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Universidade Autónoma de Lisboa

e-ISSN: 1647-7251

VOL15, N.º 2, TD1

Thematic Dossier – Brazil-China relations:

The rise of modern International Order

December 2024

290

GLOBAL HEALTH DIPLOMACY AS AN INSTRUMENT OF SOFT POWER IN BRAZIL-

CHINA RELATIONS

ANABELA RODRIGUES SANTIAGO

anabela.santiago@ua.pt

Ph.D. candidate in Public Policies at the Department of Social, Political and Territorial of

University of Aveiro (Portugal). Furthermore, she is a Ph.D. Research Grant Holder (Fundação

para a Ciência e Tecnologia + Centro Científico e Cultural de Macau), and a Ph.D. student

member of GOVCOPP (Governance, Competitiveness and Public Policies) research unit. She has

participated in several scientific projects including a scientific mission to map Chinese

investments in the agri-food sector under COST Action 18215 - China and Europe Relations

Network and CHERN Training School: China Scholarship and Policy Advice: Reaching (out to)

Decision Makers on China. Author of several articles and book chapters on global health

governance and the specific case of China. Her research activity has involved health governance,

health diplomacy, and particularly, Chinese health strategy towards global health governance.

She is currently affiliated to Research Unit on Governance, Competitiveness and Public Policies

(GOVCOPP), University of Aveiro, Portugal/ FCT-CCCM Grant Fellow.

https://orcid.org/0000-0002-3897-0323.

CARLOS EDUARDO DE ANDRADE LIMA DA ROCHA

carlos.rocha@fiocruz.br

Works at the International Platform for Science, Technology and Innovation in Health

(PICTIS/Portugal) PIC Number 887111561, Oswaldo Cruz Institute - IOC, Oswaldo Cruz

Foundation - FIOCRUZ; Post-doctoral Researcher - University of Aveiro (Portugal), 2019. Carlos

Eduardo does research in International Cooperation, Health Politics and Policy, Public

Administration, Innovation and Public Policy. Horizon Europe – Project: Multi-site Application of

Open Science in the Creation of Healthy Environments Involving Local Communities (MOSAIC),

Member. Doctor of Science (DSc) – Biomedical Engineering, Public Health Management Analyst

(Science, Technology & Innovation in Public Health), Fiocruz. He is currenlty associated to

Plataforma Internacional para Ciência, Tecnologia e Inovação em Saúde - PICTIS (Portugal)/

Instituto Oswaldo Cruz-IOC/Fundação Oswaldo Cruz – Fiocruz, Brazil.

https://orcid.org/0000-0001-7118-284X.

Abstract

As a result of significant economic growth, driven by increased international trade and the

densification of urban populations – leading to a faster global transmission of diseases – health

has been a top priority in global governance in recent decades. The coordination between

national public policies and international cooperation efforts to address public health

challenges has become crucial and acknowledged by the majority of the states in the

international system (Ibanez et. al., 2022 Ibanez, 2020). This acknowledgment – together

with the awareness of the “globalization of disease” (Fidler, 2004) – conduces to the use of

Global Health Diplomacy (GHD) as an instrument of foreign policy and soft power. Due to its

ever-growing role in the international arena, China has made efforts to play a more relevant

role in health governance, especially in the Global South. In turn, as Brazil has a long tradition

and experience in GHD, and being both Brazil and China countries that are commercial

partners and integrate the BRICS, it is quite relevant to understand the evolution of their

relationship in the sphere of GHD and governance across time. In this paper, by means of a

literature review of scientific papers relevant in the field, we use a perspective based on

JANUS.NET, e-journal of International Relations

e-ISSN: 1647-7251

VOL 15 N.º 2, TD 1

Thematic Dossier

Brazil-China relations: The rise of modern International Order

December 2024, pp. 290-308

Global Health Diplomacy as An Instrument of Soft Power in Brazil-China Relations

Anabela Rodrigues Santiago, Carlos Eduardo de Andrade Lima da Rocha

291

bilateralism to i) outline both China’s and Brazil’s positioning towards health diplomacy

between 2013 and 2023, and ii) analyse their articulation in this realm within the context of

the BRICS. The evolution of such relationship with health diplomacy at the core has been

turbulent depending on political leaderships and their respective political programs; however,

this study enables us to identify the challenges and point out best practices and potential

reinforcing partnerships for the achievement of better health for all and sustainable

development.

Keywords

Global Health Governance, Health Diplomacy, China-Brazil Relationship, BRICS.

