Abstract

This paper examines how the Union of South American Nations (Unasur) concerned itself with ensuring democracy and participation in the construction of health policies. It aims to explain the meaning of health democracy, and its importance for making the right to health effective. The concern is that the decision on these politics of the bloc should be in harmony with the interests of their citizens, so as to identify ethical activity of the States in international relations. An analysis was made of the documents of constitution, and resolutions on health policy, of this bloc, and statements were found with objectives and principles about democracy and citizen participation; but no institutionalization of mechanisms that might make participative democracy in health operational was found.

Democracy; Health policies; Global health; Right to health

Introduction

Democracy is characterized by active participation of citizens in the principal decisions that relate to the collective, which presupposes spaces and mechanisms that make possible a free and broad dialog and consensus. Thus, in democratic States it becomes imperative that environments of interaction between governors and the governed should be respected and developed, a point of view which would apply to those regional blocs that propose objectives of social development, as well as economic and commercial relationships.

This premise will be analyzed in the case of the Union of South American Nations (Unasur), the most recent initiative for integration of the countries of South America, which has strong components in the social area. The concern with promotion of citizen participation is clear in various points of the Constitution Treaty of this alliance. However, prior to this realization the question emerges of how this participation will be made viable in the construction of health policies.

For this paper, a survey was made of the bibliography and documents that are oriented to this focus subject, and the intention is to provide inputs for promoting awareness of the need for citizen participation in the scope of the discussions and decision-making of Unasur.

Democracy in health

Democracy is one of the essential values of the United Nations. Although the United Nations Charter¹1. Organização das Nações Unidas (ONU). Carta das Nações Unidas. Washington: ONU; 1945. does not mention the term democracy, this principle can be understood from the expression “We, the peoples of the United Nations”, since the will of the peoples is the source of the legitimacy of the States, and thus, of the United Nations.

The Universal Declaration of Human Rights²2. Organização das Nações Unidas (ONU). Declaração Universal dos Direitos Humanos. Washington: ONU; 1948. enunciates the concept of democracy, affirming that “the will of the people shall be the basis of the authority of government” (Article XXI, 1), and legitimizes the political participation of the citizen: “Everyone has the right to take part in the government of his country, directly or through freely chosen representatives.” (Article XXI, 3).

The significance of democracy has been enhanced by the activity of political systems in States under Law. Bonavides³3. Bonavides P. A democracia direta, a democracia do terceiro milênio. In: Bonavides P. A Constituição Aberta. 2ª ed. São Paulo: Malheiros; 1996. p. 17. understands democracy as “that form of exercise of the governing function in which the sovereign will of the people decides, directly or indirectly, all the questions of government, in such a way that the people are always the owner and the object, that is to say, the active subject and the passive subject of the legitimate power”.

According to Dallari⁴4. Dallari DA. Elementos de teoria geral do Estado. 21ª ed. São Paulo: Saraiva; 2000., democracy should be taken to include a space of debates, making possible the decision on ideas about claims in the field of human rights, in relation to the State. There is a demand for social discussion on the subjects that are very close to the interests of society, and affected directly.

Among the theories of participative democracy, we highlight the one formulated by Habermas⁵5. Habermas J. Três modelos normativos de democracia. Lua Nova [periódico na Internet]. 1995 [acessado 2017 jan 09]; (36):39-53. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-64451995000200003
http://www.scielo.br/scielo.php?script=s... , which is grounded on the principles of discourse and democracy. At the beginning of this exposition, the validity of a rule depends on its acceptance by all individuals, who are participants in rational discourses. The principle of democracy argues that a legitimate normative process requires a system of rights to participation. This model argues that political legitimacy depends on consensuses established in public debates in which participation of all those potentially affected by the decision is assured⁶6. Habermas J. Direito e democracia: entre facticidade e validade. 2ª ed. Rio de Janeiro: Tempo Brasileiro; 2012. V. 1.

