia to confront the threat ofborderless health emergencies like avian andhuman inuenza. China identied health — andparticularly the management of public health

emergencies — as a key priority for collaborationwith the ASEAN. China has also worked with theother countries in the Greater Mekong Subregionto institutionalize disease surveillance.88

China has also helped to drive global dialoguearound TB — particularly drug-resistant TB.China has one of the world’s largest burdens ofTB and one-third of all global multidrug-resistant(MDR) cases.89,90 In 2009, China hosted a WHOMinisterial Meeting of High Multi/ExtensivelyDrug-Resistant (M/XDR) — TB countries that

drew senior-level participation from 31 nations.91 Based on the outcomes of the meeting, China putforward a resolution on prevention and controlof M/XDR TB that was adopted at the 2009 WorldHealth Assembly.

While China’s engagement with multilateralscontinues to expand, some bilateral programsremain isolated from similar programssupported by other countries and global healthagencies. Greater coordination with multilateralmechanisms could therefore be useful to

maximize the impact of China’s contributions.

ch iva

ad ipa fr

Gba Hah

China’s government is currently investingenormous resources in science and technology

with the goal of catalyzing more domestic R&Dand accelerating the country’s transition frommanufacturer to innovator.92 There also continuesto be high amounts of foreign investment inChinese industries and facilities.93 Given thesheer scale of industry in China and the nancialresources available, this is expected to havesignicant global impact in areas ranging fromclean energy to transportation to health.




and the government tends to be their major — ifnot only — customer.105 The industry currentlyproduces domestic versions of almost everyvaccine available elsewhere in the world, withthe exception of the HPV vaccine and IPV.106 Yetmost companies have never focused on producing

vaccines for global customers. At the sametime, the government purchases vaccines for thenational program at xed prices, which provideslimited prot margins and stagnates innovation.107

With growing competition in the domestic market,Chinese biopharmaceutical manufacturers havebegun to look at global markets with increasinginterest. However, there are a number of systemicchallenges that inhibit scale-up for internationalproduction. Many Chinese manufacturersare not familiar with WHO prequalication

or UN agencies’ procurement programs.108 In addition, many Chinese manufacturers donot have the English-language capabilities oftheir counterparts in India. This puts Chinesemanufacturers at a disadvantage because Englishis the working language of most UN agenciesand is required for negotiations and bureaucraticapproval processes.109

These "mega projects" are supported by 500,000skilled personnel at nearly 4,000 researchinstitutes funded by the government, withresources totalling US$6.3 billion annually.101

In the meantime, China’s biopharmaceutical

and medical technology sectors, whichinclude private, semi-private and state-ownedenterprises, already produce a variety of healthproducts for the domestic market. Theseinclude vaccines, low-cost family planningtechnologies, drugs and diagnostics. China’sactive pharmaceutical ingredients (API) industry isone of the largest drivers of growth across China’sbiopharmaceutical sector, along with traditionalChinese medicines and supplements. In 2005,China’s API market was nearly US$5.7 billionand it has been growing rapidly at rate of 15-

19% per year.102 API accounts for 84% of China’spharmaceutical exports.103 However, qualityconcerns — and an abundance of counterfeiting— continue to affect global perceptions of China’sAPI industry.104

In terms of vaccines, Chinese manufacturershave historically supplied most of the productsneeded for the national immunization program,

5.6 cHinA Vs. G7: GRoss Domestic sPenDinG on R&D (USD Billions)

$450

$400

$350

$300

$150

$100

$50

$02005 2006 2007 2008 2009

$401.6

$154.1

$137.3

$83.3

$49.1$39.5$24.5$24.5

US China Japan Germany France UK Canada Italy

Source: OECD, Main Science and Technology Indicators, 2011



68


and resources to advance global health andagriculture. Under the partnership, the GatesFoundation and MOST will work to identify andco-fund projects that:

• Promote R&D around new products that

will have meaningful impact on alleviatingpoverty globally

• Accelerate the translation of project resultsinto products that can be delivered for impactin resource-poor countries

• Mobilize public and private sector support toaddress the needs of resource-poor countries

Initial priorities are likely to include innovationsin human and animal vaccines and R&D for

new technologies to combat TB and otherinfectious diseases. Eligible projects will promoteavailability of new data and information to thescientic and development communities, andensure that resulting products benet the needsof developing countries.

While specic nancial commitments by partnershave not been nalized, funding is expected tototal at least US$300 million. The MOST willmatch the foundation’s nancial contribution on aminimum 2:1 basis, meaning China’s contributionis expected to be around US$200 million.

The partnership established operations in therst quarter of 2012 and the Gates Foundationand MOST expect to begin funding and managingprojects by the end of 2012.

CHINESE VACCINES MANUFACTURERS

China is home to one of the largest and fastestgrowing vaccine industries in the world, withan annual production of more than 1 billiondoses.114 As previously noted, Chinese vaccinecompanies largely provide vaccines to the Chinese

immunization program, and have not traditionallypursued global customers.115 It is clear, however,that there is enormous potential. In 2009, in theface of a potential global health emergency, aChinese manufacturer produced the rst effectivepandemic H1N1 vaccine in just 87 days, beatingcompanies from the US and Europe.116

The MOST is working to supply manufacturerswith guidelines to accelerate preparations forglobal markets. At the same time, a numberof international organizations, including theGates Foundation, FHI 360 and PATH, are workingwith Chinese health care technology companies

to build knowledge and capacity and connecttheir innovative potential with major globalhealth needs.

key innoVAtion

cAse stUDies

HEALTH “MEgA pROjECTS”

China’s MOST has invested more than US$1.3billion in two health “mega projects,” focused ondrug development and infectious disease controland prevention.110

The drug discovery “mega project” has threespecic goals to achieve by 2020:

1) Identify, verify and produce new chemical andbiopharmaceuticals

2) Increase domestic capacity to test drug safetyand efcacy

3) Develop new Chinese traditional medicines111

The emphasis is on drugs to combat NCDs,

and specic areas of focus include cancer,cardiovascular disease, neurodegenerativediseases, diabetes and mental illness.

The infectious diseases "mega projects" is focusedon control and treatment of HIV/AIDS, hepatitisB and C, and TB. Funding is being channeledtoward the development of new vaccines,pharmaceuticals and diagnostics, as well as newprevention and treatment standards based ontraditional and Western medicine.112 Through theproject, China hopes to independently develop

40 types of unique diagnostic reagents and 15vaccines to address infectious diseases.113

gATES FOUNDATION/MOST

MEMORANDUM OF UNDERSTANDINg

In 2011, the Bill & Melinda Gates Foundationforged a partnership with the Chinese MOSTthat aims to leverage China’s technical expertise




immunized — and by the end of 2010 it had beenregistered in nine countries.124 Chengdu has builta new manufacturing facility to enable productionfor GAVI-eligible countries and, as previouslynoted, it has applied for WHO prequalication.125 Many expect the JE vaccine to be China’s rst

prequalied product.

Chinese vaccine manufacturers are also alreadyengaged in partnerships focused on other globalhealth challenges. CNBG recently announced apartnership with the Aeras TB Vaccine Foundationto conduct research on a novel TB vaccine. Thepartnership will cover every aspect of productdevelopment — from preclinical research toclinical development.126 In addition, CNBG andWuhan Institute of Biological Products are workingclosely with PATH to manufacture a new rotavirus

vaccine for use in developing countries.127

SINO-IMpLANT (II)

China has long been a leader in producing high-quality, low-cost family planning technologies,in order to support its domestic family planningpolicies. By 1995, the government had alreadybuilt more than 40 factories to produce thesetechnologies, and was supporting production withmore than US$30 million annually.128

In 2007, the non prot Family Health International

(now FHI 360) — with funding from the Bill& Melinda Gates Foundation — partneredwith Shanghai Dahua Pharmaceutical Co. toaccelerate global access to Sino-implant (II), alow-cost, highly effective injectable contraceptiveimplant. Once inserted, Sino-implant (II) worksfor up to four years with 99% effectiveness,dramatically reducing the risk of unwantedpregnancy when compared to alternativecontraceptive methods, including condomsand oral contraceptives.129 At US$8, Sino-implant(II) is signicantly more affordable than

Western-produced alternatives, which averagearound US$18.130

By February 2012, more than half a millionunits of Sino-implant (II) had been procured forglobal use under the Gates-funded initiative.Impact-modeling indicates that Sino-implant (II)'sintroduction is already beneting the health ofwomen and their families. The units are estimated

Chinese vaccines are generally high-quality, butthe country has historically lacked the regulatorycapacity to ensure they meet internationalstandards. Like Indian biopharmaceuticals,Chinese companies have also suffered from areputation for producing substandard products.117

However, in March 2011, WHO formallyrecognized the Chinese SFDA as a functionalregulatory body for vaccines.118 The validation ofChina’s primary regulatory agency means thatChinese vaccine companies can now apply forWHO prequalication and eventually sell to thelarge global public market through groups likethe GAVI Alliance and UNICEF.

The Chinese government is taking stepsto maximize this opportunity to competeinternationally. Immediately following the

announcement, the SFDA established strictregulations on quality and manufacturing, andthe government is working with companies to getup to standard by set deadlines.119 Manufacturershave been forced to invest signicant time andresources to comply with these criteria. ChinaNational Biotec Group (CNBG), for example,announced that it planned to invest about US$10billion in upgrades.120 Due to the investmentinvolved, China still doesn’t have any WHOprequalied vaccines. However, two vaccinecompanies have submitted applications — one fora seasonal u vaccine and another for a JapaneseEncephalitis (JE) vaccine.121

Given the extent to which Indian vaccinemanufacturers have driven down prices andhelped expand access in poor countries, the entryof Chinese manufacturers in the global marketcould have signicant impact. This theory is borneout by previous efforts. For more than 20 years,China has been vaccinating its children against JEwith a vaccine produced by Chengdu Institute ofBiological Products, a subsidiary of CNBG.122 Thevaccine is administered in one dose, which makesit particularly appropriate for use in low-resourcesettings. Recognizing this, the Gates Foundationand PATH have provided technical and clinicaltrial support to expand manufacturing, link thecompany to the global market, and prove thevaccine’s safety and effectiveness.123 As a result,the vaccine has been introduced in India — as of2010, more than 130 million children had been




70


to have provided 2 million couple-years ofprotection from pregnancy, and have prevented562,000 unintended pregnancies, 2,200 maternaldeaths and 107,000 abortions worldwide.131

FHI 360 estimates that if just 20% of sub-Saharan

African women already using oral or injectablecontraceptives switched to implants, they couldprevent 1.8 million unwanted pregnanciesannually.132 The organization is currently helpingDahua negotiate mutually benecial contractswith global public sector and nonprot partnersin the hopes of guaranteeing long-term access.133 As of November 2011, Sino-implant (II) had beenregistered in 20 countries and was under reviewin an additional 10.134,135

In addition, PATH has partnered with Shanghai

Dahua Medical Apparatus Company around

mass production of a next-generation Woman’sCondom. (Shanghai Dahua Medical Apparatus

Company and the Sino-implant (II) manufacturer

were once part of the same state-ownedcompany but are now separate entities.)

Under the agreement, PATH licensed Dahua

to manufacture and distribute the product,which was developed in Seattle at PATH’s

product development headquarters. Dahua was

selected because of its ability to rapidly producesignicant quantities of the Woman’s Condom at

a low cost. The product has received Shanghai

Food and Drug Administration and European CEapproval, and in March 2011, it was submitted

for WHO prequalication. The aim is to make the

Woman’s Condom available throughout Chinaand sub-Saharan Africa, and to eventually work

toward global access.136




economic lAnDscAPe

South Africa’s economy has grown steadily sincethe end of apartheid and, following a decade ofstabilization, economic growth reached almost 5%each year from 2004 through 2007. This increasedgrowth was largely due to a global commoditiesboom, which boosted exports to US$91 billion in

2008 — 33% of GDP — and helped reduce publicdebt to half its 1994 level.1 At the same time,GDP per capita (PPP) has steadily increased fromUS$6,800 in 2000 to US$10,800 in 2010.2 Followingthe global nancial crisis, South Africa’s economyslipped into recession for the rst time in 17years. However, a stable banking system andshort-term stimulus from the FIFA World Cupbrought growth back to 2.84% in 2010.3

South Africa’s economy is driven by its servicesindustry and extensive mineral resources. It iscurrently among the top ve global producersof diamonds, coal, chrome and manganese.Its mineral resources make South Africa animportant and attractive trading partner,particularly to China. Bilateral trade betweenthe two countries exceeded US$25 billion in

2010, more than ten times 1998 levels.4

Yet South Africa is still struggling to overcomemajor challenges. The global economy remainssluggish, undercutting demand for mineralresources.5 At the same time, electricityshortages, aging infrastructure, and the humanand nancial costs of HIV/AIDS are taking theireconomic toll. Growth aside, unemployment and

6 SOUTH AFRICA

S outh Africa, the newest member of the BRICS, ofcially joined the group in 2010. While

its economy is signicantly smaller than any of its BRICS counterparts, it has the largest

economy in Africa and is the only African member of the G20. Following the end of apartheid

in 1994, South Africa made a notably smooth transition to democracy and reengaged with

the rest of the world. Since that time, the country’s economy and political inuence have

grown substantially. It is the gateway to Africa’s commodity markets and home to a rapidly

expanding middle class, and its vibrant civil society is seen as a model for the rest of the

continent. However, its international efforts are nascent and nowhere near the scale of

the other BRICS. South Africa is also wrestling with growing income inequality and major

social challenges, including the world’s largest burden of HIV/AIDS. Taken as a whole, South

Africa’s history and regional inuence give the country a unique political and moral authority

among developing countries — but it is currently prioritizing domestic affairs.



72


country.12 It is the only one of the BRICS with ahigher burden of infectious diseases than NCDs,such as diabetes, cardiovascular disease andcancer (Figure 6.1).

The country’s HIV/AIDS epidemic is the largest

in the world; approximately 5.6 million people,or one-fth of the population, are currently livingwith the infection. Fueled by HIV, there are halfa million cases of TB each year. TB accounts forthe majority of HIV-related deaths and drug-resistance is a major and growing problem. 13

South Africa has increasingly taken steps to curbthese twin epidemics. Efforts to combat HIV/AIDSin the early 2000s were undercut by controversialdebates around the disease under Mbeki’sadministration. However, following a hard-fought

battle by HIV/AIDS activists, the governmentimplemented a policy of universal access to HIV/AIDS treatment in 2003.14 In 2009, President Zumatook this initiative a step further and announceda groundbreaking program to accelerate accessto HIV prevention, treatment and care, includingtreatment for all HIV-positive infants under theage of one.15

South Africa currently maintains the largeststate-funded ARV program in the world, and inMarch 2012 it announced plans to test and treat

hundreds of thousands of miners aficted by TB.The government has also ramped up fundingfor health innovation through the Department ofScience and Technology, which often partnerswith South Africa’s private sector on HIV/AIDS andTB research.16 Despite this progress, however,the national health system is over-burdened andunable to keep pace with demand, and HIV/AIDScontrol efforts continue to be hampered by a lackof nancial and human resources.