Resumo

Em resultado de um crescimento económico significativo, impulsionado pelo aumento do

comércio internacional e pela densificação das populações urbanas – que conduz a uma

transmissão mais rápida de doenças à escala global – a saúde tem sido uma das principais

prioridades da governança mundial nas últimas décadas. A coordenação entre as políticas

públicas nacionais e os esforços de cooperação internacional para enfrentar os desafios da

saúde pública tornou-se crucial e reconhecida pela maioria dos Estados do sistema

internacional (Ibanez et. al., 2022 Ibanez, 2020;). Este reconhecimento – combinado com a

consciência da “globalização da doença” (Fidler, 2004) – conduz à utilização da Diplomacia da

Saúde Global como um instrumento de política externa e de soft power. Devido ao seu papel

cada vez maior na arena internacional, a China tem feito esforços para desempenhar um papel

mais relevante na governança global da saúde, especialmente no Sul Global. Por sua vez,

como o Brasil tem uma longa tradição e experiência em Diplomacia da Saúde Global, e sendo

tanto o Brasil como a China países parceiros comerciais e integrantes dos BRICS, é bastante

relevante compreender a evolução da sua relação nessa esfera e na esfera da governança ao

longo do tempo. Neste artigo, por meio de uma revisão de literatura de artigos científicos

relevantes na área, utilizamos uma perspetiva baseada no bilateralismo para i) delinear o

posicionamento da China e do Brasil em relação à diplomacia da saúde entre 2013 e 2023, e

ii) analisar sua articulação nesse âmbito no contexto dos BRICS. A evolução dessa relação,

com a diplomacia da saúde no centro, tem sido turbulenta, dependendo das lideranças

políticas e dos seus respetivos programas políticos; no entanto, este estudo permite-nos

identificar os desafios e apontar as melhores práticas e potenciais parcerias de reforço para a

consecução de uma melhor saúde para todos e do desenvolvimento sustentável.

Palavras-chave

Governança Global da Saúde, Diplomacia da Saúde, Relação China-Brasil, BRICS.

How to cite this article

Santiago, Anabela Rodrigues & Rocha, Carlos Eduardo de Andrade Lima da (2024). Global Health

Diplomacy as An Instrument of Soft Power in Brazil-China Relations. Janus.net, e-journal of

international relations. VOL 15 N.º 2, TD1 – Temathic Dossier – “Brazil - China Relations: The Rise

Of Modern International Order”. December 2024, pp. 290-308. https://doi.org/10.26619/1647-

7251.DT0324.14.

Article received on 24 July 2024 and accepted for publication on 30 September 2024.

JANUS.NET, e-journal of International Relations

e-ISSN: 1647-7251

VOL 15 N.º 2, TD 1

Thematic Dossier

Brazil-China relations: The rise of modern International Order

December 2024, pp. 290-308

Global Health Diplomacy as An Instrument of Soft Power in Brazil-China Relations

Anabela Rodrigues Santiago, Carlos Eduardo de Andrade Lima da Rocha

292

GLOBAL HEALTH DIPLOMACY AS AN INSTRUMENT OF SOFT

POWER IN BRAZIL-CHINA RELATIONS

ANABELA RODRIGUES SANTIAGO

CARLOS EDUARDO DE ANDRADE LIMA DA ROCHA

Introduction

Health diplomacy has emerged as critical component of international relations, especially

in the context of globalization and increasing interdependence among nations. The rapid

economic growth and urbanization observed globally have facilitated the swift

transmission of diseases across borders, making health a priority in global governance

(Fidler, 1997; Fidler, 2004; Almeida, 2020). The coordination between national public

policies and international cooperation is essential to address public health challenges

effectively. This coordination is widely acknowledged by the majority of states within the

international system (Ibanez et al., 2022; Ibanez, 2020; Lee and Gomez, 2011).

Global health diplomacy has been defined in the literature in various fields of knowledge

according to different historical and geographic perceptions as well. For the purpose of

this paper, we assume the definition given in Global Health Centre Report (2021:39):

“Global health diplomacy refers to the multi-level and multi-actor negotiation processes

that shape and manage the global policy environment for health, in health and non-

health fora”. In this sense, GHD integrates the disciplines of public health, international

affairs, management, law, and economics, among others, to address global health issues

and improve relations among countries (Katz et al., 2011). Moreover, the increasing

globalization of diseases – illustrated by outbreaks such as SARS, Ebola, and COVID-19

– has underscored the importance of robust international health policies (Fidler, 2004).

Besides globalization itself, also the expansion of non-governmental organizations

(NGOs) in international health, the globalization of science and pharmaceutical research,

as well as the use of militarized languages of biosecurity impact global health (Adams,

Novotny and Leslie, 2008).