7. Estevez JV. La concepción de democracia participativa de Habermas. Ciência Política, Santiago [periódico na Internet]. 1999 [acessado 2016 dez 27]; 20(1):208-219. Disponível em: http://www.revistacienciapolitica.cl/rcp/wp-content/uploads/2013/09/11_vol_20_1.pdf
http://www.revistacienciapolitica.cl/rcp... -⁸8. Avritzer L. Teoria democrática e deliberação pública. Lua Nova [periódico na Internet]. 2000. [acessado 2016 dez 27]; (50):25-46. Disponível em: http://www.scielo.br/pdf/ln/n50/a03n50.pdf
http://www.scielo.br/pdf/ln/n50/a03n50.p... . In the case of international decisions, the parties potentially affected by the decision are not only the States, but also their populations.

Taking this conception as a starting point, the reduction of democracy to the vote is not enough to establish the participation of the people. According to Silva⁹9. Silva JA. Curso de direito constitucional. 21ª ed. São Paulo: Malheiros; 2003., “the participative principle is characterized by the direct and personal participation of the citizenry in the formation of the acts of government”.

The need for the exercise of democracy in relation to decisions on the right to health, in both the internal and international context, is grounded in the United Nations Committee on Committee on Economic, Social and Cultural Rights¹⁰10. Organização das Nações Unidas (ONU). Instrumentos Internacionales de Derechos Humanos. [formato eletrônico]. 2004 [acessado 2016 dez 27]; [cerca de 398 p.]. Disponível em: http://www.prr4.mpf.gov.br/pesquisaPauloLeivas/arquivos/Observacoes_Gerais_ONU.pdf
http://www.prr4.mpf.gov.br/pesquisaPaulo... :

(…) Another important aspect is the participation of the population in the whole of the process of adoption of decisions about the questions related to health at the community, national and international level.

Application of the model of participative democracy in the decisions related to health is referred to as ‘health democracy’. The concept of health democracy¹¹11. Tabuteau D. Démocratie sanitaire: Les nouveaux défis de la politique de santé. Paris: Odile Jacob; 2013. refers to an approach to involve all the actors of the health system in the development and implementation of the health policy in the spirit of dialog and consultation. Health democracy calls for consultation and public debate to improve the participation of the interested parties and to promote the individual and collective rights of the users. According to Aith¹²12. Aith FMA. Direito à saúde e democracia sanitária: experiências brasileiras. Revista de Direito Sanitário [periódico na internet]. 2014 [acessado 2016 dez 27]; 15(3). Disponível em: http://www.revistas.usp.br/rdisan/article/viewFile/97328/96340
http://www.revistas.usp.br/rdisan/articl... , this:

(...) requires that decisions on the outline of what is legally understood as the right to health should be made with participation by society. This means that society must be consulted and, to the extent possible, decide directly on what health means and on what breadth of protection will be offered by the State to this right.

In the Brazilian State, the following are examples of institutions and instruments of health democracy which were created and improved so as to make possible “ample democratic participation of society in the taking of State decisions in health”: the Health Conferences; the National, State and Municipal Health Councils; the Consultancy Councils and Technical Chambers of Anvisa – the National Health Supervision Agency, and of the ANS (National Supplementary Health Agency); and the Ombudsman’s department of the Single Health System (Sistema Único de Saúde – SUS), Anvisa and the ANS¹²12. Aith FMA. Direito à saúde e democracia sanitária: experiências brasileiras. Revista de Direito Sanitário [periódico na internet]. 2014 [acessado 2016 dez 27]; 15(3). Disponível em: http://www.revistas.usp.br/rdisan/article/viewFile/97328/96340
http://www.revistas.usp.br/rdisan/articl... .

The Union of South American Nations (Unasur)

The Union of South American Nations (Unasur) is a “purely intergovernmental”¹³13. Ventura DFL. Saúde pública e política externa brasileira. Sur - Revista Internacional de Direitos Humanos 2013; 10:94-113. initiative of regional integration that brings together the twelve South American countries. They have as principles: respect for sovereignty, integrity and territorial inviolability of the States; self-determination of the peoples; solidarity; cooperation; peace; democracy; citizen participation; human rights; reduction of asymmetries and harmony with nature for a sustainable development.