South Africa provides basic health services,

including HIV/AIDS treatment, largely for free.The country is spending more money onhealth per capita (US$860 per person) thanChina (US$310) or India (US$130).17 Thisincludes signicant health assistance fromdonor countries. The scale of the investment,however, belies the state of the country’s healthinfrastructure and patient outcomes, and there ismassive “brain drain” of skilled health personnel.

poverty remain entrenched in South Africa: atleast a quarter of the population is out of workand almost half lives on less than US$2 a day.6,7

Domestic Politics

AnD FoReiGn AFFAiRs

As its economy has grown, South Africa hasplayed a more prominent role in global politics.In addition to the G20, South Africa is a memberof the WTO and has increased ties with theOECD. While South Africa does not yet belongto the OECD, they have agreed to “enhancedengagement,” which could lead to futuremembership.8 South Africa also holds a regionalleadership position in the Southern AfricanDevelopment Community (SADC) and isa member of the IBSA trilateral.9

Under President Jacob Zuma, South Africa’sforeign policy is heavily inuenced by domesticsocio-economic challenges. Since his electionin 2009, Zuma has worked to strengthenrelationships with countries like China andBrazil, seeking trade and investment thatgenerates growth and creates jobs.10 SouthAfrica’s inuence with other countries is closelylinked in turn to its economic partnerships.Trading partners view South Africa as a gatewayto other African countries, while other countries

across the continent use South Africa to accessemerging markets.

Beyond economic priorities, the Zumaadministration takes a restrained, non-interventionist approach to foreign relationsthat differs from the pursuit of pan-Africanprominence by his predecessor, former PresidentThabo Mbeki.11 Although the current governmentpromotes stability through regional conictresolution and anti-poverty initiatives, Zumaappears to prefer not to be seen as a regional

mediator and honors the autonomy of otherAfrican countries.


South Africa’s domestic health landscape isdened by its decades-long battle with HIV/AIDSand the related TB epidemic, which togetheraccount for nearly 42% of all mortality in the




the promotion of development and stability inAfrica. Over the last 18 years, more than 95% ofthe country’s foreign assistance has gone to other

African nations. This approach, combined with thefact that South Africa is by far the largest economyon the continent, has helped it build regionalinuence.19 Yet at the same time, South Africa’sforeign assistance program is small comparedto the other BRICS due to its smaller economyand because the government is focused on thecountry’s own internal development challenges.

tRenDs in

FoReiGn AssistAnce

South African foreign assistance dates back tothe late 1960s, when the apartheid governmentbegan to use assistance as a tactic to win votesat the UN and temper international criticism ofits regime.20 After the transition to democracyin 1994, the South African government workedto transform its foreign assistance programinto a vehicle for promoting positive social andeconomic change across the continent.

There are also increasing numbers of privatehealth care providers that offer fee-for-servicescare to middle- and high-income individuals that

can afford them.

Current health disparities in South Africa haveled the government to revisit health care delivery,resulting in the announcement of two large-scale initiatives: the reengineering of the primaryhealth care system and the introduction of anational health insurance scheme (NHI). The NHIwill be piloted in select districts in 2012 and fullyrolled out over the course of the next decade; ifsuccessful, it could inject billions of dollars intothe health care system.18

suh Afra’

Frg Aa

Since the end of apartheid in 1994, the centraltenet of South African foreign policy has been

6.1 soUtH AFRicA leADinG cAUses oF DeAtH, 2008


HIV/AIDSAll Other


Diarrheal Diseases

TB




Cancers


Diabetes


INJURIES

Injuries


TOTAL: 670,000 deathS



74


South Africa’s regional inuence. With this inmind, the South African government tries toavoid being labeled as a “donor country.” Instead,foreign assistance programs are promoted aspartnerships established in the spirit of South-South cooperation.

cURRent FoReiGn

AssistAnce PRoGRAm

Although South Africa itself receives signicantforeign assistance, the scope of its internationalefforts is growing. Estimates currently valuethe ARF at between US$79 million and US$105million, around six times the level of 2006funding.23, 24 Total development assistance isroughly estimated to be at least US$143 millionbecause while the ARF sets the agenda for

South Africa’s development-related activities,several other government bodies — includingthe Department of Defense and Departmentof Education — also fund foreign assistanceprograms.25 However, South Africa only tracks

In 2001, South Africa established the AfricanRenaissance and International Co-operation Fund(ARF), administered by the Department of ForeignAffairs (now the Department of InternationalRelations & Cooperation), to replace the country’sapartheid-era bureaucracy, the Development

Assistance Program.21 The term “AfricanRenaissance” was coined by then-President ThaboMbeki, who believed the fall of apartheid signaleda new era of growth and prosperity across Africa.22 Mbeki also believed that South Africa couldlead this renaissance, and sought to bolster hiscountry’s prole through initiatives like the NewPartnership for Africa’s Development, an AUprogram to promote socio-economic development.

Today, the majority of South Africa’s foreignassistance efforts continue to focus on the African

continent. Goals include peacekeeping andregional stability in Southern Africa, democracypromotion, and the advancement of Africaninterests internationally. Development assistanceis also used as a foreign policy tool to enhance

6.2 estimAteD soUtH AFRicA FoReiGn AssistAnce

(USD Millions)

$160

$140

$120

$100

$80

$60

$40

$20

$0

2005 2006 2007 2008 2009 2010

Source: J. Waltz, V. Ramachandran, Brave New World: A Literature Review of EmergingDonors and the Changing Nature of Foreign Assistance, Center for Global Development, 2011;World Bank Open Data; GHSi Analysis Note: Estimates based on limited data and GHSi analysis

Low Estimate




of efforts to combat these epidemics, South Africahas also become a proving ground for innovative

tools and programs and produced a cadre ofdedicated researchers and policymakers whoseefforts impact global approaches to treatmentand prevention. While a signicant amount ofR&D and programming conducted in South Africais funded or led by international institutions,domestic scientists, innovators and volunteers aremajor contributors to these efforts. With all thisin mind, South Africa’s greatest contribution toglobal health innovation may be its abilityto serve as a prominent model for otherdeveloping countries.

soUtH AFRicA’s GloBAl

HeAltH AssistAnce

South Africa receives far more health assistancethan it contributes, including more of the USPresident’s Emergency Plan for AIDS Relief(PEPFAR) funding than any country in theworld.31 However, South Africa does allocatelimited resources to health assistance throughmultilateral agencies, bilateral channels and otherSouth-South partnerships. From 2003 to 2007, the

Mbeki administration gave US$10 million to theGlobal Fund and in 2006 it pledged US$20 millionover 20 years to the GAVI Alliance (Figure 6.3). Thecurrent government continues to collaborate onhealth-related initiatives through IBSA, includinga partnership with India on vaccine research inthe areas of HIV/AIDS, TB and malaria.32

ARF disbursements and it is difcult to quantifyoverall assistance across all programs, so thisnumber may still be low.

To deliver funds, South Africa channels most ofits development assistance through multilateral

agencies, such as the SADC, the AU and theSouthern African Customs Union. The country hasalso been exploring opportunities to work throughtrilateral partnerships like IBSA. Like many ofits BRICS counterparts, South Africa prefers tosupport technical assistance and co-nancedprojects.26 Recent examples include funding to theSeychelles for infrastructure rehabilitation and tothe Republic of Guinea to boost rice production.27

South Africa has also been working to createa centralized agency to coordinate its foreign

assistance. The South African DevelopmentPartnership Agency (SADPA) is scheduled tolaunch in April 2012 and will be housed withinthe Department of International Relations andCooperation.28 The SADPA will be the country’srst mechanism for consolidating and tracking allforeign assistance activity across all departments.29

suh Afra’ Hah

Aa ad ipa

Gba Hah iva

South Africa’s signicant domestic challengesand ongoing battle against HIV/AIDS and TBhave limited the scope and inuence of itsglobal health assistance program. Despite rapideconomic growth and a policy of universal accessto HIV/AIDS treatment, the South African healthsystem faces signicant funding gaps and only56% of those in need receive adequate access

to ARVs.30

The government has understandablychosen to prioritize domestic health over supportfor health in other countries.

That said, South Africa’s response to HIV/AIDS and TB has had broad inuence on globalhealth, particularly in terms of clinical research,advocacy and policy. Since it is on the front lines

South Arica’s response to HIV/AIDS

and TB has had broad infuence on

global health, particularly in terms

o clinical research, advocacy and

policy. Since it is on the ront lines o

eorts to combat these epidemics,South Arica has also become a

proving ground or innovative tools

and programs and produced a cadre

o dedicated researchers

and policymakers whose eorts

impact global approaches to

treatment and prevention.



76


of aggressive health programs and noveltechnologies in the hopes of saving lives.Following the successful results of the CAPRISA004 study, for instance, South Africa has moved

quickly to prepare for the potential introductionof tenofovir gel as an HIV prevention method.This push has accelerated research and globalregulatory timelines.

At the same time, on World TB Day 2011, SouthAfrica’s Minister of Health Aaron Motsoalediannounced plans for national rollout ofGeneXpert, a next-generation molecular TBdiagnostic. Molecular TB diagnostics have thepotential to revolutionize global TB controlbecause they are relatively easy to use, reduce

the time it takes to detect the disease fromdays to hours, and can accurately screen for themost common forms of drug-resistance. Thisis particularly important given South Africa’shigh rates of TB/HIV co-infection and drug-resistant TB. Yet national scale-up will require aninvestment of hundreds of millions of dollars overseveral years, and South Africa’s commitment is

South Africa’s bilateral health assistance tends tobe distributed in the form of grants or technicalsupport, but it makes up just a small part of thebroader South African development program. In

2010, for example, South Africa provided technicalsupport to aid malaria control efforts in the SADCregion.33 As in its broader foreign assistanceprogram, health-specic disbursements occuracross several government agencies andcomprehensive data on expenditures is largelyunavailable.34 However, as South Africa’s healthsituation improves — and dependence on foreignassistance declines — many expect the countryto seek out more opportunities to expand healthassistance efforts across the region.35 For thetime being, these programs are expected to

remain limited.

GloBAl imPAct oF

soUtH AFRicA’s HeAltH

Policy AnD ADVocAcy

In recent years, South Africa’s high diseaseburden, moderate resources and energeticcivil society have led to the implementation

6.3 soUtH AFRicA contRiBUtions to

key HeAltH mUltilAteRAls, 2005-2010 (USD Millions)

Source: Global Fund; GAVI Alliance; UNICEF; UNFPA Note: South Africa has pledged additional US$16 million to GAVI IFFIm from 2011-2031

$15

$10

$5

$4

$3

$2

$1

$0

UNICEF

GAVI IFFIm

UNFPA

GLOBAL

FUND




the US and Europe, the South African governmentand its research community have played anequally important role.

The South African government has also soughtto catalyze domestic innovation targeting itsmajor health challenges. Overall, South Africaninvestment in R&D has increased steadilyalongside its growing economy, rising from

US$864.9 million, or 0.73% of GDP, in 2001 toUS$2.6 billion, or 0.93% of GDP, in 2008.37 Thegovernment hopes to increase this to 2% ofGDP by 2018.38 The South African Department ofScience and Technology (DST) directly funds someof this research across disciplines, including basicresearch, clinical research and public healthprojects. Translational research focused on newproducts is funded by the Technology InnovationAgency (TIA; see below), which sits within DST.TIA supports work at governmental organizations,academic institutions, private enterprises and

innovative public-private partnerships.

DST-funded public health initiatives includeprograms like the South African TB Research andInnovation Initiative (SATRII), which specializesin TB diagnostics, testing and treatment. Othergovernment institutions such as the NationalResearch Foundation (NRF) and MedicalResearch Council (MRC) help universities boostresearch capacity in the areas of HIV/AIDS andTB. The NRF also sponsors training programs indrug discovery and provides grants to up-and-

coming researchers. In 1999, the MRC partneredwith a consortium of local and internationalstakeholders to establish the South AfricanAIDS Vaccine Institute, which coordinates thedevelopment and testing of HIV vaccines and hasconducted clinical trials for international anddomestically produced vaccine candidates.39

by far the most aggressive that any country hasmade to rolling out molecular diagnostics for TB.

South Africa’s early adoption of these tools andapproaches — should they prove effective —could inuence other high-burden countries.

Along similar lines, South Africa’s health activistcommunity has provided inspiration and modelsthat have helped to shape the internationalresponse to HIV/AIDS. Internationally knownorganizations like the Treatment Action Campaign(TAC) and AIDS Law Project (now Section 27)played an important role in advocating for broaderaccess to affordable ARVs and health care servicesin South Africa — pushing both the South Africangovernment and international donors to respondmore aggressively to AIDS. As noted above, in2003, a coalition of these advocacy groups helped

force the South African government to announce apolicy of universal access to HIV/AIDS treatment.This set a signicant precedent for other high-burden countries.

TAC, formed in 1998, boasts more than 16,000members across South Africa. TAC has publiclypressured the global pharmaceutical industry tomake ARVs affordable for developing countries,played a key role in combating AIDS denialismin South Africa, and fought to ensure that SouthAfrican women received the drug zidovudine to

prevent mother-to-child HIV transmission duringpregnancy. In 2004, TAC was nominated for aNobel Peace Prize in recognition of its globalinuence on the battle against HIV/AIDS.36

soUtH AFRicAn

HeAltH innoVAtion

Due to its well-established clinical infrastructure,high prevalence of HIV/AIDS and TB, and localexpertise, South Africa is a hub for R&D andclinical research focused on infectious diseases.

Research institutes, including the DesmondTutu AIDS Centre at the University of CapeTown, the Perinatal HIV Research Unit at theUniversity of the Witwatersrand, and the just-launched KwaZulu-Natal Research Institute forTuberculosis and HIV, have contributed to a broadrange of impactful studies. While much of thisresearch is backed by scientists and funding from

Due to its well-established clinical

inrastructure, high prevalence o

HIV/AIDS and TB, and local expertise,

South Arica is a hub or R&D

and clinical research ocused on

inectious diseases.




78


Biovac (Vaccine Production): In 2001, the DSTcommitted more than US$50 million to catalyzegrowth in South Africa’s health biotechnologysector, which focuses on the productionof vaccines and biogenerics, therapeutics,diagnostics and medical devices. Two years later,

the Department of Health and a group of local andinternational stakeholders launched the BiovacInstitute to develop and manufacture vaccines ataffordable prices. Biovac is currently the largestvaccine distributor in South Africa and hopes tobecome a full-edged manufacturer by 2013.The institute supplies all eight of the vaccinesthat comprise South Africa’s Expanded Programof Immunization and also supplies vaccines toNamibia, Botswana and Swaziland.43

PRiVAte sectoR innoVAtion

South Africa’s private health technology sectoris small, but the country is home to regionalmanufacturing and distribution centers for manyglobal pharmaceutical companies. In 2009,more than 70% of sub-Saharan Africa’s annualpharmaceutical production took place in SouthAfrica. There are also several local companiesthat specialize in producing competitively pricedgeneric drugs, including rst-line ARVs.

