The first interregional cooperation project with specific health concerns was “Strengthening the health sector in Latin America as a vector of social cohesion”, referred to as EUROsociAL/Salud, which was implemented between 2005 and 2009. In its website [22], we read that the contribution of health systems to social cohesion depends in large part on the equity of these systems in a broad sense. In this sense, health equity contemplates three dimensions: equity in the health status of individuals, access to services and treatments, and financing. The EUROsociAL programme assists with policies that address the first two.

EUROsociAL is multisector, being divided into five priorities that are part of the EU Cohesion Policy: administration of justice, education, taxation system, employment and health. The health sector, in turn, is divided into five areas: (i) development of social protection in health, (ii) good governance in health services, systems and hospitals, (iii) health services based on quality primary care and efficient and equal access to medication, (iv) public health policies and risk control, and (v) promotion of health policies in the community for the benefit of the most vulnerable and excluded sector [45]. The project is financed by the European Commission under the coordination of Spain (Fundación Internacional y para Iberoamérica de Administración y Políticas Públicas—FIIAPP), encompassing other European countries such as Italy, Germany and France. It also has two Latin American countries within the coordinating partners, which are Brazil (Escola Nacional de Saúde Pública Sergio Arouca—ENSP/Fiocruz) and Colombia (Agencia Presidencial de Cooperación Internacional de Colombia—APC), in addition to SICA (Sistema de la Integración Centroamericana).

As with other EU projects, EUROsociAL/Salud comes from the EU view that Latin America needs knowledge transfer to improve social cohesion and public policies. Therefore, these countries participate as receivers through a template of practices (inspections, workshops, internships, training activities, technical assistance), a timeline of exchanges, a set of goals to be achieved, and EU values that must be incorporated into mechanisms of social inclusion such as universal social protection, democratic participation, equality in the enjoyment of rights and access to opportunities. Although social cohesion was a main element of the EU-LAC Strategic Partnership initiated in 1999, we would need a better assessment of how such practices and exchanges took place in Peru, Panama and Uruguay, for instance.

The second project that can be considered part of the interregional cooperation in health is COPOLAD, the EU-CELAC Cooperation Programme on Drugs Policies, initiated in 2011 with EU funding [13]. Each phase has four years, and it is currently in its third phase, with a budget of €15 million from February 2021. It has nearly the same EU and LAC partners of EUROsociAL/Salud in addition to the EMCDDA (European Monitoring Centre for Drugs and Drug Addiction), with a focus on promoting technical cooperation based on scientific evidence as well as political dialog on drug policies between Latin America, the Caribbean and the EU. As regards to objectives, we read that they “will be fully respectful of the national sovereignty of each country and will be based on the demand raised by the participating countries themselves” (COPOLAD website).

I have already made a qualitative assessment of COPOLAD elsewhere [60] and will not discuss here the criticisms we could raise about how the EU communicates the programme, in light of how practices take place and how LAC countries understand the cooperation. After more than ten years since task forces were designated for implementation, expressions such as triangular cooperation, south‒south cooperation and national sovereignty began to emerge, at least in discourse, from the EU side.

The third project, and I would say the most specific in terms of health cooperation, was the “EU-LAC Health (2011–2017): Roadmap for Cooperative Health Research”. The five-year project is cofunded with the support of the European Community’s Seventh Framework Programme (FP7/2007–2013) and was presented on 29 May 2012 by its coordinator, Carlos Segovia, Deputy Director of International Research Programmes and Institutional Relations of the Institute of Health Carlos III (Spain), at the Open Information Day for the 7th call of FP7 Health Theme, as we can see in a press release of the event available online. Among the project partners, we have ISCIII and INNOVATEC (Spain), RIMAIS (Costa Rica), COHRED (Switzerland/Mexico), DLR (Germany), FIOCRUZ (Brazil), MINCyT (Argentina), and APRE (Italy).

According to its website [18], the EU-LAC Health is a project aimed at defining a Roadmap to support cooperative Health Research. A key aspect of the project will include linking and coordinating two important policy areas: science and technology policy (research) and international development cooperation. The EU-LAC Health is to be implemented through 6 different thematic areas: State of Play Analysis, Operational Road-mapping, Roadmap Consultation, Public Presentation, Final Dissemination and Management.