In sequence, due to several factors – namely their economic relevance and wide know-

how in health governance and diplomacy – Brazil and China are two key players in

international order whose relationship is important to be understood. Brazil and China

have established a robust partnership over the years, marked by significant trade

relations and cooperation in various sectors (Herrero & Tussie, 2015). Both nations are

JANUS.NET, e-journal of International Relations

e-ISSN: 1647-7251

VOL 15 N.º 2, TD 1

Thematic Dossier

Brazil-China relations: The rise of modern International Order

December 2024, pp. 290-308

Global Health Diplomacy as An Instrument of Soft Power in Brazil-China Relations

Anabela Rodrigues Santiago, Carlos Eduardo de Andrade Lima da Rocha

293

integral members of the BRICS group, which emphasizes collaboration among emerging

economies from the Global South. The partnership between Brazil and China extends into

the realm of health diplomacy, which serve as an instrument of soft power and foreign

policy (Herrero & Tussie, 2015). Understanding the evolution of their relationship in GHD

is crucial, given their influential roles in the Global South. The diplomatic relationship

between Brazil and China has seen various phases, with an increasing focus on

cooperation in science and technology, public health, and sustainable development. This

relationship is further strengthened by the creation of new institutional framework to

reform global governance structures and promote a multipolar world order, namely

financing institutions, such as the New Development Bank and the Asian Infrastructure

and Investment Bank (Santiago & Rodrigues, 2023).

Indeed, health diplomacy can be perceived as a tool of soft power as previously stated.

Soft power, a concept popularized by Joseph Nye (1990, 2004, 2008), refers to the ability

of a country to shape the preferences of others through appeal and attraction rather than

coercion or payment. Health diplomacy is then a vital tool of soft power, enabling nations

to foster goodwill, build alliances, and promote their values and interests on the global

stage. As defined by Fidler (2001), GHD encompasses the policymaking processes

through which both state and non-state actors address global health challenges,

extending their efforts beyond the health sector. Similarly, Kickbusch et al., in a 2021

report by the Global Health Centre, described GHD as involving “multi-level and multi-

actor negotiation processes that shape and manage the global policy environment for

health, in health and non-health fora” (Global Health Centre, 2021:39). This perspective

underscores the complex and collaborative nature of GHD, highlighting its role in

coordinating a wide array of stakeholders and forums to effectively tackle health issues

on a global scale.

Since the end of World War II, GHD has become an essential part of foreign policy

agendas. It now plays a pivotal role in discussions related to national security,

international trade, and diplomatic relations (Almeida, 2020; Ruckert et. al., 2022;

Almeida, 2010). This development highlights the growing recognition that global health

issues are closely linked to broader geopolitical and economic stability. This connection

became particularly evident in the 1980s and 1990s during the rapid spread of HIV/AIDS

in the developing world (Mahani et. al., 2018). The widespread impact of such health

crises led to the integration of health concerns into foreign policy and international

diplomacy, establishing GHD as a distinct field (Labonté and Gagnon, 2010). As a result,

nations have increasingly recognized the importance of health diplomacy not only for

safeguarding their own citizens, but also for enhancing global health security and

fostering international goodwill (Gauttam et. al., 2020). The role of GHD, especially

through the World Health Organization (WHO), in uniting countries towards the common

goal of improving global health, has been consistently demonstrated during public health

crises, most recently during the COVID-19 pandemic (Kickbusch and Liu, 2022). This

ongoing emphasis underscores the crucial function of GHD in addressing contemporary

health challenges and promoting international cooperation for a healthier world.

By using a perspective based on their bilateral relations, we can better understand the

collaborative efforts and joint initiatives undertaken by Brazil and China in the fields of

health diplomacy, by assessing how bilateral cooperation enhances their soft power and

JANUS.NET, e-journal of International Relations

e-ISSN: 1647-7251

VOL 15 N.º 2, TD 1

Thematic Dossier

Brazil-China relations: The rise of modern International Order

December 2024, pp. 290-308

Global Health Diplomacy as An Instrument of Soft Power in Brazil-China Relations

Anabela Rodrigues Santiago, Carlos Eduardo de Andrade Lima da Rocha

294

contributes to global health governance. This approach allows us to identify the

challenges and opportunities in their relationship and explore the potential for reinforcing

partnerships to achieve better health outcomes.