In 2003, South Africa-based Aspen Pharmacare

developed Africa’s rst generic ARV and hassince obtained licenses to develop tenofovir andother ARVs for local and regional markets.44 In2009, GlaxoSmithKline acquired a 15% stake inAspen Pharmacare in hopes of strengthening itscommercial presence in sub-Saharan Africa.45 Durban-based Cipla Medpro Ltd., a subsidiaryof India’s largest pharmaceutical company, isalso one of the fastest growing pharmaceuticalcompanies in South Africa and an importantdomestic provider of ARVs. Expanded, localgeneric production has the potential to further

reduce ARV prices in South Africa and acrossthe region.

KEY ExAMpLES OF SOUTH AFRICAN

CONTRIBUTIONS TO HEALTH INNOVATION

Technology Innovation Agency (Health R&D): Launched in 2010, the TIA was formed throughthe merger of several smaller funding agencies

within the DST with the goal of promotinginnovation in health, biotechnology, agricultureand other areas.40 The TIA, which started with abudget of US$54 million, actively funds multiplehealth R&D initiatives, including a new DrugDiscovery and Development Centre, and ithas supported several clinical research trials,including the CAPRISA 004 study.

Centre for the AIDS Program of Research in

South Africa (HIV Microbicides): At the 2010AIDS Conference in Vienna, CAPRISA, an institute

based at the University of KwaZulu-Natal,released the results of the CAPRISA 004 study,which found that a vaginal gel containing theARV tenofovir could prevent HIV transmissionin women during sex. This provided the rstproof-of-concept that ARV-based microbicidesand ARV-based HIV prevention more broadlycould signicantly reduce the risk of infection.41 CAPRISA and its partners conducted thestudy with funding from the TIA, US Agency forInternational Development (USAID) and others.Designed and led by South African researchers,the CAPRISA 004 study is widely regarded as alandmark in global efforts to develop HIV preventionmethods that women can initiate themselves.

Orange Farm Clinical Trial (Male Circumcision):

In 2005, a clinical trial sponsored by the FrenchAIDS Research Agency and conducted in OrangeFarm, a large township outside of Johannesburg,found for the rst time that male circumcisionprotects men against HIV infection.42 Sincethen, circumcision has been proven to reducemen’s risk of contracting HIV by more than half,prompting high-burden countries from Botswanato Kenya to promote the procedure as an effectivemeans of prevention.




7 BEYOND BRICS

L ooking beyond the BRICS, there are a number of other countries that can have —

or are already having — signicant impact on global health. These include

the remaining members of the G20, the Gulf States, and ‘frontier markets’ in Latin

America, Asia, Africa and Eastern Europe. While some of the BRICS are larger or

their programs better known, these countries may soon play a more substantial role

in improving health in developing countries through assistance programs and

pharmaceutical, nancial or policy innovation.

This section takes a brief look at some of thesecountries, including a select group of Gulf States(Saudi Arabia, Kuwait, Qatar and the United

Arab Emirates), Indonesia, Mexico, South Korea,and Turkey. These countries, as well as otheremerging donors, offer very different approachesto foreign assistance, as well as a range ofresources and expertise. Each brief proleincludes some key country characteristics andhighlights some of their existing or potentialcontributions to global health.

tHe GUlF stAtes

Of the countries proled in this section, the Gulf

States — particularly Saudi Arabia, Kuwait andthe United Arab Emirates (UAE) — have the mostdeveloped foreign assistance programs. Each hasalso recently made substantial contributions toglobal health multilaterals.

These three countries have been providing aidfor 35 years or more, with an average assistancelevel of 1.5% of GNI — more than double the

UN recommended 0.7% — since 1973.1 At thesame time, bilateral assistance, which makes up87% of their assistance, is signicantly higherthan the 70% from OECD-DAC countries.2 The

Gulf States generally coordinate their donationsamong themselves and with regional multilateralorganizations through a Coordination Grouphoused at the Arab Fund for Economic and SocialDevelopment.3 Though not ofcial members, allthree countries report on their aid to the DAC. 4

The majority of bilateral assistance from SaudiArabia, Kuwait and the UAE goes to infrastructure

While some o the BRICS are larger

or their programs better known,

these countries may soon play a

more substantial role in improving

health in developing countries

through assistance programs and

pharmaceutical, nancial or

policy innovation.



80


families have also made personal commitmentsto global health. In 2011, His Highness SheikhMohamed bin Zayed Al Nahyan, the crown princeof Abu Dhabi, pledged US$50 million towardpolio eradication in Pakistan and Afghanistan.10 He also pledged an additional US$33 million to

the GAVI Alliance from 2011 to 2013 and US$10million to the eradication of guinea worm from2012 to 2015.11,12 Beyond these commitments, theGulf States contribute to regional multilateralinstitutions such as the Islamic DevelopmentBank, which has begun to put a greater focus onhealth and education.13

Qatar is another potentially signicant donor inthe Gulf region. In 1995, its Emir chartered theQatar Foundation to aid the country’s transitioninto a knowledge economy.14 Although the

development, with a limited amount dedicatedto social sector projects related to educationand health.5 However, all three countrieshave provided signicant funding to healthmultilaterals over the past decade. Saudi Arabiaand Kuwait have pledged US$53 million andUS$4.5 million, respectively, to the Global Fund.6,7 All three countries have donated to GPEI, led bySaudi Arabia, which contributed US$15 millionin 2011 and pledged an additional US$15 millionfor 2012.8,9 Members of these countries’ royal

7.1 BRics economic AnD HUmAn DeVeloPment inDicAtoRs*

Beyond BRICSOther Leading

Economies

Indicator Year KuwaitSaudiArabia

UnitedArab

EmiratesIndonesia Mexico

SouthKorea

TurkeyUnitedStates

Japan

Population, total 2010 2,736,000 27,448,000 7,512,000 239,870,000 113,423,000 48,875,000 72,752,000 309,052,000 127,450,0

Reserves of Foreign

Currency and Goldand Rank

2010 US$28.0B53 US$556.2B4 US$55.3B31 US$136.2B19 US142.0B18 US$306.4B9 US$96.1B24 US$132.4B20 (2010) US$1.1T2 (2010

Life expectancy atbirth (years)

2009 74.5 73.6 76.4 68.5 76.5 80.3 73.4 78.1 82.9

Literacy rate, adulttotal (% of people ages15 and above)

-93.9

(2009)86.1

(2009)90.0

(2005)92.2

(2008)94.0

(2009)-

90.8(2009)

- -

Income inequalitymeasuredby GINI coefcient**

- - - -36.8

(2009)51.7

(2008)31.6

(1998)43.2

(2005)45.0

(2007)37.6

(2008)

CO2

emissions (kt) 2008 77,000 434,000 155,000 406,000 476,000 509,000 284,000 54,561,000 1,208,00

Mobile cellularsubscriptions(per 100 people)

2010 160.8 187.9 145.5 91.7 80.6 103.9 84.9 90.2 94.7

Health expenditureper capita, PPP (constant 2005international $)

2009 US$1,500 US$1,150 US$1,760 US$100 US$850US$1,800

(2008)US$950 US$7,400 US$2,70

Source: World Bank Open Data; CIA World Factbook

Note: *World Bank and CIA World Factbook indicators were used over local sources to allow for cross-country analysis;**The higher the GINI coefcient, the larger income inequality

The Gul States contribute to

regional multilateral institutions such

as the Islamic Development Bank,

which has begun to put a greater

ocus on health and education.




tURkey

Turkey is the 17th-largest global economy bynominal GDP, and it had an 8.9% GDP growthrate in 2010.19,20 The country sits at the physicaland political crossroads of Europe, Central Asiaand the Middle East, and — alongside the sizeof its economy — this gives Turkey a measure ofinuence in all three regions.

The Turkish government sees assistance as both

a foreign policy tool that can help drive stability inthe region, and as an economic tool for increasingexports to burgeoning “Southern” markets.22 Turkey has maintained a foreign assistanceprogram since 1985. In 2010, Turkey disbursedUS$967 million, focused primarily on activities inCentral Asia but also in the Middle East, Africa andLatin America.23,24,25 Turkey’s foreign assistancefocuses primarily on education in recipient

foundation is not currently focused on health

efforts, it has invested billions of dollars intostate-of-the-art research, education andtechnology centers, emphasizing domestic andregional growth.15 In 2010, the Qatari governmentalso established a Qatar Development Fundmodeled after agencies in Saudi Arabia, the UAEand Kuwait, and it has begun regional food securityand energy projects through the Fund.16,17,18

7.2 BRics Vs. BeyonD BRics:

GDP AnD GDP PeR cAPitA (USD Billions, USD)

- $60,000

- $50,000

- $40,000

- $30,000

- $20,000

- $10,000

$0

$7,000

$6,000

$5,000

$4,000

$3,000

$2,000

$1,000

$0

Brazi l Russia In di a Chi na SouthAfrica

SaudiArabia

Kuwait* UnitedArab

Emirates

Indonesia Mexico SouthKorea

Turkey

G D P

( U S D B

i l l i o n s )

$11,200

$3,600

$7,600$10,600

$22,700

$52,700

$47,200

$4,300

$14,500

$29,000

$15,300

$19,800

GDP Nominal (USD Billions)

GDP Per Capita, PPP (USD)

Source: World Bank Open DataNote: *Most recent GDP Nominal and GDP per capita PPP indicators forKuwait were from 2009 and 2007, respectively; World Bank indicators wereused to allow for cross-country analysis

The country’s pharmaceutical

industry has been singled out as

an area or investment as Turkey

continues to move toward EU

membership. The goal is or Turkey

to develop into a major exporter o

brand name and generic drugs.



82


At the same time, Indonesia is having directimpact on global health through its state-ownedvaccine company, Bio Farma. The rm produces15 WHO pre-qualied vaccines, including low-costvaccines for hepatitis B, polio, tetanus, measlesand DTP.33 The company exports millions ofdoses of vaccines annually, including sendingapproximately 1.4 million doses of its oral poliovaccine to India.34 Indonesia has also reinstituted

its National Vaccine Research Forum with a goalof developing a new set of vaccines for diseaseslike dengue and avian u.35

Indonesia is leveraging innovative partnershipswith international organizations to supportdomestic health — and it has the potentialto inuence other countries to do the same.Indonesia is one of three recipient countryparticipants in the Global Fund’s Debt2Healthprogram, in which Germany and Australia haveagreed to waive debt owed in exchange for

Indonesia paying 50% of that debt to Global Fund-approved programs in the country.36,37,38 To date,Indonesia has directed roughly US$22 million tohealth through this program.39 The Global Fund’srecent decision to make Indonesia ineligible forTB funds, which have historically comprisedmore than 40% of the country’s total Global Fundreceipts, may impact this program.40,41

countries, but its 2010 budget included US$68million for basic health, water and sanitationprojects. This included small commitmentsfor GPEI.26,27

Beyond government funded foreign assistance,

Turkey’s pharmaceutical industry also hassignicant potential to impact global health.The country’s pharmaceutical research anddevelopment has been singled out as an area forinvestment as Turkey continues to move towardEU membership. The goal is for Turkey to developinto a major exporter of brand name and genericdrugs.28 Turkey’s domestic pharmaceuticalmarket, ranked 12th in the world in 2009 withUS$10.4 billion in sales, helps to justify thisinvestment. In 2006, IMS Health named Turkey— along with the BRICS, South Korea and Mexico

— as a ‘Pharmerging Market’ with signicantpotential for growth.29

inDonesiA

With 200 million citizens, Indonesia is the world'sfourth most populous country, behind China,India and the US.30 While the country still receivessignicant amounts of assistance, it has been aleader in health assistance policy. In the 1960s,Indonesia was one of the founders of the “non-aligned” movement, which, through the Bandung

Conference, laid the groundwork for greaterSouth-South collaboration.31 In 2006, Indonesiawas also a co-founder of the Foreign Policy andGlobal Health initiative, and a signatory of theresulting Oslo Ministerial Declaration on GlobalHealth and Foreign Policy that advocated for theintegration of global health assistanceinto foreign policy discussions.32

At the same time, Indonesia is

having direct impact on global

health through its state-owned vaccine company, Bio Farma....The

company exports millions o doses o

vaccines annually, including sending

approximately 1.4 million doses o its

oral polio vaccine to India.

Bandung Conference

The Bandung Conference, which took

place in Indonesia in 1955, is considered

the birthplace of the concept of South-

South collaboration. The conference wasconvened to promote geopolitical solidarity

among a group of African and Asian states

in response to the rising inuence of the US

and the Soviet Union during the Cold War.

The 29 attending countries, which included

India and China, discussed mechanisms

to minimize inequalities in global power

relations. Participants also pledged to lessen

their dependence on wealthy countries by

providing technical assistance to one another

for development projects.




initiative focuses on maternal and child health inCentral America, specically among the lowestincome quintile.49

Beyond funding for global health, Mexico’spharmaceutical industry also has strong potential

for impact. Mexico is home to the state-ownedvaccine company Birmex, a “prospective fullmember” of the Developing Country VaccineManufacturing Network.50 Birmex only producesvaccines for national use, but the companyintends to boost production and expand intothe global market.51 Alongside other low-costmanufacturers, this could further increase globalvaccine supply and drive down prices. Birmexcurrently produces vaccines for polio, tetanus anddiphtheria, as well as antitoxins and antivenoms.It also has avian u, rubella, and Hib vaccine

candidates in development.52

soUtH koReA

South Korea has long been considered aneconomic power in Asia, and it currently hasthe 15th largest economy worldwide by nominalGDP.53 South Korea is also a signicant sourceof foreign assistance, and is the only country toofcially transition from OECD-DAC recipient todonor.54 In 2010, South Korea provided US$1.2billion to assistance programs, an increase

of 55% since 2006 and 440% since 2001.55,56 The country aims to again double its foreignassistance levels, from 0.12% of GNI in 2011 to0.25% by 2015.57 South Korea also uses its voiceto inuence assistance policy globally and inNovember 2011 it played host to the Global AidEffectiveness Forum at Busan.58

meXico

Mexico has the second largest economy in LatinAmerica, and the 14th largest globally by nominalGDP.42 This year Mexico also serves as President

of the G20, and the country will host the annualG20 Summit in June 2012.

In terms of public sector foreign assistance,the Mexican government focuses its efforts onbilateral development aid within Latin Americaon a wide range of subjects, including health. 43 Currently, Mexico is working to streamline itsforeign assistance program by developing formaltracking systems and creating a central agency tomanage its efforts.44,45 That agency, the MexicanInternational Development and Coordination

Agency, is chairing the preparatory meetings forthe 2012 G20 Summit.46

Another major source of funding for health inLatin America is the privately operated CarlosSlim Health Institute, a division of the Carlos SlimFoundation based in Mexico City. Supported by aUS$500 million donation from Mexican billionaireCarlos Slim, the Institute focuses on maternaland child mortality and NCDs.47 It operatesthroughout Latin America and the Caribbeanand has a strong focus on in-house development

R&D.48

The Institute is also a primary funder —alongside the Gates Foundation and the Spanishgovernment — of the Mesoamerican HealthInitiative, a US$142 million program administeredby the Inter-American Development Bank. The

Another major source o unding

or health in Latin America is the

privately operated Carlos Slim Health

Institute, a division o the Carlos

Slim Foundation based in Mexico

City. Supported by a US$500 milliondonation rom Mexican billionaire

Carlos Slim, the Institute ocuses on

maternal and child mortality

and NCDs.