In November 2012, the project launched the first newsletter with main outcomes from the project activities, which, by that time, were basically an expert workshop held in Fiocruz (Brazil) and another one called ‘Scenario Building Workshop’ held in Buenos Aires, “in order to sort possibilities for a common funding of biregional research cooperation initiatives” and to prepare for the second one, to be held in Italy in 2013 [19]. Other newsletters were published over time, always indicating future activities.

We also have a kind of evaluation published in 2018: funded by the project and authored by researchers from Spain, Italy, Germany and Brazil who have participated in all activities of the project, already in the abstract we read that “EU-LAC Health represents a successful example of biregional collaboration and the emerging networks and expertise gathered during the lifetime of the project have the potential to tackle common health challenges affecting the quality of life of citizens from the two regions and beyond” ([41]:1). Although they were not independent actors but participants of the project, we can say that these are experts working in research and national health institutions. Among the main outcomes, the first is the EU-LAC Health Strategic Roadmap [17] which, according to the authors, “the methodology used for its definition is sound, the procedures have been tested, and the areas of common interest have been demonstrated to be of interest for R&I funding agencies and researchers. Those arguments make the roadmap a useful guide for policy-makers interested in biregional R&I collaboration” (op cit:7).

The Roadmap has seven sections: Context, Vision and Mission, Objectives and Principles, Swot Analysis, Scientific Research Agenda, Governance, and Roadmap Timeline 2015–2020. The authors detail what has been done in each of the six thematic areas mentioned above, relating to the main goals previously set. Other outputs cited in the publication were a network for collaboration among scientists, policy-makers and R&I funding agencies and the establishment of a coordinating body for future EU-LAC collaboration in health R&I.

Multilateral engagement: EU-LAC support of the Oslo Group resolutions approved in the UN General Assembly (2008–2020)

The Foreign Policy and Global Health Initiative (FPGHI) was launched in NY in September 2006. In March 2007, the Ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa, and Thailand issued the "Oslo Ministerial Declaration—Global Health: a pressing foreign policy issue of our time" [27]. Since 2008, every year the Oslo Group, which is how the FPGHI became known, approves a resolution at the UN General Assembly (UNGA). After mapping the EU-LAC engagement, as sponsors and/or supporters, in each of the thirteen UNGA resolutions (until 2020),Footnote 6 in addition to analyzing six Ministerial Communiqués, we have three resolutions that present the highest engagement among countries of both regions:

2009, A/RES/64/108, about reinforcing the interdependence between foreign policy and global health to coordinate efforts against the H1N1 pandemic throughout local, regional and global levels;

2010, A/RES/65/95, about considering Universal Health Coverage a central factor for the social determinants of health;

2012, A/RES/67/81, about financing mechanisms for enlarging systems of Universal Health Coverage (UHC).

The Oslo Declaration, by its turn, has an agenda organized around three main themes: ‘Capacity for global health security’; ‘Facing threats to global health security’; ‘Making globalization work for all’. The first theme has three specific actions: preparedness to respond to health risks and threats, control of infectious diseases, and strengthening human resources for health. The second theme has four specific actions, all related to conflicts, threats and natural disasters. The third theme has three specific actions, which are development, trade policies and measures to implement and monitor agreements, and improve governance for health. According to these findings regarding the UNGA resolutions, it is possible to say that the EU-LAC cooperation is potentially more effective within the scope of the third theme, which actions reflect the focus on development and trade.

Results

For what we have seen until the COVID-19 pandemic, projects on interregional cooperation, such as EUROsociAL/Salud, COPOLAD and EU-LAC Health, approached different dimensions within a pattern of development through health that is part of a revisionist behavior adopted by both partners, although by different means, throughout the cooperation process. Revisionist behavior, as stated in the introduction, is likely to be seen in longstanding relations among actors with power asymmetry. It is therefore a behavior through which political coordination does not undermine respective interests, preferences, instruments and worldviews that may be different and non-negotiable. Social cohesion and health equity, technical assistance and political dialog on drug policies, and strengthening of health R&I collaboration are goals that represent the politics of cooperation, that is, the common denominators which encompass what each partner expected from the projects. Social development is indeed the premise of consensus-building between policymakers in both regions, through which they achieve significant outputs for global governance for health. In many regards, these projects reflect what is agreed upon in UNGA resolutions, especially in their social dimensions, such as the emphasis on social determinants of health and the enlargement of public systems of UHC.