Methodology

This paper adopts a qualitative approach, using a literature review to explore the role of

health diplomacy in the context of Brazil-China relations within the BRICS framework

from 2013 to 2023. The research is grounded in bilateralism, emphasizing the importance

of collaborative efforts and joint initiatives between Brazil and China to address global

health and scientific challenges. The literature review involved a comprehensive set of

relevant scientific literature, including peer-reviewed journal articles, reports from

international organizations and book chapters focusing on GHD and international,

bilateral relations between Brazil and China. The literature search was conducted using

several academic databases, including PubMed, Scopus and Google Scholar, filtered by

some criteria such as articles either in English, Spanish or Portuguese, that after the

abstract reading revealed to be relevant in one or more of the key topics of the study

(global health governance, global health diplomacy, soft power, BRICS, China-Brazil

cooperation, Chinese foreign policy, Brazilian foreign policy). Some grey literature,

namely new in media, was used to complement the scientific literature. The resulting

analysis that composes this paper is grounded in a total of 76 references and aims to

make a contribution to the status quo of health diplomacy as an instrument of soft power

in Brazil-China Relations.

Brazil’s Positioning Towards Health Diplomacy (2013-2023)

Brazil has a long-standing tradition in health diplomacy, particularly through its

involvement with international health organizations and its leadership in global health

initiatives (Ibanez et. al., 2022). The country’s Unified Health System (Sistema Único de

Saúde - SUS) has been recognized as a model for public health, emphasizing universal

health coverage and equitable access to healthcare services (Paim et al., 2011). Indeed,

Brazil was the first developing nation to successfully integrate trade and public health by

effectively challenging and renegotiating the barriers to medicine access within the

framework of the Agreement on Trade-Related Aspects of Intellectual Property Rights

(TRIPS). This initiative culminated in Brazil offering free antiretroviral treatment to

HIV/AIDS patients, leading to a significant decrease in AIDS-related morbidity and

mortality (Mahani et. al., 2018). In the international health arena, Brazil has been

particularly proactive, pioneering several health measures that have been adopted by

other health systems and endorsed by the WHO. Prominent examples include the

provision of universal primary care services, the strategic training and deployment of

healthcare personnel, and efforts to address the social determinants of health (Almeida

et al., 2023), as well as the role of Brazil in the Framework Convention on Tobacco Control

(FCTC) that offers valuable insights into the country's efforts to foster global health

cooperation and achieve broader foreign policy goals (Lee, Chagas and Novotny, 2010).

Indeed, in 1999, the Inter-Ministerial National Commission on the Control of Tobacco Use

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VOL 15 N.º 2, TD 1

Thematic Dossier

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Global Health Diplomacy as An Instrument of Soft Power in Brazil-China Relations

Anabela Rodrigues Santiago, Carlos Eduardo de Andrade Lima da Rocha

295

was established. Supported by top government officials, this commission served as an

advisory group to shape the government's stance on FCTC negotiations. Notably, the

commission included representatives from nine ministries, such as Inland Revenue, Trade

and Development, and Agriculture. By involving all relevant stakeholders (not only direct

health-related ones), the commission ensured that tobacco control was integrated into

consistent policies across the entire government, rather than being solely a concern of

the health ministry (Lee, Chagas and Novotny, 2010).

During the 2013-2023 period, Brazil's health policies continued to prioritize these

principles, even as the country faced economic and political challenges. Brazil has

challenged the traditional model of aid, development assistance, and the typical donor-

recipient relationships by promoting 'South-South' or 'horizontal cooperation'. This

alternative framework emphasizes reciprocal learning and exchange between countries.

Unlike the conventional model, where external health aid packages are imposed, this

demand-driven approach enables recipient countries to request health aid tailored to

their specific needs (Mahani et al., 2018; Almeida et al., 2010). By fostering this model

of cooperation, Brazil not only enhances the effectiveness of health interventions, but

also empowers partner countries to take an active role in their own health development,

thereby promoting sustainable and contextually relevant health solutions.

The country has been a vocal advocate for health equity and the right to health in

international forums. Its health policies have emphasized the importance of social

determinants of health and the need for comprehensive primary healthcare (Buss and

Ferreira, 2010; Almeida, 2023). The country's commitment to these principles has been

evident in its active participation in global health initiatives and its efforts to strengthen

health systems in developing countries. Going back to the early 2000s, to further

contextualize our current period of analysis, by that time diplomacy and health in Brazil

were highly connected, with a shift in the discussion on global health towards the

priorities of foreign policy. The Lula’s government emphasized multilateralism and

integration with developing and emerging countries – particularly highlighted through the

coordination with BRICS and South America (Ibanez et al., 2022) – aiming for a policy

of international cooperation for development. In this context, within the health sector,

there was a consolidation of a universalist discourse, according to Pinheiro (2020), with