South Korean organizations have also

had specic impact on global health

through their work on vaccines.

IVI, based in Seoul, is the only international organization working

exclusively on vaccine development

or developing countries.



84


IVI has been instrumental in research anddevelopment efforts targeting diarrheal,respiratory and neglected viral diseases.With funding from the Gates Foundation, itdeveloped the leading cholera vaccine Shanchol,manufactured by Shantha Biotech in India,

and focused global efforts against typhoidfever.64 In addition to providing a state-of-the-art headquarters for IVI, South Korea is by farthe organization’s largest government funder,supplying US$5.7 million, 25% of IVI’s budget,in 2010.65 South Korea is also home to LG LifeSciences, which announced in 2011 that itwould work with WHO and governments andorganizations in the Netherlands, China andIndia to produce a lower-cost, easier-to-produceinactivated polio vaccine that could decrease theincidence of vaccine-derived poliovirus.66

South Korea’s overall assistance programs focusheavily on economic infrastructure. However,in 2010, it provided US$136 million in healthassistance.59 South Korea has also contributedto several global health multilaterals, includingproviding an annual contribution of US$2 million

to US$3 million to the Global Fund and a US$1million pledge to the GAVI Allliance over threeyears.60,61 United Nations Secretary-GeneralBan Ki-moon, a native of South Korea, is alsoa known champion for global health, includingon women’s and children’s health and polioeradication efforts.62

South Korean organizations have also hadspecic impact on global health through theirwork on vaccines. IVI, based in Seoul, is the onlyinternational organization working exclusively on

vaccine development for developing countries.63




Beyond direct assistance, the BRICS are investingconsiderable time, money and energy buildingtheir capacity for science and technology.Through platforms like the BRICS forum, theyare also exploring opportunities for more formal

collaboration among themselves and with otherdeveloping countries.

Below are some key ndings from our researchthat highlight areas where the BRICS are alreadycontributing new global health resources andmodels. We also suggest some opportunities forthe BRICS to potentially use their experiencesand expertise to have impact in areas beyondthose where they are already visibly contributing.This could be through assistance, innovation, orpolicies and programs that can be emulated in

other countries.

While our conclusions focus on the BRICSspecically, many of these comments could easilybe extended to include other emerging leaders,such as those highlighted in the “Beyond BRICS”section of this report.

The BRICS are all established providers of foreign

assistance; however their contributions have

increased signicantly over the last ve years.

The BRICS are often referred to as “emerging”

or “non-traditional” donors, but each has beenproviding different levels of assistance to othercountries for decades. As the US and Europe haveslowed donor spending, the BRICS’ assistanceprograms have become much more prominent.The funding involved is still relatively small whencompared to overall spending by the US andWestern European countries. China is by far thelargest contributor, and South Africa is likelythe smallest by a signicant margin. However,in recent years the growth in their assistancespending has accelerated. Between 2005-2010,

Brazil’s assistance spending grew by 20.4%annually, India’s by 10.8% annually, China’s by23.9% annually, and South Africa’s by 8% annually.Russia’s assistance increased substantially earlyin the same period, before stabilizing at around$450 million per year.

8 KEY FINDINgS

AND CONCLUSIONS

T he expanding inuence of the BRICS is impacting global economics, politics and

culture — and health is no exception. While growth in the BRICS has recently begun

to slow, they have shown much greater resilience than the US and Europe in the face of

the global nancial crisis, and their foreign assistance spending has been increasing at

very high rates.



86


BRics: FoReiGn AssistAnce AnD GloBAl HeAltH




the most prominent example: its assistanceprogram overtly emphasizes mutually benecialprograms that seek to build long-term economicdevelopment. This aligns with China’s approach toits own development, which favors infrastructure,investment and market-driven growth — albeitwith strict government oversight.

Because the BRICS still face major health andeconomic challenges, continued investments in

global health will likely be made in the contextof issues at home. At the same time, the BRICSare likely to have greatest global impact in areaswhere their own health issues overlap with thoseof other countries.

As with Western donors, economic and

political interests are inuencing the BRICS

as they expand their development and health

assistance programs.

There is no question that BRICS health and

development programs and policies are guidedby broader strategic priorities. Some of this isarguably for the better: Brazil’s emphasis onhealth equity has guided technical cooperationefforts, while efforts to build health R&D capacityin all ve BRICS can also improve access inresource-poor countries. Other approaches havegenerated criticism: both India and China may tiesome assistance to the purchase of domesticallyproduced goods. In all of these cases, the truth islikely more complex than it appears. Indian andChinese policymakers, for instance, would argue

that “mutually benecial” programs create moreequal partnerships. But while “South-South”models of cooperation may prove to be moresustainable, all of the BRICS also use them astools to build allies and inuence among otherdeveloping countries.

It is important to note that many traditionaldonors are inuenced by politics and economics.

Brazil and Russia prioritize health within theirbroader assistance agendas. China, India and SouthAfrica are all contributing to some degree, but theirformal programs focus on other issue areas.

The BRICS’ foreign assistance programs are also

evolving: as assistance spending increases, theyare investing time and resources in developinggreater capacity and stronger policies. Brazil,Russia, India and South Africa all have or arelaunching central assistance agencies, althoughmuch of Brazil’s assistance continues to falloutside ABC’s mandate. While China’s assistanceprogram involves a variety of governmentministries led by MOFCOM, China’s 2011 whitepaper provided a formal, public guidepost for itsapproach to international development. As thescale of China’s assistance efforts grow, a central

aid agency could help maximize the impact of itsinvestments. At the same time, across the BRICS,better management systems, more coordinationacross agencies, and increased monitoring andevaluation will likely be needed.

The BRICS are employing approaches to foreign

assistance that are different from traditional

donors and shaped by domestic experiences.

The BRICS have made health advances overthe past few decades, and BRICS policymakers

feel this equips them with unique perspectiveon improving health outcomes in developingcountries. As a result, all of the BRICS except forRussia openly reject “Western” approaches toforeign assistance in favor of models anchored indomestic programs and their own political andsocial philosophies. For Brazil, this translatesinto programs that emphasize health equity anddraw directly on successful domestic programssuch as Bolsa Família. Similarly, Russia is leadingefforts to address NCDs because they are havinga signicant impact on Russia’s own population.

Aside from Russia, the BRICS do not like tosee themselves as donors. Instead, they seethemselves as developing country partners thatare sharing best practices and helping othercountries build self-sustaining growth. MostBRICS health assistance programs focus oninfrastructure, human resources training orhealth systems strengthening. China provides

The BRICS have made health

advances over the past ew decades,

and BRICS policymakers eel this

equips them with unique perspective

on improving health outcomes in

developing countries.



88


largely been through examples produced in itsefforts to combat HIV/AIDS and TB — particularlyin recent years as it has strengthened itsdomestic programs. Similarly, India’s low-costhealth service delivery programs and recentsuccess interrupting polio transmission offer

templates for countries trying to get to themost difcult-to-reach populations. Brazil’scommitments to health equity, HIV treatment andnutrition programs have all been recognized asmodels for success in resource poor countries.And at the same time, the IP battles fought by theBrazilian government, India’s public and privatesectors, and South African activists have all hadbroad impact on global treatment access.

The BRICS are taking steps to prioritize healthas an essential element of development and

foreign policy more broadly, and to coordinatethese efforts through the BRICS forum. At theirJuly 2011 Ministers of Health meeting, the BRICScommitted “to support other countries in theirefforts to promote health for all,” although thesestatements have yet to produce any tangibleoutcomes. All the BRICS are also asserting agreater role in health governance at WHO andmultilaterals like the World Bank.

The production of high-quality, lower-cost health

technologies by the BRICS is improving access

in resource-poor countries, and the growinginvestment in early-stage R&D by the BRICS

could have a similar long-term impact.

Arguably one of the most impactful examplesof BRICS contributions to health is the role thatIndian companies have played in expandingglobal access to vaccines and essentialmedicines. Between 60% to 80% of the vaccinespurchased by the United Nations Children’s Fund(UNICEF) for the world’s poorest countries comefrom India, and millions of people living with HIV/

AIDS have access to affordable ARVs because ofIndian companies. These products have savedmillions of lives, though complex legal and IPissues remain unresolved.

While India has long dominated the genericmedicines and vaccines industry, China is poisedto compete thanks to recent improvements inregulation and quality control. Brazil, Russia

Between 1970 and 1994, 78% of the UK’s bilateralaid and 57% of France’s bilateral aid went toformer colonies, and the UK recently announced itwas refocusing aid on Commonwealth countries.Meanwhile, much US aid is used to procuredomestically produced goods and services. Four

out of the US Government’s ve food assistanceprograms procure their food aid in-country, andthe US requires that 75% of its commodities areshipped on US-ag vessels. Rough estimatessuggest that in scal year 2004 more than 90% ofUS food aid expenditures were spent in the US.

There are opportunities for the BRICS to havesignicant health impact in areas that align withtheir foreign policy priorities. For example, eachBRICS country has specic regional interestsand inuence that could help improve health in

neighboring countries. South Africa has focusedon stability in Southern Africa, and domesticefforts to combat HIV/AIDS have implicationsfor the whole continent. Russia has soughtto maintain its inuence in Eurasia, and itsinvestments in regional capacity building andhealth surveillance have benetted CIS countries.India has contributed to a range of healthprograms and policies in South Asia, while Chinais involved in disease surveillance and emergencypreparedness through regional bodies inSoutheast Asia. Brazil, meanwhile, has sought to

expand its inuence and impact in Latin Americaand the Lusophone countries. While each countryhas regional political ambitions, their uniquespheres of inuence provide distinct opportunitiesto work bilaterally, or with global partners, toimprove health in these areas.

Innovative domestic health programs and

policies in the BRICS are increasingly

inuencing health practices worldwide.

The BRICS are all struggling to address highburdens of infectious diseases and/or NCDs, butthey also have capacity and resources availablefor innovative health programming. Many of theirhealth successes and failures are happening inparallel to similar efforts in developing countries,so the BRICS are uniquely positioned to providerelevant models.

Given its small international assistance program,South Africa’s inuence in global health has




To date, there have been no notable joint efforts— although India’s proposal that the BRICScreate a development bank funded by developingcountries could be a step in this direction. Byworking together to leverage their respectiveknowledge and experiences, these countries havethe potential to do more on health than any coulddo on their own.

some PotentiAl AReAs

FoR imPAct

With all of the above in mind, independentand collective action by the BRICS could havesignicant regional and global health impactgoing forward.

As examples, we suggest a few specic areaswhere the BRICS could leverage their uniqueresources and expertise to support global healthin ways beyond those where they already have

enormous impact. The specic areas below buildon existing efforts and on the statements of theBRICS Ministers of Health.

1) Providing political and technical support that

accelerates access to life-saving vaccines: Inrecent decades, the number of children aroundthe world who receive basic, life-saving vaccineshas increased dramatically. In 1980, only 20%of children received DTP vaccines that protectagainst diphtheria, pertussis and tetanus. Today,approximately 85% receive these vaccines. As

noted throughout this report, BRICS countriessupport global immunization efforts througha wide range of nancing, manufacturing, andR&D efforts. Yet despite massive progress, morethan 19 million of the world’s poorest childrenstill do not receive basic vaccines, and 1.7million children still die each year from vaccine-preventable diseases.

and South Africa are also investing in increasedpharmaceutical capacity with the global market inmind. As supply increases, quality improves andprices drop, developing countries stand to benet.

At the same time, all of the BRICS are investing

heavily in science and technology. China,for example, has pledged to increase R&Dexpenditures to 2.5% of GDP by 2020, while Indiahas just launched a US$1 billion innovationfund focused on problems aficting developingcountries. Alongside technical and nancialsupport from international organizations,domestic investments have already producedinnovations that are improving global health.MenAfriVac and China’s work on JapaneseEncephalitis (JE) demonstrate the potential fornew, affordable vaccines; Chinese reproductive

health technologies are beginning to reach otherdeveloping countries; and South African HIV/AIDSresearch drove the successful CAPRISA 004 study.

Some of these innovations have grown out ofcommercial interests, and others from effortsto address domestic health challenges. Yetbecause BRICS health challenges are oftensimilar to those in many developing countries,their innovations could quickly reach and benetpopulations in need. As the BRICS continue toprioritize innovation, they could expand the supply

of health technologies that are appropriate andaffordable for developing country settings, whilepushing down prices across the globe.

The BRICS have declared health collaboration

a priority, but they have not yet begun to work

collectively to enhance the impact of their

assistance programs.

Despite increased foreign assistance budgets,BRICS investments are still limited compared tothose of the US and Western Europe. Collective

action could help the BRICS have greater impact,and this was acknowledged at their July 2011Ministers of Health meeting. There, BRICSMinisters of Health committed themselves to“collaborate in order to advance access to publichealth services and goods in our own countriesand…to support other countries in their efforts topromote health for all.”

As the BRICS countries prioritize

innovation, they could expand

the supply o health technologies

that are appropriate and aordable

or developing country settings,

while pushing down

prices across the globe.



90


other countries to do the same. Collaborativeefforts, such as joint purchasing agreements andregulatory harmonization, could also help reduceprices and streamline introduction. Another areawhere the BRICS could have an impact is onglobal access to second-line TB drugs, which treat

drug-resistant TB but are currently very expensiveand in short supply. BRICS manufacturers areuniquely positioned to help produce greaterquantities of lower-cost treatments.

The BRICS could also focus on producinglow-cost TB diagnostics and vaccines. Globalefforts are underway to develop these new TBtools, and the BRICS are already contributing.But additional investment and research is needed,and coordinated research efforts among theBRICS could accelerate results. A jointly hosted

meeting on TB innovation could be one way toshare best practices and explore opportunitiesfor technical cooperation.

3) Supporting efforts toward polio eradication: India’s recent success on polio gave newmomentum to global efforts to eradicate thisdisease. Since 1989, the number of polio casesglobally has dropped 99%, to less than 1,000 in2011. Yet several countries are still strugglingwith polio elimination. While India receivedtechnical support from a range of global partners,

its polio program was almost entirely self-funded,and the country was able to mobilize millions ofpeople to support immunization campaigns.

The October 2011 report of the Global PolioEradication Initiative’s Independent MonitoringBoard raised the idea of “twinning,” where “apolio-free country would pledge support to acountry trying to rid itself of polio.” This, theboard believed, would create “a more directand meaningful relationship” than complexmultilateral programs. Given their success in

eliminating polio, existing links to countriesstruggling with polio (i.e., Brazil’s relationshipwith Lusophone Angola, India’s relationship withAfghanistan), and the risk of regional outbreaks(such as those in Tajikistan and Russia in 2010and China in 2011), the BRICS are uniquely suitedto support coordinated twinning efforts to polio-impacted countries.

The BRICS could continue to accelerate globalvaccine access efforts in a variety of ways.Most BRICS have high immunization rates andsuccessful programs that can offer lessonslearned for other developing countries lookingto roll out new vaccines. Brazil and China in

particular have prioritized domestic manufactureof essential vaccines. As they continue to scaleup production, they may follow India’s lead inboosting supply and driving down prices forcountries worldwide. India continues to scale upits national immunization program, so it couldwork to share innovative practices for getting tothe hardest-to-reach populations. Meanwhile,continued nancial and technical support formultilaterals working on vaccines, such as theGAVI Alliance and UNICEF, could help supportglobal immunization delivery programs.