Therefore, we can say that until the COVID-19 pandemic, the EU-CELAC health cooperation has characterized an approach of development through health within a two-way revisionist behavior embedded in those projects. And that, in practice, the projects were aligned with their multilateral engagement in the UN and in declarations for the occasion of EU-LAC summits over the period. Despite expected disagreements likely emerging out of their essential differences and asymmetries, both regions recognized potential issue areas in which a constructive dialog and policy-oriented outputs were reached. Foreign policy and multidimensional cooperation, embracing from local farmers to academics, have historically favored interregional governance for health. In the next section, I analyze whether and how this has changed since COVID-19.

After the COVID-19 pandemic: any changes?

The first important move occurred after the pandemic came from the EU and, as we will see, affected the CELAC through some changes in the partnership itself. By the end of 2021, in a political response to the pandemic, the European Commission and the EU High Representative have set out the Global Gateway, a new European foreign policy strategy. As regards the budget, “between 2021 and 2027, Team Europe, meaning the EU institutions and EU Member States jointly, will mobilize up to €300 billion of investments for sustainable and high-quality projects, taking into account the needs of partner countries and ensuring lasting benefits for local communities”. It is also expected that the strategy will “create opportunities for the EU Member States’ private sector to invest and remain competitive, while ensuring the highest environmental and labor standards, as well as sound financial management” (Global Gateway website) [15].

Before exposing what is at the core of EU expectations for health, it is important to say more about the Team Europe approach, as it is the group responsible for allocating the budget and sizing the implementation of the Global Gateway strategy. In the website “Team Europe approach: leadership, cooperation, resources”, we find that Team Europe consists of the European Union, EU Member States — including their implementing agencies and public development banks — as well as the European Investment Bank (EIB) and the European Bank for Reconstruction and Development (EBRD). It offers a joint programming tracker with an overview on Team Europe Initiatives (TEIs) by country and region in which we see that thus far, for the LAC region, health is not yet contemplated (Team Europe Initiatives and Joint Programming Tracker website [29]) despite being one among the five key areas (digital sector, climate and energy, transport, health, education and research) selected under the Global Gateway for the EU-CELAC partnership from 2021.

Returning to EU expectations for health within the Global Gateway, we have a summary provided by the DG for International Partnerships in its website:

“Global Gateway will prioritize the security of pharmaceutical supply chains and the development of local manufacturing.Footnote 7 (…) However, health issues extend beyond the pandemic. Thus, the Global Gateway will also facilitate investment in infrastructure and the regulatory environment for the local production of medicine and medical technologies. This will help integrate fragmented markets and promote research and cross-border innovation in healthcare, helping us to overcome diseases such as COVID-19, malaria, yellow fever, tuberculosis or HIV/AIDS” (DG for International Partnerships website).

In addition to this summary, we also have an [16], which starts by saying “The first two essential priorities are: investing in the well-being of all people and reaching universal health coverage with stronger health systems. The third core priority is combatting current and future health threats, which also requires a new focus. It calls for enhanced equity in the access to vaccines and other countermeasures,for a One Health approach,Footnote 8which tackles the complex interconnection between humanity, climate, environment and animals” [16]:6). In the report, we have an agenda leading up to 2030 with three policy priorities—“2.1. Deliver better health and well-being of people across the life course; 2.2. Strengthen health systems and advance universal health coverage; 2.3. Prevent and combat health threats, including pandemics, applying a One Health approach -, provides for twenty guiding principles to shape global health, makes concrete lines of action that operationalize those principles, and creates a new monitoring framework to assess effectiveness and impact of EU policies and fundingFootnote 9” (op cit:8).

