Given the consistent attention afforded the health ministerial activity of the BRICS in the grey literature as well as extensive coverage in the media, one might have expected to find more than the 7 studies we identified that satisfied our inclusion criteria. Of these, only 3 were peer-reviewed journal articles. What might explain this paucity of literature? One study concluded that it was still ‘early days’ for the BRICS and global health: “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” , page 11. Oliver Stuenkel has made a similar point:
“Very little serious academic writing has been published so far on the BRICS, simply because it is such a recent phenomenon and many academics are reluctant to speculate and prefer to wait for tangible evidence before putting their thoughts on paper”.
The BRICS have only been a collective group since 2010, so it is perhaps unrealistic to expect any coordinated output beyond the level of a communiqué. The BRIC countries have been together for longer, but health has simply not been a sector priority – at least not until 2011 and the 1st Health Ministers Meeting. Indeed, it has taken this bloc of countries 7 years to get to the point where a new financing mechanism – the BRICS bank – is being publicly mooted as a serious possibility. So we should not be surprised that a ‘softer’ issue such as health is being negotiated at a more measured pace.
An important, and unexpected, finding from our review was that the acronym BRICS was described using both the indefinite and definite articles, which were often used interchangeably within the same document. Thus Brazil was a BRICS country but also a member of the BRICS. This raised an interesting ontological question: what was the unit of analysis – what was BRICS?
Admittedly, we are not the first to ask this question. In the field of International Relations, for example, Armijo asks whether the term ‘BRICs countries’ is “a viable analytical category” . The author notes, as we do, that the four BRICs (Armijo does not include South Africa in her analysis) have quite different domestic political institutions, international goals, and economic structures. She argues that the BRICs could be considered “an analytically viable set… [if]…some other economic characteristic plausibly distinguished the four from the larger set of developing and post-communist countries known as emerging market economies” , page 39. Armijo found no such distinguishing characteristic and thus concluded that the BRICs was “strictly speaking, a mirage—but one that nonetheless has provided considerable insight” , page 40. Our literature review concurs with this general conclusion.
Each of the studies we identified drew attention to the political, economic and ideational differences between the individual countries, with some analysis of common themes . As noted above, just one study provided sustained analysis of the BRICS’ collective influence . The other studies implicitly assumed that the BRICS did, or would, influence global health as a bloc in the future, without considering critically what influence might mean.
One of the studies we identified made the point that while government institutions were important actors both nationally and internationally, institutional influence was “not just about governments” , page 32. However, notable by its absence are analyses of BRICS’ non-state actors – particularly civil society, but also the private sector. International development scholars and geographers have noted the extent to which BRICS countries encouraged and supported the reach of these sectors beyond the domestic sphere . Further research is required on the role of emerging economies’ non-state actors in supporting global health priorities such as universal health care.
Our findings suggest that we have arrived at an intersection between multiple disciplines: international development, international relations, and global health. Of the three journal articles in our dataset, just one article was from a public health journal: the remaining two were published in development and law journals. BRICS and global health is a subject amenable to inter-disciplinary analysis: analysis of influence, for example, is a mainstay of both international development and international relations [9, 10, 30, 31] and global health could draw on this body of work. Conversely, analysis of the BRICS’ contribution to global health – or failure to contribute – could inform international relations and development understanding of the ontology, and identity, of BRICS.
Critical analysis of BRICS by the global health community is essential. It is not sufficient to assume that the BRICS will contribute to global health; an understanding their influence in global health would benefit from critical attention, drawing on insights developed within the major paradigms of International Relations – Realism, International Institutionalism, and Critical Theory [9, 30, 31]. In one of the seven studies we identified, the authors argued that, historical and political contexts aside, the five countries “frequently do collaborate as BRICs, IBSA, or BASIC on issues related to health” , page 6. However, we know very little about the nature of that collaboration or, more importantly, whether it was/is effective. We also found an uncritical presentation of the various elements of the ‘new model’ of the BRICS’ development assistance. The temptation to aggregate these various elements and present them as the BRICS approach is tempting but upon closer scrutiny it is clear that few of those elements are common to all five countries .
Furthermore, the consequences for global health of adopting ‘novel’ approaches to international relations such as South-South, or mutuality, or ‘demand-driven’ are not critically assessed in any of the studies. For example, many of the studies reported that BRICS countries’ global health agendas were driven by domestic priorities and/or regional concerns. Whilst that is understandable, how realistic is it to expect the BRICS to reflect more than a parochial interpretation of global health?
Values, such as Brazil and South Africa’s promotion of equity in global health, also warrant further attention. There are good reasons to wish for an equity-driven model. However, as the process of drafting the text of the key document of the 2012 Rio + 20 UN Conference on Sustainable Development (UNCSD) shows, inclusion of the word ‘equity’ was a source of diplomatic tension between emergent economies such as Brazil and Western economies such as the United States . Other values such as transparency are a central tenet of Western conceptions of global governance, though China has shown reluctance to include it as a standard for South-South cooperation. As reported above, one study describes the BRICS alliance as presenting a ‘countervailing force’ to Western-dominated prescriptions for global health. On the one hand, it is possible that BRICS “may be able to establish, shape, and enlarge a pro-development negotiating agenda” and “help enlarge the policy space less developed countries need” , page 258. On the other, not aligning with those prescriptions may create a two-track development agenda that impedes diplomatic efforts to agree a needs-driven, rights-based, or even equitable global health agenda.