Newer vaccines cost more to produce thantraditional vaccines, so BRICS manufacturerscan play a unique role in bringing these pricesdown further as they increase their capacity. Weare already seeing this through internationalpartnerships developing rotavirus vaccinesin India, Brazil and China. And as the BRICSincrease their investment in innovation andhealth R&D, there are opportunities to supportdevelopment of vaccines for diseases wherenone currently exist, such as TB and HIV/AIDS.

2) Catalyzing access to innovative TB tools and

strategies: Each of the BRICS is on WHO's list ofhigh TB-burden countries. India and China alonehave 40% of the world’s TB, a disease that causes1.1 million deaths annually. Yet the BRICS alsohave the resources and innovative potential toprovide models of success for others. India helpedprove DOTS, and DOTS scale-up in India has beena template used globally. South Africa has alreadymade unprecedented commitments to scaleup use of new TB diagnostics, and China, Indiaand Brazil are exploring the same technology. Inaddition, China and South Africa have helped pushTB higher on the global public health agenda.

Widespread implementation of moleculardiagnostics in the BRICS could help quicklyidentify cases and cut the spread of TB off at thesource. This would help reduce TB in the BRICS,and provide an evidence base to encourage




The BRICS could continue to leverage theirdomestic experiences combatting NCDs andboosting tobacco control to provide models foreducation, prevention and diagnosis programsin other countries. Pharmaceutical companiesin the BRICS could also play an important role in

improving access to medicines for chronic diseases,in the same way that Indian companies have alreadysignicantly reduced the price of insulin.

5) Strengthening regional disease surveillance

networks: BRICS efforts to control infectiousdiseases have led them to develop strongnetworks for tracking illnesses within theirborders. India’s recent success on polio would nothave been possible without focused surveillanceprograms, and Russia’s surveillance capacityhelped curb the 2010 polio outbreak in Tajikistan

before it spread much further.

Since many of these surveillance networks havebeen developed recently, they offer potentiallessons learned for other countries. Russia, Chinaand Brazil are already working with neighboringcountries to strengthen regional surveillancenetworks. Russia, for example, has partnered witha number of CIS countries to improve capacity,upgrade antiquated facilities, and train in-countryspecialists to track diseases like HIV/AIDS andinuenza. Russia is also working with multilateral

partners to bring best practices in surveillance tocountries in Africa. Similarly, following the 2003SARS outbreak, China strengthened collaborationwith countries across Southeast Asia to preparefor and track public heath emergencies. Brazil’sHealth Surveillance Agency has also worked withcountries in Africa, Latin America and Asia to sharetechnical knowledge and domestic experiences.

As diseases continue to cross borders, theBRICS could play a powerful role in strengtheningthese networks in their regions and globally,

and work together to establish potential newcollaborative mechanisms.

6) Helping to harmonize global regulatory

processes: Many of the BRICS are investingsignicant resources in ensuring that theirrespective biopharmaceutical industries meetinternational regulatory standards. This requiresharmonizing their own regulations with those

In addition, successful polio eradication mayrequire widespread access to an affordablewhole-killed polio vaccine, similar to the Salkpolio vaccine, which prevents vaccine-derivedpolio but is currently much too expensive fordeveloping countries. India produces vaccines

of this type, and in February 2012 it introducedthem in Nigeria’s private health care sector.By producing more, cheaper polio vaccines,innovators in the BRICS could play a decisive rolein eradicating this disease.

4) Increasing leadership on NCDs and tobacco

control: Rates of NCDs such as diabetes,cancer and cardiovascular ailments — andsmoking-related ailments specically — arerising alongside greater wealth and changes inlifestyle and diet. The full global burden of NCDs

is expected to increase by 17% over the next tenyears, and developing countries are increasinglyat risk. NCDs could cause more deaths in Africathan all other causes combined by 2030.

All of the BRICS except South Africa now facehigher burdens of NCDs than infectious diseases,and incidence of NCDs is increasing even asinfectious diseases are being brought undercontrol. Russia has one of the world’s highestrates of cardiovascular disease, and China andIndia now have the two highest diabetes burdens.It is estimated that the two countries have acombined 138 million cases of diabetes. ChineseHealth Minister Chen Zhu recently went so far asto call NCDs “the number one threat.”

As the BRICS invest in measures to control andprevent NCDs, they have a unique opportunity tocontribute to efforts in other developing countries.All ve countries were active participants in the2011 UN NCD Summit, and they have committedto inject signicant resources and funds intoNCD campaigns. Brazil, among others, has beena global leader on tobacco control — including

on the 2005 FCTC — and it is likely to continueto support these efforts. Russia convened therst global ministerial meeting on NCDs in 2011,and it has committed US$35 million to supportthe global response. In India, the governmenthas strengthened NCD and tobacco awarenessefforts, and it is integrating NCD controlstrategies into improvements in its nationalhealth infrastructure.



92


global health agenda. As seen throughout thisreport, the BRICS’ support for foreign assistanceis growing. At the same time, the manufactureof low-cost drugs, diagnostics and vaccinesacross multiple diseases will continue to providehuge benets to developing countries — as will

the BRICS’ increased focus on health R&D andinnovative programming.

The scale of the BRICS’ long-term impact on

global health will depend on much broader

political and economic trends. Their approaches

will also vary from those of traditional donors,

and will be shaped by their own experiences,

philosophies and interests. However, to maximize

their global health investments, the BRICS could

consider steps that improve coordination with

other countries and each other. These include

accelerating the development of dedicated

assistance agencies and stronger monitoring and

evaluation policies, and improving communication

with global multilateral mechanisms.

Like traditional donors, the BRICS countries

have their own motives for engaging in global

health. And there are, to be sure, reasonable

concerns about their role and the effectiveness

of their programs. Yet these countries represent

a potentially transformative source of new

resources and innovation for global health anddevelopment. Over the long term, the BRICS can

play an increasingly important role in helping to

improve the health and well-being of the world’s

poorest countries.

of WHO to ensure products are eligible forprequalication. In 2011, WHO formally recognizedChina’s SFDA as a functional regulatory bodyfor vaccines. At the same time, a signicantportion of Russia’s US$4.4 billion investment inits pharmaceutical industry is focused on helping

producers meet GMP standards, and a numberof vaccines manufactured by Brazil’s Fiocruz arealready WHO-prequalied.

Meeting international regulatory standardscan open international markets while helpingto ensure access to safe, effective medicaltechnologies at home. There are still challengesand quality concerns, and some BRICS regulatorybodies continue to lack the capacity they need tobe fully effective. As they move forward, however,there is a signicant opportunity to link the

BRICS’ work in this area with broader efforts onregulatory harmonization.

Working together and with other developingcountries, the BRICS could help harmonizetechnical requirements for medical technologiesand use their respective expertise to achievehigher regulatory standards across all partners.This could also help reduce costs and accelerateaccess to new health products worldwide, sinceregulatory approval in one country would meetthe regulatory standards of others, reducing theneed for additional clinical studies.

conclUsions

Among other shifts, the BRICS and otheremerging powers will increasingly inuence the




Brazil

1 Montagne, Renee. “Brazil Outshines Other BRICEconomies.” NPR. 21 Dec. 2011. Web.

2 Open Data. The World Bank. Web.

3 “Brazilian Economy Overtakes UK’s, Says CEBR.” BBC. 26 Dec. 2011. Web.


5 “Country Statistical Prole: Brazil.” OECD iLibrary. 18Jan. 2012. Web.

6 Coppola, Gabrielle, and Ben Bain. “Brazilian RealStrengthens as Ination-Adjusted Rates AttractInvestors.” Bloomberg. 26 Jul. 2011. Web.

7 “Brazilian Regulatory Tax Scrapped to Promote ForeignInvestment.” Transact Brazil. Dec. 2011. Web.

8 “Chinese Investments in Brazil: A new phase in the

China-Brazil relationship.” China-Brazil BusinessCouncil. May 2011. Web.

9 Lemann, Nicholas. “The Anointed.” The New Yorker. 5Dec. 2011. Print.

10 Ibid.

11 “Members and Partners.” OECD. Web.

12 Jairnilson, Claudia, et al. “The Brazilian health system:history, advances, and challenges.” The Lancet 377.9779(2011): 1778-1797. Print.

13 Victora, Cesar, Mauricio Barreto, and Maria Do CarmoLeal. “Health Conditions and Health-policy Innovationsin Brazil: The Way Forward.” The Lancet 377.9782(2011): 2042-2053. Print.

14 Bliss, Katherine, Judyth Twigg, and Yanzhong Huang.“Brazil and Russia’s Engagement in Global Health.”Council on Foreign Relations, New York, NY. 10 Jan.2012. Roundtable Discussion.


16 “Brazil: HIV/AIDS Health Prole.” USAID. Sep. 2010.Web.

17 “Brazil.” Global Health Observatory (GHO). World HealthOrganization. 4 Apr. 2011. Web.

18 Ibid.

19 “Free diabetes and blood pressure drugs forBrazilians.” BBC. 3 Feb. 2011. Web.

20 Vaz, Alcides Costa, and Cristina Yumie Aokie Inoue.“Emerging Donors in International DevelopmentAssistance: The Brazil Case.” International DevelopmentResearch Centre. Dec. 2007. Web.

21 “Speak softly and carry a blank cheque.” The Economist. 15 Jul. 2010. Web.

22 Vaz, Alcides Costa and Cristina Yumie Aokie Inoue.“Emerging Donors in International DevelopmentAssistance: The Brazil Case.” International DevelopmentResearch Centre. Dec. 2007. Web.

23 Farani, Marco. Personal interview. 13 Jan. 2012.

24 “Brazil as an Emerging Actor in InternationalDevelopment Cooperation: A Good Partner forEuropean Donors.” German Development Institute.May 2010. Web.

25 Ibid.

26 Vasquez, Karen, et al. “From a edging donor to apowerhouse.” Columbia School of International andPublic Affairs. 2011. Web.

27 “Brazil as an Emerging Actor in InternationalDevelopment Cooperation: A Good Partner forEuropean Donors.” German Development Institute.May 2010. Web.

28 “Speak softly and carry a blank cheque.” The Economist.15 Jul. 2010. Web.

29 Vaz, Alcides Costa, and Cristina Yumie Aokie Inoue.

“Emerging Donors in International DevelopmentAssistance: The Brazil Case.” International DevelopmentResearch Centre. Dec. 2007. Web.

30 “Brazil as an Emerging Actor in InternationalDevelopment Cooperation: A Good Partner for EuropeanDonors.” German Development Institute. May 2010. Web.

31 Vasquez, Karen, et al. “From a edging donor to apowerhouse.” Columbia School of International andPublic Affairs. 2011. Web.

32 “Brazil.” Global Humanitarian Assistance. Web.

33 “Brazil as an Emerging Actor in InternationalDevelopment Cooperation: A Good Partner forEuropean Donors.” German Development Institute. May2010. Web.

34 Cabral, Lídia, and Julia Weinstock. “Brazilian technicalcooperation for development.” Overseas DevelopmentInstitute. Sep. 2010. Web.

35 Ibid.

36 “Speak softly and carry a blank cheque.” TheEconomist. 15 Jul. 2010. Web.

37 Cabral, Lídia, and Julia Weinstock. “Brazilian technicalcooperation for development.” Overseas DevelopmentInstitute. Sep. 2010. Web.

38 Ibid.

39 Brazil. Ministry of Health. International Health MattersAdvisory Department. Health Cooperation: Brazilian

International Health Activities Bulletin. Nov. 2011. Web.40 Pimenta, Cristina, et al. “Access to AIDS treatment

in Bolivia and Paraguay.” Associação BrasíleriaInterdisciplinar de AIDS. 2006. Web.

41 Jairnilson, Claudia, et al. “The Brazilian health system:history, advances, and challenges.” The Lancet 377.9779 (2011): 1778-1797. Print.

42 Brazil. Ministry of Health. International Health MattersAdvisory Department. Health Cooperation: BrazilianInternational Health Activities Bulletin. Apr. 2010. Web.

citAtions



94


67 Ortiz, Fabiola. "Providing Alternatives for Small-ScaleTobacco Farmers."Inter Press Service. 23 Dec. 2011.Web

68 Almeida, Celia, et al. “Brazil’s conception of South-South ‘structural cooperation’ in health.” RECISS 4.1(2010): 23-32. Web.

69 Brazil. Institute for Applied Economic Research.Brazilian Cooperation for International Development:2005-2009. Nov. 2011. Web.

70 “How UNITAID came about.” UNITAID. Web.

71 Rezaie, Rahim et al. “Brazilian health biotech —fostering crosstalk between public and private.”Nature Biotechnology 26.6 (2008): 627-644. Print.

72 Ibid.

73 Serruya, Suzanne, et al. “Research and Innovationin Brazil: The Institutional Role of the Ministry ofHealth.”Global Forum Update on Research for Health 5(2008): 24-27. Web.

74 Brazil. Ministry of Science, Technology and

Innovation. Brasil: Dispêndios públicos em pesquisa edesenvolvimento (P&D), por objetivo socioeconômico,2000-2010. 14 Feb. 2012. Web.

75 Rousseff, Dilma. “FINEP Innovation Prize AwardCeremony.” Presidential Palace Blog. 15 Dec. 2011.

76 Brasil Maior . Web.

77 Chamas, Claudia Ines. “Developing Innovative Capacityin Brazil to Meet Health Needs.” MIHR Report to CIPIHon Innovation in Developing Countries to Meet HealthNeeds. Apr. 2005. Web.

78 “Neglected Disease Research & Development: NewTimes, New Trends.” G-FINDER. The George Institutefor International Health. 2009. Web.

79

“Enhancing Brazil’s Capacity for BiopharmaceuticalInnovation.” IAVI Insights. Jul. 2010. Web.


81 Serruya, Suzanne, et al. “Research and Innovationin Brazil: The Institutional Role of the Ministry ofHealth.”Global Forum Update on Research for Health 5(2008): 24-27. Web.

82 Brazil. Ministry of Health. Pesquisa Estratégica para o

Sistema de Saúde. 2011. Web.

83 Brazil. Ministry of Health. Decit 10 Anos. 2010. Web.

84 Gadelha, Carlos. “Valor Economico: Seminar onPerspectives for the Health Sector.” 16 Mar 2011.


86 Brazil. CONFAP. Orcamento. 2009. Web.

87 Brazil. Ministry of Health. Decit 10 Anos. 2010. Web.

88 Brazil. Ministry of Health. Pesquisa Estratégica para oSistema de Saúde. 2011. Web.

43 Ministers of Foreign Affairs. “Oslo MinisterialDeclaration — global health: a pressing foreign policyissue of our time.” The Lancet 369.9570 (2007): 1373-1378. Print.

44 Farani, Marco. Personal interview. 13 Jan. 2012.

45 Figueiredo, Mauro. Personal interview. 24 Jan. 2012.

46

Vallini, Juliana. Personal interview. 13 Jan. 2012.47 Ferreira, José Roberto, et al. Personal interview. 30

Jan. 2012.