Unasur constitutes an environment of political integration that covers energy, infrastructure, security and citizenship. That is to say, it comprehends the integration as a totality, and not only through a purely economic perspective – which had been the basis on which other regional organisms had historically been conceived¹⁴14. Ventura DFL, Baraldi C. A Unasul e a nova gramática da integração sul-americana. Boletim Pontes ICTSD-FGV 2008; jul:14-16..

In relation to the social aspect, Article 3 of the Treaty of Constitution includes in its specific objectives: “(j) universal access to social security and health services”; and “(u) sectorial cooperation as a mechanism for deepening of South American integration, through exchange of information, experiences and training”.

Unasur has a minimum structural hierarchy – though that does not mean it is a simple one – and is marked by its intergovernmental character, in an attempt to promote international cooperation based on the consensus of priorities between the member States.

Unasur has bodies for decision and advice, comprising exclusively representatives of the executive of the member-countries. According to its treaty of constitution (Article 4) they are the following: The Council of Heads of State and Government; the Council of Foreign Ministers; the Council of Delegates; and the General Secretariat.

The Council of Heads of State and Government is the highest decision body. It is chaired by a head of one of the member States. Under Article 6 of the Unasur Treaty it has the competency to decide the plans of action for the process of integration, with annual ordinary meetings, and the possibility of calling extraordinary meetings.

The functions of the Council of Foreign Ministers make up a long list (Article 8, of the Unasur Treaty). This includes: putting into operation the guidelines/directives set out by the higher Council; approving the program of activities, budget and financing of common projects; monitoring and evaluation of the process of integration; approval of Resolutions on these subjects; and creation of Workgroups.

The Council of Delegates, comprising one representative from each member State, has the role of helping the other Councils, with emphasis on coordination between the Workgroups and initiatives of Unasur with other processes of integration, for the purpose of ensuring their complementarity; and the responsibility to promote spaces for dialog to favor citizen participation in this process of integration (Article 9, g, Unasur Treaty).

The General Secretariat (Article 10, Unasur Treaty), is responsible for executing the mandates of the other bodies. The General Secretary is chosen by the highest body of the organization, for a period of office of two years, which is renewable.

There is also the Pro Tempore Chairmanship (Article 7, Unasur Treaty), successively exercised by each one of the member states, in alphabetical order, for two-year periods: the function is to chair the meetings of the other bodies, and propose a program of annual activities. The Treaty gives Unasur its own legal existence, in its first Article, in a way that is different from the manner broadly accepted in other organizations:

This capacity to assume international commitment appears to be something that is prosaic, but it is not. As an example, consider the case of Mercosur, which only acquired this capacity three years after its creation, under pressure from the European Union for negotiation of the agreement between the two blocs¹⁴14. Ventura DFL, Baraldi C. A Unasul e a nova gramática da integração sul-americana. Boletim Pontes ICTSD-FGV 2008; jul:14-16..

The legal personality, like the power to represent Unasur internationally, is exercised by this Presidency (Article 7, c and d), but the treaty establishes the need for prior authorization by the parties to the treaty (States), which somewhat empties this body of its duty, and also makes Unasur more fragile as an international organism, since its Treaty of Constitution ought to be enough to identify the consensus between the States.

The Treaty provided for the creation of Councils at the levels of Minister, Workgroups and other institutional instances either permanent or temporary in nature, with the objective of complying with the directives/guidelines of the official bodies (Article 5, Treaty of Constitution). Twelve Councils were created, including the South American Health Council, known as Unasur-Saúde (CSS). The Councils are made up of the ministers for the related area of each Member-State, with no provision for participation by society, although the interest of the public, and the social interest, are evident.

The decisions adopted by the Heads of State, and the agreements and Resolutions of the Ministers in their respective Councils, are the base that makes the rules of Unasur. Note that due to their intergovernmental character, because they are mandatory, the decisions of the Heads of State need to be incorporated into the individual body of law of each nation (Article 12, Treaty of Constitution of Unasur).