The EU understands itself as having a unique potential to drive international cooperation, expand partnerships and promote health sovereignty “for more resilience and open strategic autonomy supported by partners’ political commitment and responsibility” (op cit:6). Therefore, which kind of changes in EU-CELAC interregional cooperation in health pushed by the Global Gateway and EU Global Health Strategy 2022 can we expect? It seems that this is not an easy question and requires a careful analysis of the documents and speeches mobilized thus far. I propose some ideas in this regard: on the one hand, it is notable that the second policy priority (‘strengthen health systems and advance universal health coverage’)Footnote 10 recovers the Oslo Group resolutions in which the EU and CELAC have reached more consensus and support, in addition to being in line with the two main joint programmes of the past, EUROsociAL/Salud and EU-LAC Health.

On the other hand, with regard to the third policy priority ("prevent and combat health threats, including pandemics, by applying a One Health approach"), it could be interpreted as the novelty promoted by the COVID-19 pandemic, although in reality, only the mention of the ‘One Health approach’ constitutes an innovation. This can be evidenced, for instance, in the 2009 UNGA resolution approved by the Oslo Group, in which the H1N1 pandemic was the target underpinning necessity to ‘coordinate efforts to prevent and combat health threats in local, regional and global levels’. In the same way, other diseases that are long-standing health threats dealt within the EU-CELAC interregional cooperation since at least 2005, such as malaria, yellow fever, tuberculosis and HIV/AIDS, are also mentioned in the Global Gateway for continuing cross-border research and innovation. Therefore, at least in terms of language, of the way ideas are presented and discourses are written, I do not see a stark turnaround. Even so, can we still expect change?

Looking deeper at the EU Global Health Strategy

In the report, each policy priority is developed through guiding principles. When we zoom in on guiding principles of the second policy priority, we see what I just mentioned before: at least in the way they are stated, they remain aligned with the path of EU-CELAC interregional cooperation in health to date, characterized by a pattern of development through health. For this reason, I focus on the third policy priority to explore subsidies for us to reflect upon the following question: should we analyze this interregional partnership in health from 2022 onward in light of a revisionist behavior characterized by ‘reviewing previous disagreements’ or a reformist behavior identified by ‘setting new priorities’? To what extent could it be said that the pattern of cooperation has changed?

Having a closer look at the third priority, ‘Prevent and combat health threats, including pandemics, applying a One Health approach’, we find guiding principles 7 to 11:

GP 7: Strengthen capacities for prevention, preparedness and response and early detection of health threats globally;

GP 8: work toward a permanent global mechanism that fosters the development of and equitable access to vaccines and countermeasures for low- and middle-income countries;

GP 9: negotiate an effective legally binding pandemic agreement with a One Health approach and strengthened International Health Regulations;

GP 10: build a robust global collaborative surveillance network to better detect and act on pathogens;

GP 11: apply a comprehensive One Health approach and intensify the fight against antimicrobial resistance.

To answer the above questions, I will base myself on these guiding principles and add what we have to date: since the EU published the report, three initiatives with CELAC have been announced by the Directorate-General for International Partnerships within the framework of the EU Global Gateway. They are:

1.

22 June 2022: “EU-Latin America and Caribbean Partnership on manufacturing vaccines, medicines and health technologies and strengthening health systems” [7];

2.

21 March 2023: “EU – Latin America and Caribbean high-level pharmaceutical forum to promote local manufacturing”;

3.

17 July 2023: “EU builds new partnership for improved Latin American and Caribbean health technologies with Pan American Health Organization” [8].

As we can see, all of them are placed within GP 7, which is part of seven lines of action. I reproduce such lines in the figure below.

Regarding the first initiative (‘EU-LAC Partnership on manufacturing vaccines, medicines and health technologies and strengthening health systems’), which seems to be the most robust, we read in the EU communication that it “will complement and further enhance social, economic and scientific ties between the two regions. It will boost Latin America's manufacturing capacity, foster equitable access to quality, effective, safe and affordable health products and help strengthen health resilience in the region to tackle endemic and emerging diseases, and enhance capacities to cope with noncommunicable diseases” (DG for International Partnerships website, News Communication section).