48 Passarelli, Carlos André, and Veriano Terto Jr. “GoodMedicine: Brazil’s Multi-Front War on AIDS.” NACLA:Report on the Americas 35.5 (2002): 35-37, 40-42. Web.

49 “Brazil: HIV/AIDS Health Prole.” USAID. Sep. 2010. Web.

50 Lee, Kelley, et al. “Brazil and the Framework Conventionon Tobacco Control: Global Health Diplomacy as SoftPower.” PLoS 7.4 (2010). Web.

51 Pimenta, Cristina, et al. “Access to AIDS treatmentin Bolivia and Paraguay.” Associação BrasíleriaInterdisciplinar de AIDS. 2006. Web.

52 Ibid.

53 Brazil. Ministry of Health. International Health MattersAdvisory Department. Health Cooperation: BrazilianInternational Health Activities Bulletin. Oct. 2009. Web.

54 Brazil. Ministry of Health. International Health MattersAdvisory Department. Health Cooperation: BrazilianInternational Health Activities Bulletin. Nov. 2011. Web.

55 “Brazil World Bank — Sharing a quiet socialrevolution.” The South-South Opportunity Case Stories. Task Team on South-South Cooperation. Web.

56 “A donation from the heart.” PATH. Web.

57 US CDC. “Latin American Breast Milk Banks Catch on

Worldwide.” The Body. 29 Jul. 2008. Web.58 "Institutes". Fiocruz. 2005. Web.


60 Almeida, Celia, et al. “Brazil’s conception of South-South ‘structural cooperation’ in health.” RECISS 4.1(2010): 23-32. Web.


62 Ibid.

63 “UNAIDS and Brazil to strengthen technicalcooperation on AIDS.” Feature stories – 2008. UNAIDS.30 May 2008. Web.

64 Ferreira, José Roberto, et al. Personal interview. 30Jan. 2012.

65 Brazil. Ministry of Health. International Health MattersAdvisory Department. Health Cooperation: BrazilianInternational Health Activities Bulletin. Apr. 2010. Web.

66 Lee, Kelley, et al. “Brazil and the Framework Conventionon Tobacco Control: Global Health Diplomacy as SoftPower.” PLoS 7.4 (2010). Web.




8 Russia. State Statistics Service. Web.

9 “Russia: Economy Overview.” The World Factbook. CIA.Web.

10 Mankoff, Jeffrey. Russian Foreign Policy: The Returnof Great Power Politics. Lanham, MD: Rowman &Littleeld, 2009. Print.

11

Bridge, Robert. “As Global Economy Cools, Russian-Chinese Relations Heat up.” Russia Today . 11 Oct. 2011.


13 “Highlights on health in the Russian Federation.”World Health Organization 2005. Web.

14 “MDG+ Agenda in Russia: Translating Economic GrowthInto Sustainable Human Development with HumanRights.” United Nations. Dec. 2004. Web.

15 Suhrcke, Marc, et al. “Economic Consequences ofNoncommunicable Diseases and Injuries in the RussianFederation.” The European Observatory on HealthSystems and Policies. 2007. Web.

16 “HIV/AIDS Policy Framework and Implementation

in Russia.” Global Business Coalition on HIV/AIDS,Tuberculosis and Malaria and Transatlantic Partners

Against Aids. 2007. Web.

17 “TB Policy Framework and Implementation in Russia.”Global Business Coalition on HIV/AIDS, Tuberculosis andMalaria and Transatlantic Partners Against Aids. 2007.Web.

18 Ferris-Rotman, Amie. “Insight: Russia Says No toWest’s Way with HIV.” Reuters. 21 Dec. 2011. Web.

19 Ibid.

20 “HIV/AIDS Policy Framework and Implementationin Russia.” Global Business Coalition on HIV/AIDS,Tuberculosis and Malaria and Transatlantic Partners

Against Aid. 2007. Web.21 “ Health at a Glance: Europe 2010.” European

Commission. OECD. 1 Dec. 2010. Web.

22 Ibid.

23 Gamser, Marius. “Putin Talks Russia Health careReform.” International Insurance News. 19 Apr. 2011. Web.

24 Walz, Julie, and Vijaya Ramachandran. “Brave NewWorld: A Literature Review of Emerging Donors andthe Changing Nature of Foreign Assistance.” Center for Global Development. 2011. Web.

25 Ibid.

26 “Russian Federation - net ofcial developmentassistance and ofcial aid received.” index mundi. 1 Mar. 2012. Web.

27 Russia expert. Personal interview. Feb. 2012.

28 Russia. Ministry of Finance. Russia’s Participation inInternational Development Assistance, Concept. 2007. Web.

29 Bliss, Katherine, et al. “Key Players in Global Health:How Brazil, Russia, India, China and South Africa AreInuencing the Game.” CSIS Global Health Policy Center.Nov. 2010. Print.

89 Rezaie, Rahim, et al. “Brazilian health biotech —fostering crosstalk between public and private.”Nature Biotechnology 26.6 (2008): 627-644. Print.

90 Ibid.

91 “The Brazilian Life Sciences Industry:Pathways to Growth.” Fundação Biominas andPriceWaterhouseCoopers. 2011. Web.

92 Gadelha, Carlos. “Valor Economico: Seminar onPerspectives for the Health Sector.” 16 Mar. 2011.

93 “O mercado privado de vacinas no Brasil: AMercantilização no Espaço da Prevençã.” Cadernos deSaúde Pública 19.5 (2003):1323-1339. Print.


95 "History." Fiocruz. 2005. Web.

96 "Introduction." Fiocruz. 2005. Web.

97 Chamas, Claudia Ines. “Developing Innovative Capacity

in Brazil to Meet Health Needs.” MIHR Report to CIPIHon Innovation in Developing Countries to Meet HealthNeeds. Apr. 2005. Web.

98 "Fiocruz in Africa." Fiocruz. 2005. Web.

99 "Institutes." Fiocruz. 2005. Web.

100 "Bio-Manguinhos."Fiocruz. 2005. Web.


102 "Center for Technological Development in Health."Fiocruz. Web.

103

"About Us." Butantan. Web.104 Butantan ofcial. Personal interview. 2012.

105 Boseley, Sarah. “Thousands will go untreated unlessBrazil steps up production of essential drugs.”The Guardian. 6 Oct. 2011. Web.

106 “Brazil to become world supplier of Chagas diseasedrug.” News Medical. 22 Oct. 2011. Web.

Russia

1 “Energy-rich Russia Hit Hard by Global FinancialCrisis.” PBS Newshour . 1 Jul. 2009. Web.


3 Ibid.

4 Ibid.

5 “Russia’s middle class must grow – Putin.” RIA Novosti. 16 Jan. 2012. Web.

6 Bierman, Stephen. “Russian Crude Oil Production Rose toPost-Soviet High in 2011.” Bloomberg. 2 Jan. 2012. Web.

7 “Russia: Economy Overview.” The World Factbook. CIA.Web.



96


52 Ibid.

53 Ibid.

54 Russia. Ministry of Finance. Deauville Accountability Report G8 Commitments on Health and Food Security State of Delivery and Results The Russian FederationContribution. 2010. Web.

55

"Indicators for Science, Statistical Information." Higher School of Economics. 2009. Web.

56 World Health Organization ofcial. Personal interview.Feb. 2012.

57 "Indicators for Science, Statistical Information." Higher School of Economics. 2009. Web.

58 Academic ofcial. Personal interview. Feb. 2012.

59 Ibid.

60 Russia. Ministry of Education and Sciences. Educationof Foreign Citizens in the Higher Educational Institutionsof the Russian Federation. 2011. Web.

61 World Health Organization ofcial. Personal interview.

Feb. 2012.62 Ibid.

63 Russia. Ministry of Industry and Trade. Medical Industry 2009. 2010. Web.

64 “Pharmaceutical Market Russia Issue.” Russian Association of Pharmaceutical Manufacturers. 2011. Web.

65 “Pharma 2020: The Strategy of Development of thePharmaceutical Industry of the Russian Federation.”Swiss Embassy in the Russian Federation. 2011. Web.

66 “Russian drug rst time approved in the US.” RB News.25 Feb. 2011.

67 Russia. Ministry of Industry and Trade. Medical Industry 2009. 2010. Web.

68 “Pharma 2020: The Strategy of Development of thePharmaceutical Industry of the Russian Federation.”Swiss Embassy in the Russian Federation. 2011. Web.

69 “Support for domestic production will not be dominantin the transition Pharmstandard GMP.” Pharma2020. 27Apr. 2010. Web.

70 Peach, Gary. “Russia Pledges $4 billion for Pharma-2020plan.” Nature Medicine News. 5 May 2011. Web.

71 Jerome Gavet. Interview with Focus Reports. FocusReports. 1 Mar. 2012. Web.

72 “Pharma 2020: The Strategy of Development of the

Pharmaceutical Industry of the Russian Federation.”

Swiss Embassy in the Russian Federation. 2011. Web.73 “Our commitment to Russia.” Akrikhin. 2 Mar. 2012.

Web.

74 “Foreign companies are increasing their levels ofinvestment in Russia.” Pharmaceutical News. 15 Jul.2011. Web.

75 Russia innovation and technology expert. Personalinterview. Feb. 2012.

30 Russia. Ministry of Finance. Russia’s Participation inInternational Development Assistance, Concept. 2007. Web.


32 “World Bank-Russian Federation Partnership: CountryProgram Snapshot.” The World Bank. 2011. Web..

33 “Russia." The Data Report 2011. ONE. 1 Mar. 2012. Web.


35 Russia. Ministry of Finance. Russia’s Participation inInternational Development Assistance, Concept. 2007.Web.

36 “Russia.” Research Centre for International Cooperationand Development. 1 Mar. 2012. Web.

37 Russia. Ministry of Finance. Russia’s Participation in

International Development Assistance, Concept. 2007.Web.

38 “Russian Finance Ministry Will Fight Poverty.” Newsru.com. 26 Aug. 2011. Web.

39 Russia innovation and technology expert. Personalinterview. Feb. 2012.

40 Russia. Ministry of Finance. Russia’s Participation inInternational Development Assistance, Concept. 2007.Web.

41 Bliss, Katherine, et al. “Key Players in Global Health:How Brazil, Russia, India, China and South Africa AreInuencing the Game.” CSIS Global Health Policy Center.Nov. 2010. Print.

42

Larionova, M. “ODA: forming a new collaborationparadigm.” Web.

43 World Health Organization ofcial. Personal interview.Feb. 2012.


45 Ibid.

46 “Government Statements at the UN High-LevelSummit on NCDs, 19-20 September 2011.” InternationalDiabetes Federation. 2011. Web.

47 Russia expert. Personal interview. Feb 2012.


49 Ibid.

50 Russia expert. Personal interview. Feb 2012.

51 Ibid.




28 Ibid.

29 Mullen, Rani. Personal interview. Feb. 2012.

30 Government of India ofcial. Personal interview. Feb. 2012.

31 India. Ministry of External Affairs, Ministry of Finance.Union Budget and Economic Survey 2011-2012. Web.

32 Ibid.

33 Agrawal, Subhash. “Emerging Donors in InternationalDevelopment Assistance: The India Case.” InternationalDevelopment Research Centre. Dec. 2007. Web.

34 Chanana, Dweep. “India as an Emerging Donor.”Economic and Political Weekly 44.12 (2009). Web.

35 Mullen, Rani. Personal interview. Feb. 2012.

36 Baru, Sanjaya. Personal interview. Feb. 2012.

37 “India announces $5 bn credit line for Africa.” IndianExpress. 24 May 2011. Web.

38 India. Ministry of External Affairs, Ministry of Finance.Union Budget and Economic Survey 2011-2012. Web.

39

Agrawal, Subhash. “Emerging Donors in InternationalDevelopment Assistance: The India Case.” InternationalDevelopment Research Centre. Dec. 2007. Web.

40 Ibid.

41 Bijoy, C. J. "India: Transiting to a Global Donor." Reality of Aid. 2010. Web.

42 India. Ministry of External Affairs. Outcome Budget 2011-2012. Web.

43 Government of India ofcial. Personal interview. Feb.2012.

44 Ibid.

45 "Budget 2012 India: Highlights of Pranab Mukherjee'sspeech." Economic Times. 16 Mar. 2012. Web.

46 Ibid.

47 Ibid.

48 Ibid.

49 India. Ministry of External Affairs. Budget Outlay, 2008-2009, 2010-2011, 2011-2012. Web.

50 Ibid.

51 India. Ministry of External Affairs. Budget Outlay, 2008-2009, 2010-2011, 2011-2012. Web.


53 India. Ministry of External Affairs. Budget Outlay, 2008-

2009, 2010-2011, 2011-2012. Web.54 Ibid.

55 India. External Publicity Division. Ministry of ExternalAffairs. India and Afghanistan: A DevelopmentPartnership. Web.


57 Global Polio Eradication Initiative. 2010. Web.

India

1 Narayanan, Dinesh and Udit Misra. “UPA’s InclusiveGrowth Agenda For India.” Forbes India Magazine. 25Feb. 2010. Web.


3 Ibid.

4 “Economic Survey of India, 2007.” OECD. Oct. 2007. Web.

5 “Manufacturing Helps GDP Grow 7.4% in FY10.”Economic Times. 1 Jun. 2010. Web.

6 Vaidyanathan, R. “The Real Engines of Indian EconomicGrowth.” The Edge 5.1 (2008). Web.

7 Development expert. Personal interview. Jan. 2012.

8 “India’s economic growth sags to 6.1 percent inDecember quarter, slowest in over 2 years.” AssociatedPress. 29 Feb. 2012. Web.

9 Swaminathan S. "Economic Survey 29012: GDP growthpegged at 7.6 per cent for FY'13." Economic Times. 16Mar. 2012. Web.

10 Development expert. Personal interview. Jan. 2012.

11 “Ination Hits 26-month Low of 6.55%.” The Times of India. 15 Feb. 2012. Web.

12 Ibid.

13 Mohan, C. Raja. “India and the Balance of Power.”Foreign Affairs. Jul-Aug. 2006. Web.

14 “Chinese PM Wen Jiabao Begins Bumper Indian TradeTrip.” BBC. 15 Dec. 2010. Web.

15 Dhawan, Himanshi. “India Leads Commonwealth Tallyin Underweight Children.” The Times of India. 14 Oct.2010. Web.

16 WHO Mortality Database. World Health Organization.Web.

17 Ibid.

18 Global Burden of Disease. World Health Organization.2008. Web.

19 IDF Diabetes Atlas. International Diabetes Federation. Web.

20 Gale, Jason. “India’s Diabetes Epidemic Cuts Down MillionsWho Escape Poverty.” Bloomberg. 7 Nov. 2010. Web.

21 "Budget 2012 India: Highlights of Pranab Mukherjee'sspeech." Economic Times. 16 Mar. 2012. Web.

22 India. Planning Commission. Faster, Sustainable andMore Inclusive Growth: An Approach to the Twelfth FiveYear Plan (2012-2017). Oct. 2011. Web.