Health policies in Unasur

The South American Health Council (CSS) was created in 2008, as a permanent political institution that would enable the health authorities of the member-states to deal with common challenges that transcend their frontiers. The premise of this Council is that health is a fundamental right of the human being and a vital component for both human development and regional integration¹⁵15. Unión de Naciones Suramericanas (Unasur). Tratado Constitutivo de la Unión de Naciones Suramericanas, 2008. [acessado 2016 dez 27]. Disponível em: http://www.itamaraty.gov.br/images/ed_integracao/docs_Unasul/DEC01.2014.pdf.
http://www.itamaraty.gov.br/images/ed_in... .

The Council approved a South American Health Agenda, covering the followed subjects: (1) preparation of the South-American Policy on supervision and control of health events; (2) development of universal health systems; (3) promotion of universal access to medication and other inputs for health, with development of the production complex for health in South America; (4) promotion of health, and joint confrontation of its social determinant factors; and (5) development of health human resources.

The CSS has the following composition: The Health Ministers of each country, plus one representative, as observers, of each of the following: the South American Common Market (Mercosur); the Andes Health Organization (the Hipólito Unanue Convention – ORAS/CONHU); the Amazon Cooperation Treaty Organization (OTCA); and the Pan-American Health Organization (OPAS). Its objective – somewhat ambitious – is to consolidate South America as a space of integration in health, helping to achieve health and development for all, also incorporating actions and progress achieved in the health cooperation organism and spaces created previously:

Thus, the Council has channeled and continues to channel the successes achieved in other areas of integration for the purpose of promoting common policies and coordinated activities between the member countries of Unasur¹⁶16. Racovschik MA. Consejos de la Unasur: origen, funciones y perspectivas. Observatorio de la Unasur, FLACSO, 2010. [acessado 2016 dez 27]. Disponível em: http://observatoriounasur.files.wordpress.com/2010/07/consejos-de-la-unasur1.pdf
http://observatoriounasur.files.wordpres... .

The ministers, through the Health Council or the Council for Social Development, have the duty to implement the standards adopted. The decision-making mode within Unasur is still very loose, partly because it builds on regional entities that were already in place. The entity is firmly inter-governmental and nations remain entrenched in their national approaches to common challenges¹⁷17. Langenhove LV, Kingah S. Conditions for Effective Regional Social (Health) Policies: the EU and Unasur Compared. UNU-CRIS Working Papers [recurso eletrônico]. 2014. [acessado 2016 dez 27]; [cerca de 19 p.]. Disponível em: http://cris.unu.edu/sites/cris.unu.edu/files/W-2014-3.pdf
http://cris.unu.edu/sites/cris.unu.edu/f... .

The South American Health Council is organized on the basis of a Coordinating Committee, a Technical Secretariat, Technical Groups in accordance with the five lines of priority action, and Structuring Networks.

The Technical Groups (TGs) comprise the focal points at ministerial level of the countries of the respective technical areas related to the subjects of the Health Agenda. They have a principle, and an alternate, coordinator function, exercised by two countries that take turns annually.

We highlight, among these, the TG for Promotion, Health and Action on the Social Determinant Factors, which aims to organize action between sectors and community participation in the formulation, execution and compliance with public health policies¹⁸18. Instituto Suramericano de Gobierno en Salud [homepage na internet]. Conselho de Saúde/ Grupos Técnicos [acessado 2016 dez 27] . Disponível em: http://www.isags-unasul.org/gts.php?lg=1
http://www.isags-unasul.org/gts.php?lg=1... .

The constitution of Structuring Health Institution Networks was decided as one of the priorities for construction and development of the common and cooperative health policies. These Networks comprise institutions or representatives indicated by the Health Ministries of the member countries. According to Buss and Ferreira¹⁹19. Buss PM, Ferreira JR. Cooperação e integração regional em saúde na América do Sul: a contribuição da Unasul-Saúde. Cien Saude Colet 2011; 16(6):2699-2711. the institutions should be capable of operating in an efficacious, efficient and sustainable manner in the health systems and services through activities of research and development and training of personnel. Their principal objective is to contribute to the development of health systems and services or to train health professionals and generate the knowledge that facilitates taking of decisions inside health systems.