The second initiative (‘EU-LAC high-level pharmaceutical forum to promote local manufacturing’) is a development of the first. The Commissioner for International Partnerships Jutta Urpilainen and Commissioner for Internal Market Thierry Breton hosted in Brussels the EU-LAC High-level Forum Sharing pharmaceutical innovations under the Global Gateway [6]. Political leaders, technical experts, pharmaceutical companies, entrepreneurs, investors, and financing institutions from both regions were brought together to explore collaboration, for instance, in effective and affordable pharmaceutical innovations (DG for International Partnerships website, Conferences and Summits section).

The third initiative (‘EU builds new partnership for improved LAC health technologies with PAHO’) emerged from the EU-CELAC Summit held on 17 and 18 July 2023Footnote 11 and was also a development of the first initiative. Ms. Urpilainen and Director of Health Systems and Services of the Pan American Health Organisation (PAHO), Dr James Fitzgerald signed a €3,8 million agreement building a partnership to strengthen LAC access to healthcare technology. The contribution agreement supports the main objectives of the EU-LAC partnership on health, launched by Ms. von der Leyen and Mr. Sánchez in June 2022 (first initiative listed). It focuses in particular on strengthening regulatory frameworks, technology transfers and increasing manufacturing capacities.Footnote 12

After the Summit, an EU-CELAC Roadmap for 2023 to 2025 [14] indicated that a High-Level event on “Health Regulatory Frameworks” is planned for November 2023, and meetings on Health Self-sufficiency involving regulatory authorities from both regions are planned for 2024–2025. Finally, in the Declaration of the EU-CELAC Summit [4], we read on paragraph 30, page 8:

“We express our commitment to take forward the biregional partnership on local manufacturing of vaccines, medicines, and other health technologies, and strengthening health systems resilience to improve prevention, preparedness, and response to public health emergencies, in support of the CELAC Plan on Health Self-Sufficiency [see the link to access the Plan in footnote 6]. We look forward to the progress of the ongoing discussions on a new legally binding instrument on pandemic prevention, preparedness, and response in the framework of the World Health Organization, with the aim to agree it by May 2024”.

Results

Taking these primary sources and empirical examples as references for our analysis, the research indicates that the kind of changes in EU-CELAC interregional cooperation in health reflects the dominance of EU interests. Considering the material produced from the EU Global Gateway strategy, launched after the COVID-19 pandemic, until the last EU-CELAC Summit, we can see that the main pattern of interregional cooperation moved from development through health to the current economy-driven health development – a movement clearly propelled by the EU by means of elevating health technologies and manufacturing as priorities despite knowing the enormous structural differences between both regions in this regard.

First and foremost, health technologies and manufacturing in CELAC are mainly conducted with public investment and in public institutions, while in the EU, this field is dominated by big pharma—private transnational companies, among the most profitable and richest in the world, that also count on EU subsidies (Polish Polpharma is a good exampleFootnote 13) and normative facilities. However, in cooperation with CELAC, the centralization of the involvement of the private sector and the International Finance Corporation (IFC), as well as the harmonization of the economic interests in the health sector of several EU Member States, do not seem to be easy tasks for EU foreign policy to effectively implement this change of priorities declared in the official post pandemic documents and in the projects already underway.

With regard to the question of whether this political change on the EU side indicates revisionist or reformist behavior, i.e., a review of previous divergences or an attempt to establish new priorities, a qualitative evaluation of the primary sources from a historical perspective allows me to affirm that we are witnessing a reformist behavior on the part of the EU in its interregional cooperation with CELAC in the area of health. However, it is important to remember that, at the time of writing, the first initiatives have not yet been implemented, and therefore, we still have to wait to empirically evaluate the impacts of such change. We cannot anticipate reactions, contestations or resistance, but we do have lessons learned from the path of EU-LAC partnership in health issues that add valuable insights to our analysis, especially on how the historical differences in terms of health approaches between the two regions have been negotiated. In the next section, I give some of these insights, focusing on the issue of manufacturing pharmaceuticals and health technologies.