23 Chanana, Dweep. “India as an Emerging Donor.”Economic and Political Weekly 44.12 (2009). Web.

24 Bijoy, C. J. “India: Transiting to a Global Donor.” Reality of Aid. 2010. Web.

25 Ibid.

26 Ibid.

27 Government of India ofcial. Personal interview.Feb. 2012.



98


81 Inerfurth, Karl, and Persis Khambatta. “A U.S.-IndiaInnovative Partnership.” U.S.-India Insight. Center forStrategic and International Studies. Aug. 2011. Web.

82 “Innovation for a new world? Emerging markets, frugalinnovation and changing R&D.” Swedish Agency For Growth Policy Analysis. 2011. Web.

83 “Case 19: Treating Cataracts in India.” Center for GlobalDevelopment. Web.

84 “Lessons from a frugal innovator.” The Economist. 16Apr. 2009. Web.

85 “Innovating Around India’s Health Care Challenges.”India Knowledge @ Wharton. University of Pennsylvania.29 Jul. 2010. Web.

86 India. Department of Biotechnology. Ministry of Scienceand Technology. Annual Report (2009-2010). Web.

87 Ibid.

88 Ibid.

89 India. Department of Biotechnology. Ministry of Scienceand Technology. Small Business Innovation Research

Initiative. Web.90 India. Department of Biotechnology. Ministry of Science

and Technology. Annual Report (2009-2010). Web.

91 India. Department of Biotechnology. Ministry of Scienceand Technology. Biotechnology Industry ParnershipProgram (BIPP). Web.

92 “Developing New Vaccines Against Rotavirus.” PATH.Nov. 2008. Web.

93 Koul, Rahul. “Mission: An indigenous rotavirusvaccine.” BioSpectrum. 13 Feb. 2012. Web.

China


2 “China.” The World Bank. Web.


4 “Modernisation in Sheep’s Clothing.” The Economist. 26Aug. 2011. Web.

5 “China.” The World Bank. Web.

6 “China.” U.S. Department of State. 6 Sep. 2011. Web.


8 “WTO: China Overtakes Germany as World’s LargestExporter.” People’s Daily Online. 30 Mar. 2010. Web.

9

Wang, Feng. “China’s Population Destiny: The LoomingCrisis.” Brookings-Tsinghua Center . Sep. 2010. Web.

10 Ibid.

11 “Chinese vice premier urges expanding domesticdemand, keeping property curbs.” Xinhua. 15 Dec. 2011.Web.

12 Back, Aaron, and Esther Fung. “China to IncreaseDomestic Consumption to Aid Global Economy, Willingto Expand Europe Investment.” The Wall Street Journal. 15 Sep. 2011. Web.

58 India. External Publicity Division. Ministry of ExternalAffairs. India and Afghanistan: A DevelopmentPartnership. Web.

59 Government of India ofcial. Personal interview.Feb. 2012.

60 “Sierra Leone link to India medics.” BBC. 3 Nov.2009. Web.

61 Malone, Berry. “Telemedicine links Africans to Indianexpertise.” Reuters. 3 Apr. 2008. Web.

62 Padma, TV and Ochieng Ogodo. "India to boost sciencecollaboration with Africa." Science and DevelopmentNetwork. 9 Mar. 2012. Web.

63 Patil, Shrimati Pratibha Devisingh. “Address by theHon’ble President of India, Shrimati Pratibha DevisinghPatil, to Parliament.” New Delhi, India. 4 Jun. 2009. Web.

64 India. National Innovation Council. India to launch $1-bninnovation fund by June-July. Jan. 2012. Web.

65 “Brazil co to buy Lupin TB drug.” The Financial Express.6 Jan. 2011. Web.

66 Waning, B, et al. “A lifeline to treatment: the role ofIndian generic manufacturers in supplying antiretroviralmedicines to developing countries.” Journal of theInternational AIDS Society 13.35 (2010). Web.

67 Chirac, Pierre. “Increasing the Access to AntiretroviralDrugs to Moderate the Impact of AIDS: an Explorationof Alternative Options.” AIDS, Public Policy and ChildWell-Being. UNICEF. 2007. Web.

68 “AIDS, Drug Prices and Generic Drugs.” AVERT . Web.

69 Hamied, Yusuf. “An interview with Cipla’s Yusuf Hamied– Indian Drug-Maker Leads the Charge for Low-CostAIDS Drugs.” TREAT, amfAR. Mar. 2003. Web.

70 Bajaj, Vikas and Pollack, Andrew. “India Orders Bayer

to License a Patented Drug.” The New York Times. 12Mar. 2012. Web.

71 Mathew, Joe. “Pharma FDI: Panel for urgent reversal.”Business Standard. 23 Nov. 2011. Web.

72 Ojambo, Fred. “Cipla’s Ugandan Unit to Invest $50 Millionin Tablet Expansion.” Bloomberg. 26 Jan. 2012. Web.

73 India. Press Information Bureau. Ministry of EarthScience. India vaccine market reaches $900 million. Nov.2011. Web.

74 Ibid.

75 “Quality of vaccines produced in India becoming aconcern.” Press Trust of India. 10 Feb. 2012. Web.

76 Jadhav, Suresh. Personal interview. Feb. 2012.

77 Ibid.

78 Ibid.

79 Chakma, Justin, et al. “Indian vaccine innovation: thecase of Shantha Biotechnics.” Globalization and Health7.9 (2011). Web.

80 “Dramatic fall in cases of meningitis A in three WestAfrican nations after new vaccine introduction.”Meningitis Vaccine Project. 9 Jun. 2011. Web.




35 Chin, Gregory, and B. Michael Frolic. “Emerging Donorsin International Development Assistance: The ChinaCase.” International Development Research Centre. Dec.2007. Web.

36 Huang, Yanzhong. “Domestic Factor’s and China’sHealth Aid to Africa.” China’s Emerging Global Healthand Foreign Aid Engagement in Africa. Ed. Xiaoqing Lu

Boynton. Center for Strategic and International Studies.2012. Print.

37 Huang, Yanzhong. “Domestic Factor’s and China’sHealth Aid to Africa.” China’s Emerging Global Healthand Foreign Aid Engagement in Africa. Ed. Xiaoqing LuBoynton. Center for Strategic and International Studies.2012. Print.

38 China. Information Ofce of the State Council. China’sForeign Aid. 2011. Web.

39 Brautigam, Deborah. “U.S. and Chinese Efforts inAfrica in Global Health and Foreign Aid: Objectives,Impact, and Potential Conicts of Interest.”China’sEmerging Global Health and Foreign Aid Engagement in

Africa. Ed. Xiaoqing Lu Boynton. Center for Strategic

and International Studies. 2012. Print.40 Huang, Yanzhong. “Domestic Factor’s and China’s

Health Aid to Africa.” China’s Emerging Global Healthand Foreign Aid Engagement in Africa. Ed. Xiaoqing LuBoynton. Center for Strategic and International Studies.2012. Print.

41 “Transparency could be the sticking point for China atBusan.” The Guardian. 14 Nov. 2011. Web.


43 Ibid.

44 Brautigam, Deborah. “Testimony on China’s GrowingRole in Africa before the United States SenateCommittee on Foreign Relations Subcommittee onAfrican Affairs.” United States Senate Committee onForeign Affairs 1 Nov. 2011. Web.

45 “Understanding Chinese Foreign Aid: A Look at China’sDevelopment Assistance to Africa, Southeast Asia, andLatin America. New York University Robert F. Wagner Graduate School of Public Service. 28 Apr. 2008. Web.


47 Ibid.

48 Brautigam, Deborah. “U.S. and Chinese Efforts inAfrica in Global Health and Foreign Aid: Objectives,Impact, and Potential Conicts of Interest.”China’s

Emerging Global Health and Foreign Aid Engagement in Africa. Ed. Xiaoqing Lu Boynton. Center for Strategicand International Studies. 2012. Print.

49 Ibid.

50 Ibid.

51 “Decade-old China-Africa co-op forum yields richresults, has promising future.” Xinhua. 18 Nov. 2010. Web.

13 “China’s massive stimulus creates side effects,economic development adjustments needed:economist.” Xinhua. 2 Dec. 2011. Web.

14 Alderman, Liz, and David Barboza. “Europe Tries toLure Chinese Cash to Back Rescue of Euro.” The New York Times. 28 Oct. 2011. Web.

15 “Rising Power, Anxious State.” The Economist. 23 Jun.2011. Web.

16 Bliss, Katherine, et al. “Key Players in Global Health:How Brazil, Russia, India, China and South Africa AreInuencing the Game.” CSIS Global Health Policy Center .Nov. 2010. Print.

17 “China’s Developing-country Identity RemainsUnchanged.” Xinhua. 13 Aug. 2010. Web.

18 Chenxi, Wang, and Wei Jianhua. “China-AfricaFriendship Enhanced by Diverse, GrowingCooperation.” Xinhua. 29 Jan. 2012. Web.

19 Huang, Yanzhong. “The Sick Man of Asia.” Foreign Affairs. Nov-Dec. 2011. Print.

20

Ibid.21 “2010: A global view of HIV infection.” UNAIDS. 2010. Web.

22 Wu, Zunyou, et al. “Evolution of China’s response toHIV/AIDS.” The Lancet 369.9562 (2007): 679-690. Print.

23 “HIV/AIDS Infections Soaring in China GeneralPopulation: Experts.” Xinhua. 30 Nov. 2011. Web.

24 Yang, Gonghuan, et al. “Emergence of Chronic Non-communicable Diseases in China.” The Lancet 372.9650(2008): 1697-1705. Print.


26 “Towards a Tobacco-free China.” WHO Western PacificRegion. World Health Organization. 7 Sep. 2011. Web.



29 Chan, Lai-Ha, et al. “China’s Engagement with GlobalHealth Diplomacy: Was SARS a Watershed?” Ed. KelleyLee. PLoS 7.4 (2010): E1000266. Web.


31 China. Information Ofce of the State Council of the

People’s Republic of China. China’s Foreign Aid. 2011. Web.32 “Charity begins abroad.” The Economist. 13 Aug.

2011. Web.

33 China. Information Ofce of the State Council ThePeople’s Republic of China. China’s Foreign Aid. 2011. Web.

34 Huang, Yanzhong. “Domestic Factor’s and China’sHealth Aid to Africa.” China’s Emerging Global Healthand Foreign Aid Engagement in Africa. Ed. Xiaoqing LuBoynton. Center for Strategic and International Studies.2012. Print.



00



Africa. Ed. Xiaoqing Lu Boynton. Center for Strategicand International Studies. 2012.

71 Ibid.

72 Huang, Yanzhong. “Pursuing Health as Foreign Policy:The Chase of China.” Indiana Journal of Global LegalStudies 17.1 (2010): 105-146.

73 Liu, Peilong, et al. “China health aid to Africa.” PekingUniversity Institute for Global Health. 2011. Print.


Africa. Ed. Xiaoqing Lu Boynton. Center for Strategicand International Studies. 2012. Print.

75 Ibid.

76 China. Information Ofce of the State Council. China’s

Foreign Aid. 2011. Web.77 Brautigam, Deborah. “U.S. and Chinese Efforts in

Africa in Global Health and Foreign Aid: Objectives,Impact, and Potential Conicts of Interest.”China’sEmerging Global Health and Foreign Aid Engagement in

Africa. Ed. Xiaoqing Lu Boynton. Center for Strategicand International Studies. 2012.

78 "China." Grant Portfolio. The Global Fund to Fight AIDS,Tuberculosis and Malaria. Web.

79 “Donor Governments.” The Global Fund to Fight AIDS,Tuberculosis and Malaria. 28 Feb. 2012. Web.

80 LaFraniere, Sharon. “AIDS Funds Frozen for China inGrant Dispute.” The New York Times. 20 May 2011. Web.

81 “HIV/AIDS: Global Fund cancels funding.” IRIN News. 24Nov. 2011. Web.

82 “UNAIDS applauds China’s decision to ll its HIVresource gap.” UNAIDS. 1 Dec. 2011. Web.


84 China Ministry of Health ofcial. Personal interview.Feb. 2012.

85 Brown, Hannah. “And the next Director-General of WHOis…” The Lancet 368.9549 (2006): 1757–1758. Web.

86

“Dr Margaret Chan nominated for a second term to beWHO Director-General.” World Health Organization. 18Jan. 2012. Web.

87 Huang, Yanzhong. “Pursuing Health as Foreign Policy:The Chase of China.” Indiana Journal of Global LegalStudies 17.1 (2010): 105-146. Print.

88 Ibid.

89 “Drug-resistant tuberculosis now at record levels.”World Health Organization.18 Mar. 2010. Web.



53 Tarnoff, Curt, and Larry Nowels. “Foreign Aid: An

Introductory Overview of U.S. Programs and Policy.”Congressional Research Service. 15 Apr. 2004. Web.


55 Ibid.

56 Ibid.



59

Huang, Yanzhong. “Pursuing Health as Foreign Policy:The Chase of China.” Indiana Journal of Global LegalStudies 17.1 (2010): 105-146. Print.




62 Ibid.

63 “About PPD.” Partners in Population and Development.Web.

64 “China Starts its First Foreign Aid Program inPopulation and Reproductive Health.” NationalPopulation and Family Commission of China. 25 Oct.2007. Web.



66 Huang, Yanzhong. “Pursuing Health as Foreign Policy:

The Chase of China.” Indiana Journal of Global LegalStudies 17.1 (2010): 105-146. Print.


68 Huang, Yanzhong. “Pursuing Health as Foreign Policy:The Chase of China.” Indiana Journal of Global LegalStudies 17.1 (2010): 105-146. Print.

69 “Chinese doctors treat 260 mln patients by 2009 inforeign aid: white paper.” Xinhua. 21 Apr. 2011. Web.




112 McGregor, James. “China’s Drive for IndigenousInnovation: A Web of Industrial Policies.” GlobalIntellectual Property Center, U.S. Chamber of Commerceand APCO Worldwide. 2010. Web.

113 Ibid.

114 Hendriks, J., Yan Ling, and Bing Zeng. “China’semerging vaccine industry.” Human Vaccines 6.7 (2010):602-607. Web.

115 “Preparing for the Global Market: China’s ExpandingRole as a Vaccine Manufacturer.” The National Bureau of

Asian Research. 25 May 2011. Web.

116 Wong, Gillian. “China prepares for big entry into vaccinemarket.” The Associated Press. 29 Nov. 2011.

117 Ibid.



119 Ibid.

120 Ibid.

121 “Chinese vaccines struggling to go global.” Xinhua. 29Feb. 2012. Web.

122 “Historic protection for Asia's children.” JapaneseEncephalitis Project. PATH. Dec. 2009. Web.

123 Ibid.

124 Ibid.

125 “On the fast track to control: Recognition of Japaneseencephalitis leads to action.” Japanese EncephalitisProject. PATH. Web.

126 “Aeras and CNBG Sign Agreement on TuberculosisVaccine R&D.” PR Newswire. 1 Jan. 2012. Web.

127 “New vaccine partnership in China.” PATH. 9 Jul. 2007.Web.

128 China. Information Ofce of the State Council. Family Planning in China. 1995. Web.

129 “Expanding Contraceptive Choice: Five PromisingInnovations.” Population Reference Bureau. Jun. 2009. Web.

130 Yun, Hu. “China’s Practice in Commodity Security forNational Family Planning Program.” China TrainingCenter of Reproductive Health and Family Care. 10 Dec.2010. Web.