At present there are six Structuring Networks in the scope of Unasur Health: (1) The National Health Institutes Network (RINS); (2) the Unasur Technical Health Schools Network (RETS); (3) the Network of National Cancer Institutes and Institutions (RINC); (4) the Public Health Schools Network (RESP); (5) the Disaster Risk Management Network; and (6) the Network for International Relations Advisory and International Cooperation in Health (REDSSUR-ORIS).

The networks operate as spaces for technical cooperation between the institutions of each specific field, which prepare their respective work plans with defined actions and projects. The Coordinator of the Networks is decided by an election between members every four years.

Health participation and democracy in Unasur

Achievement of Unasur’s objectives, which include reduction of social inequalities, directly involves actors such as representatives of government, of institutions and health professionals of the member countries, and thus participation of citizens in the process of taking of decisions and monitoring of actions becomes essential.

Thus it becomes essential to open spaces that are appropriate for promotion of this citizen participation.

The Treaty of Constitution of Unasur states, in its preamble, the need to foster democracy and participation, emphasizing that the exercise of citizenship should not be limited to the national space to which the individual belongs, but should be assured on a wider basis, throughout the bloc.

The importance of citizen participation, in this context, is so great that achieving it is stated as one of the general objectives of Unasur:

Article 2 – Objectives: The Union of South American States has the objective of building, in a participative and consensual manner, a space for integration and union in cultural, social, economic and political terms between its peoples, giving priority to subjects including political dialog, social policies, education, energy, infrastructure, financing and the environment, with a view to eliminating socio-economic inequality, achieving social inclusion and citizen participation, strengthening democracy and reducing the asymmetries in the framework of strengthening of the sovereignty and independence of the States.

And as a specific objective, Unasur aims to strengthen citizen participation through introduction of instruments of interaction and dialog between the member state and society in the formulation of the integration policies (Unasur, 2008, Article 3).

As well as the provisions quoted, which, by themselves, would already be enough to determine that it is mandatory to incentivate citizen participation in the process of South American integration, two other articles of the Treaty stand out: Articles 9 and 18.

Article 9, which deals with the competencies of the Council of Delegates, includes promotion of spaces for dialog that can enable the people to have active participation in this process of integration. Article 18 determines the creation of channels of information and consultation for the populous:

Article 18 – Citizen participation: Full participation of citizens in the process of South-American integration and union will be promoted through wide dialog and interaction that is democratic, transparent, pluralist, diverse and independent, with the various social actors, establishing effective channels of information, consultation and follow-up in the various instances of Unasur.

The member states and the bodies of Unasur will generate mechanisms and spaces that are innovative and incentivate discussion of the various subjects, ensuring that the proposals that have been presented by citizens receive appropriate consideration and response.

Although there is this highlight for the creation of mechanisms that enable citizen participation, there is no indication of what these instruments would be, and how individuals would be able to exercise this prerogative. One finds only general provisions, which lay down that the member states must create mechanisms and include their population in the debates and in the process of integration, but it does not explain how each State and Unasur itself should effectively act in this sense.

The most concrete action of this type was the creation, by the Heads of State and Government of Unasur, of the Unasur Citizen Participation Forum²⁰20. Unasur. Unasur/CJEG/DECISIÓN/Nº7 /2012: Por la cual el consejo de jefas y jefes de estado y de gobierno de la Unión de Naciones Suramericanas, decide crear un foro de participacion ciudadana de Unasur. [recurso eletrônico]. 2012. [acessado 2016 dez 27]. Disponível em: http://www.iirsa.org/admin_iirsa_web/Uploads/Documents/rp_lima12_decision7.pdf
http://www.iirsa.org/admin_iirsa_web/Upl... , in 2012, providing for annual in-person meetings with national and regional social actors, to formulate recommendations (Article 1). One of the most important points of the Resolution, detailed in the document that defines the guidelines of functioning²¹21. Brasil. Ministério das Relações Exteriores. [homepage na internet]. Declaração de Paramaribo, aprovada na VII Reunião de Cúpula da Unasul – Paramaribo, 30 de agosto de 2013. [acessado 2016 dez 27]. Disponível em: http://www.itamaraty.gov.br/pt-BR/notas-a-imprensa/2193-declaracao-de-paramaribo-aprovada-na-vii- reuniao-de-cupula-da-unasul.
http://www.itamaraty.gov.br/pt-BR/notas-... , covers the provision for citizen participation in the bodies and instances of Unasur, including the duty that the Sector Councils and other instances must incorporate activities for dissemination and dialog, enabling the social actors to participate in its meetings with the right to a voice:

6. Citizen participation in the bodies and instances of Unasur

a) The Sector Ministry Councils and other instances of Unasur must incorporate in their plans of action the holding of events of dissemination and dialog with the citizenry and their organizations, which include in-person meetings, accompanied by the respective representative.

The first and only meeting of the Forum carried out so far took place in 2014, in Bolivia. It brought together approximately 200 representatives of some sectors of civil society of 10 member countries. A series of proposals resulted from this meeting: Creation of the Latin American University; progress on intercultural public policies; democratizing cyber space; creation of a permanent regional communication network to publicize citizen participation in the preparation of public polices; creation of theme commissions and work groups on gender and integration; afro-descendants and indigenous peasant peoples; food sovereignty, with exchange of technology and ancestral knowledge, and participation of young people in decision-making. No proposals directly related to the subject of health are found in the minutes of the meeting.

In relation to the participation of citizens in the construction of health policy – health democracy – as per the concept presented above, this was found to be provided for in the document that created the Health Ministers’ Council (Article 4, g. CSS):

g) To promote citizen responsibility and participation in the subjects of Health, as a public good which involves society as a whole, and also the incorporation of social and community organizations into Unasur Health;

However, this is no provision in Unasur Health for public meetings, forums for debates, plebiscites, referendums, means of communication or other spaces that would enable the citizen to express his ideas and propose actions. The population remains at the margin of the decision process and of development of the bloc, unable to contribute to the transformation of the social reality. We have not found spaces for publication of information, ideas, discussions or statements related to health subjects and policies between members of the community, beyond the bureaucratic bodies of Unasur Health. Meanwhile, the member states continue to negotiate and take decisions without listening to the people who will be directly affected by these acts.

Citizen participation should be guaranteed on a wide basis, through dialogs and interaction between the various social actors. Sólon²²22. Solón P. Reflexiones a mano alzada sobre el Tratado de Unasur. Revista de la Integración 2008; (2):12-18. says: “This relationship with the social actors should be democratic, transparent, and pluralist, and should recognize the independence of the various instances of civil society”.

It is clear that the provision for citizen participation stated in the Treaty of Constitution of Unasur and in the decision to create the Unasur Health Council are important advances in the process of Latin American integration, but there is a lot yet to be achieved. It becomes essential in any discussion about decision on regional public policies in health, and also on process of international integration and cooperation, that mechanisms of health democracy should be included.

Final considerations

The ethical approach to international relations in health relates to the challenge of developing transparent mechanisms for activity by the States in their relationships, whether in regional blocs that they are part of, or in the system of the United Nations itself.

Health democracy is seen as a principle that should serve to lead to the adoption of health policies in Unasur in a way that is coherent with the concerns of a population, and thus support the actions of the member states.

Unasur, although it speaks in favor of strengthening of democracy in the Treaty of Constitution, and presents as its general and specific basis and objectives the fostering of citizen participation in its fullest form – being considered innovative in relation to the other attempts at integration precisely because it establishes a communication between the social, cultural, political and environmental sectors that goes beyond economic preoccupation and customs benefits – fails by not providing, in practice, spaces and mechanisms for participation in the Councils or the Workgroups.

At the same time, the analysis points to the fragility of mechanisms that might allow participation by the party with the greatest interest in the decisions taken by this bloc in the area of health: the individual citizen.

The conclusion is that citizen participation in the construction of health policies needs to be made an effective reality, by making instruments available with which individuals can interact, discuss, acquire and exchange information, expose their ideas, and build their own conception of health, and of social demands, and struggle for effective responses.

References

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