131 “Sino-Implant (II) Project Fact Sheet.” FHI 360. Feb.2012. Web.

132 “Sino-Implant (II) – A Dramatically Less-Expensive

Implant Option.” USAID. Jun. 2009. Web.133 “Sino-Implant (II). FHI 360. Oct. 2008. Web.

134 “Sino-Implant (II) Project Fact Sheet.” FHI 360 . Feb.2012. Web.

135 Steiner, Markus. Personal interview. Feb. 2012.

136 “Female Condom: A Powerful Tool for Protection.”UNFPA and PATH. 2006. Web.

90 Wang, Longde, Jianjun Liu, and Daniel Chin.“Progress in tuberculosis control and the evolvingpublic-health system in China.” The Lancet 369.9562(2007): 691-696. Print.

91 “Meeting Report: A Ministerial Meeting of High M/ZDR-TBBurden Countries.” World Health Organization. 2009. Web.

92 Stone, Richard. “China Bets Big on Small Grants, LargeFacilities.” Science 331 (2011): 1251. Web.

93 Kaufman, Joan. “IAVI Internal Strategy Paper(unpublished).” IAVI. 2009. Print.

94 Topal, Claire, and Karuna Luthra. “A Pivotal Momentfor China & Vaccine Manufacturing: An Interview withJiankang (Jack) Zhang.” The National Bureau of AsianResearch. 25 May 2011. Web.

95 Bill & Melinda Gates Foundation Program Ofcer.Personal interview. Feb. 2012.

96 Topal, Claire, and Karuna Luthra. “A Pivotal Momentfor China & Vaccine Manufacturing: An Interview withJiankang (Jack) Zhang.” The National Bureau of AsianResearch. 25 May 2011. Web.


98 Kaufman, Joan. "IAVI Internal Strategy Paper (unpublished)."IAVI. 2009. Print.

99 Stone, Richard. “China Bets Big on Small Grants, LargeFacilities.” Science 331 (2011): 1251. Web.

100 Li, Liu. “Research Priorities and Priority-setting inChina.” Vinnova. Nov. 2009. Web.

101 Ibid.

102 Bumpas, Janet and Ekkehard Betsch. “ExploratoryStudy on Active Pharmaceutical IngredientManufacturing for Essential Medicines.” The World

Bank. Sep. 2009. Web.103 Ibid.

104 Ibid.

105 "Preparing for the Global Market: China’s ExpandingRole as a Vaccine Manufacturer.” The National Bureau of


106 Bill & Melinda Gates Foundation Program Ofcer.Personal interview. Feb. 2012.



108 Topal, Claire and Karuna Luthra. “A Pivotal Moment

for China & Vaccine Manufacturing: An Interview withJiankang (Jack) Zhang.” The National Bureau of AsianResearch. 25 May 2011. Web.

109 Ibid.

110 Cyranoski, David. “China rushes through major fundingsystem.” Nature 455.142 (2008). Web.




02


25 Walz, Julie, and Ramachandran, Vijaya. “Brave New World:A Literature Review of Emerging Donors and theChangingNature of Foreign Assistance.” Center for GlobalDevelopment. 2011. Web.

26 Kragelund, Peter. “The Potential Role of Non-Traditional Donors’ Aid in Africa: Issue Paper11.” International Centre for Trade and Sustainable

Development.. Feb. 2010. Web.27 South Africa. Department of International Relations

and Cooperation. Report on the African Renaissance andInternational Cooperation Fund 2009/10. Web.

28 Tapula, Tobelo, et al. “South Africa’s developmentpartnership agency: A burden or blessing?”The South

African Institute of International Affairs. 21 Oct. 2011. Web.

29 “Brieng by Department of International Relations &Co-operation on legislation for establishment of SADPA.”Parliamentary Monitoring Group. 2 Aug. 2011. Web.

30 Bliss, Katherine, et al. “Key Players in Global Health:How Brazil, Russia, India, China and South Africa AreInuencing the Game.” CSIS Global Health Policy Center .

Nov. 2010. Print.31 Government of South Africa ofcial. Personal interview.

Feb. 2012.

32 Government of South Africa ofcial. Personal interview.Jan. 2012.

33 South Africa. National Department of Health. NationalDepartment of Health, Annual Report, 2009/2010. Web.

34 Okole, Blessed. Personal interview. Jan. 2012.

35 Ibid.

36 “About the Treatment Action Campaign.” Treatment Action Campaign. Web.

37 South Africa. Department of Science and Technology.

National Survey of Research & Experimental Development2008/09. Oct. 2010. Web.

38 Al-Bader, Sara, et al. “Small but tenacious: SouthAfrica’s health biotech sector.” Nature Biotechnology 27 (2009): 427 – 445. Print.

39 South African AIDS Vaccine Initiative. Web.

40 Creamer, Terence. “SA sets up agency to bridge gapbetween research and commercialization.” EngineeringNews. 29 Oct. 2010. Web.

41 “Anti-HIV gel leadership team acknowledged foroutstanding achievement in world health.” EurekaAlert.20 Jun. 2011. Web.

42 Auvert, Bertrand, et al. “Randomized, Controlled

Intervention Trial of Male Circumcision for Reductionof HIV Infection Risk: The ANRS 1265 Trial.” PLoS 2.11(2005). Web.

43 Al-Bader, Sara, et al. “Small but tenacious: SouthAfrica’s health biotech sector.” Nature Biotechnology 27 (2009): 427–445. Print.

44 “Aspen Generics.” Aspen Holdings. Web.

45 “GSK buys into Aspen Pharmacare.” SouthAfrica.info.13May 2009. Web.

South Africa

1 “Jobless Growth.” The Economist. 3 Jun. 2010. Web.


3 Ibid.

4 “China Becomes South Africa’s Biggest Export

Destination: Ambassador.” Xinhua. 21 Aug. 2011. Web.5 “Sub-Saharan African GDP Growth Forecasts.” The

Economist. 22 Oct. 2011. Print.

6 “Quarterly Labour Force Survey: Quarter 3 (July toSeptember), 2011.” Statistics South Africa. 1 Nov. 2011. Web.

7 “2011 World Population Data Sheet.” PopulationReference Bureau. 2011. Web.

8 “South Africa.” OECD. Web.

9 “South Africa.” African Economic Outlook. 2011. Web.

10 Alves, Ana C. “South Africa-China Relations: GettingBeyond the Cross-roads?” Sunday Independent. 29 Aug.2010. Web.

11 South Africa. Building a Better World: The Diplomacy of Ubuntu.13 May 2011. Web.

12 “Disease and injury country estimates.” World HealthOrganization. 2008. Web.

13 “South Africa - Tuberculosis Prole.” World HealthOrganization. 2010. Web.

14 “HIV and AIDS in South Africa.” HIV & AIDS Around theWorld. AVERT. Web.

15 “Country of South Africa: Country Progress Report onthe Declaration of Commitment on HIV/AIDS.” UNAIDS.31 Mar. 2010. Web.

16 Government of South Africa ofcial. Personal interview.Feb. 2012.

17 World Databank. The World Bank. Web.

18 “South Africa unveils universal health scheme.” BBC. 12 Aug. 2011. Web.

19 Grimm, Sven. “South Africa as a DevelopmentPartner in Africa: Policy Brief Number 11.” EuropeanDevelopment Cooperation to 2020. Mar. 2011. Print.

20 Braude, Wolfe, et al. “Emerging Donors in InternationalDevelopment Assistance: The South Africa Case.”International Development Research Centre. Jan. 2008.Web.

21 “South Africa.” Global Humanitarian Assistance. Web.

22 Chidaushe, Moreblessings, Pearl Thandrayan, and

Elizabeth Sidiropailos. “South-South Cooperation orSouthern Hegemony? The Role of South Africa as a‘superpower’ and donor in Africa.” Reality of Aid AfricaProject. Web.

23 “Brieng by Department of International Relations &Co-operation on legislation for establishment of SADPA.”Parliamentary Monitoring Group. 2 Aug. 2011. Web.

24 South Africa. Department of International Relationsand Cooperation. Report on the African Renaissance andInternational Cooperation fund 2009/10. Web.




26 “DAC1 Ofcial and Private Flows.” OECD. Web.

27 “Contributions.” Global Polio Eradication Initiative. Web.

28 Ökem, Z. Güldem. “Innovation in the health sector inTurkey.” Turkish Industry and Business Association andCentre for European Policy Studies. Feb. 2011. Web.

29 Campbell, David, and Mandy Chui. “Pharmerging

Shake-Up: New Imperatives in a Re-Dened World.”IMS Health. 2010. Web.

30 “Population (in Thousands) Total.” United Nations. Web.

31 Walz, Julie and Vijaya Ramachandran. “Brave NewWorld: A Literature Review of Emerging Donors andthe Changing Nature of Foreign Assistance.” Center for Global Development. 2011. Web.

32 Fidler, David P. “Assessing the Foreign Policy andGlobal Health Initiative: the Meaning of the OsloProcess.” Chatham House. Jun. 2011. Web.

33 “WHO Prequalied Vaccines.” World Health Organization.22 Jun. 2011. Web.

34 “Looking for a Shot in the Arm.” Bio Farma. Web.

35 “Indonesia expecting to produce bird u vaccine nextyear.” Jakarta Globe. 26 Jan. 2012. Web.

36 “Debt2Health.”The Global Fund to Fight AIDS,Tuberculosis and Malaria. Web.

37 “Start of Debt2Health in Indonesia.” The Global Fund toFight AIDS, Tuberculosis and Malaria. 1 Jun. 2008. Web.

38 “Third Debt2Health Agreement Signed BetweenAustralia, Indonesia and the Global Fund Over AUS$ 75Million to Increase Tuberculosis Services in Indonesia.”The Global Fund to Fight AIDS, Tuberculosis and Malaria. 15 Jul. 2010. Web.

39 “Donor Governments Statistics.” The Global Fund toFight AIDS, Tuberculosis and Malaria. 15 Apr. 2011. Web.

40 “Global Fund Eligibility List for 2012 FundingChannels.” The Global Fund to Fight AIDS, Tuberculosisand Malaria. 13 Jan. 2012. Web.

41 “Indonesia.” The Global Fund to Fight AIDS, Tuberculosisand Malaria. 23 Feb. 2012. Web.

42 “World Economic Outlook Database.” InternationalMonetary Fund. Sep. 2011. Web.

43 Lätt, Jeanne. “Mexico as an ‘Emerging Donor.’”European Development Cooperation to 2020. Mar. 2011.Web.

44 Mexico. Economic Relations and InternationalCooperation Unit. Secretaría de Relaciones Exteriores.Information System of Mexico’s International Cooperationfor Development. Web.

45 Mexico. Embassy of Mexico in Canada. Secretaría deRelaciones Exteriores. Landmark in Mexican ForeignPolicy, Creation of The Mexican Agency for InternationalCooperation for Development (AMEXCID). 27 Sep. 2011.Web.

46 “The G20 development working group to meet in MexicoCity.” G20. 30 Jan. 2012. Web.

47 “2010 Annual Report.” Carlos Slim Health Institute. 2011.Web.

Beyond BRICS

1 "Arab Development Assistance: Four Decades ofCooperation." The World Bank. Jun. 2010. Web.

2 Ibid.

3 Ibid.

4 “DAC1 Ofcial and Private Flows.” OECD. Web.5 Ibid.

6 “Saudi Arabia Donates US$25,000,000 to the GlobalFund.” The Global Fund to Fight AIDS, Tuberculosis andMalaria. 24 Jan. 2012. Web.

7 “Kuwait donates USD 500,000 to Global Fund to FightAIDS, Tuberculosis, Malaria.” Kuwait News Agency .21 Nov. 2012. Web.

8 “Contributions.”Global Polio Eradication Initiative. Web.

9 “Saudi Arabia Gives $30 Million toward PolioEradication Efforts.” United Nations Foundation. 28 Sep.2011. Web.

10

Tinder, Paul. “UAE Donates $50 Million to Fight Polio.”Vaccine News Daily . 20 May 2011. Web.

11 “His Highness Sheikh Mohamed bin Zayed Al Nahyan.”GAVI Alliance. Web.

12 “Carter Center Welcomes Gates Foundation, UAE, CIFFFunding to Achieve Guinea Worm Eradication.” Carter Center . 30 Jan. 2012. Web.

13 “Arab Development Assistance: Four Decades ofCooperation.” The World Bank. Jun. 2010. Web.

14 “Mission.” Qatar Foundation. Web.

15 “Annual Report 2009-10.” Qatar Foundation. Web.

16 “Qatar Development Fund Meets.” Qatar News Agency .19 May 2011. Web.

17 Agonia, Ailyn. “Qatar to Launch Global Alliance on FoodSecurity.” Qatar Tribune. 12 Dec. 2011. Web.

18 Ghumann, Mushtaq. “Joint Exploration of Hydropower:Pakistan, Qatar May Sign Two MOUs.” BusinessRecorder . 4 Feb. 2012. Web.


20 “Business: Turkey’s 2010 GDP Growth Is Highest inEurope.” SE Times. 4 Jan. 2011. Web.

21 Moussaoui, Rana. “Moderate Arab Spring Islamistslook to ‘Turkish model’ for new democracies.” AgenceFrance Presse. 2 Dec. 2011. Web.

22 Kulaklikaya, Musa and Rahman Nurden. “Turkey asa New Player in Development Cooperation.” InsightTurkey 12.4 (2010): 131-145. Web.



25 “Turkey Key Development Indicators.” AidFlows. TheWorld Bank. Web.



04


Embassy of the Republic of Korea in the United Kingdomof Great Britain and Northern Ireland. 29 Feb. 2012. Web.

58 “4th High Level Forum on Aid Effectiveness.” AidEffectiveness. Asia-Pacic Aid Effectiveness Portal. Web.


60 “Donor Governments Statistics.” The Global Fund to

Fight AIDS, Tuberculosis and Malaria. 15 Apr. 2011. Web.61 “Republic of Korea.” GAVI Alliance. Web.

62 Grahl, Arnold R. “Ban Ki-moon receives polio championaward.” Rotary International. 21 Jun. 2009. Web.

63 “2010 Annual Report.” International Vaccine Institute.2010. Web.

65 Ibid.

66 Ibid.

67 “WHO facilitates new polio vaccine technology transfer.”Global Polio Eradication Initiative. 12 Jan. 2012. Web.

48 Ibid.

49 “Bill & Melinda Gates Foundation, Carlos Slim HealthInstitute, Spain, and the IDB Collaborate to ImproveHealth of the Poor in Mesoamerica”. Inter-AmericanDevelopment Bank. 14 Jun. 2010. Web.

50 “Birmex.” Developing Countries Vaccine ManufacturersNetwork. Web.

51 Ibid.

52 “Investigación y Desarrollo.” Birmex. 12 Nov. 2010. Web.


54 “S. Korea becomes rst former aid recipient to joinOECD Development Assistance Committee.” TheHankyoreh. 26 Nov. 2009. Web.


56 “Republic of Korea Key Development Indicators.” AidFlows. The World Bank. Web.

57 Choo, Kyu-Ho. "Britain's Generosity in Aid Provision."




For inquiries please contact:

[email protected]

ghsi brics report

Documents