Brazil's participation in the creation of the Foreign Policy and Global Health Initiative

(FPGH), which aimed to position health as an essential and strategic issue on the foreign

policy agenda. Furthermore, there was a significant regional presence with the

establishment of the South American Health Council within the Union of South American

Nations (UNASUL) in 2008. This council sought to collectively combat the H1N1 and

dengue epidemics, which were intensifying at the time, and to plan a response to the

potential arrival of Ebola on the continent (Ibanez et. al., 2022). During Dilma's

government, there was a continuation of this stance of participation in international

initiatives (Lima, 2017). However, political instability and economic constraints have

sometimes hindered the continuity and expansion of these initiatives. From 2019 until

2022, Jair Bolsonaro's tenure represented a significant shift in Brazil's health diplomacy

approach. His administration's policies were marked by a strong nationalist stance and

conservative ideology, which often resulted in a reduced emphasis on international health

cooperation. Bolsonaro's government faced intense criticism for its management of the

JANUS.NET, e-journal of International Relations

e-ISSN: 1647-7251

VOL 15 N.º 2, TD 1

Thematic Dossier

Brazil-China relations: The rise of modern International Order

December 2024, pp. 290-308

Global Health Diplomacy as An Instrument of Soft Power in Brazil-China Relations

Anabela Rodrigues Santiago, Carlos Eduardo de Andrade Lima da Rocha

296

COVID-19 pandemic, both within Brazil and from the global community (Trivellato and

Ventura, 2022; Vieira de Jesus, 2022). This criticism, combined with Bolsonaro's

skepticism towards multilateral organizations like the WHO, led to a decline in proactive

health diplomacy. Effectively, Jair Bolsonaro's administration exhibited a strong anti-

globalist stance, marked by a rejection of liberal multilateral institutions and international

treaties (Ventura and Bueno, 2021). Bolsonaro threatened to exit key agreements such

as the Paris Climate Accords and the WHO and actually withdrew from the UN Global

Compact for Migration. His government distanced itself from the Global South and

showed indifference towards South-South cooperation forums like BRICS (Trivellato and

Ventura, 2022). Overall, engagement in health diplomacy was diminished (Buss and

Tobar, 2020). Not only because of Brazil or China – but as a whole group – the COVID-

19 pandemic exposed the BRICS' internal divisions and shortcomings in their collective

policymaking and implementation, highlighting their constrained influence within the

WHO (Moore, 2022).

With his return to the presidency in 2023, Luiz Inácio Lula da Silva had to deal with many

issues domestically. As far as health is concerned, rebuilding the SUS after significant

setbacks stands as a top priority and a monumental challenge for Lula’s administration.

Upon taking office, President Lula was faced with a dire situation marked by severe

deterioration in health indicators (Ortega and Pele, 2023). Various stakeholders have

identified the key challenges for his administration, which include: (i) outlining a

progressive plan to increase public funding for SUS from the current 4% to 6%-7% of

the GDP, while also improving the efficiency of resource allocation; (ii) addressing

regional health disparities by implementing new governance mechanisms; (iii)

reestablishing and enhancing primary health care to function as a comprehensive,

effective, community-based model within the regionalized SUS network; (iv) managing

health market regulations to prevent costly treatments from being accessed through the

judicial system; (v) restructuring the training, placement, and provision of health

workers, introducing policies to prevent precarious working conditions, and addressing

the shortage and uneven distribution of doctors; (vi) developing a national health data

policy to support the management and digital transformation of SUS (Ortega and Pele,

2023).

Besides the domestic health issues, Lula also has made revitalizing Brazil's health

diplomacy a key priority. Lula's administration seeks to reassert Brazil's leadership role

in global health initiatives, focusing on principles of South-South cooperation and

solidarity (Ventura, 2023). Efforts are being made to rebuild relationships with

international health organizations and enhance Brazil's participation in global health

forums. In subsequent sub-sections of this paper, we focus on the health cooperation

between Brazil and China under their respective health diplomacy approach.

China’s Positioning Towards Health Diplomacy (2013-2023)

China’s health policies have evolved significantly over the past decade, reflecting its

growing influence in global affairs. The country has made substantial investments in

health infrastructure and scientific research, aiming to enhance its soft power through

health diplomacy (Hu et. al., 2017). China’s Health Silk Road initiative, part of the larger

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e-ISSN: 1647-7251

VOL 15 N.º 2, TD 1

Thematic Dossier

Brazil-China relations: The rise of modern International Order

December 2024, pp. 290-308

Global Health Diplomacy as An Instrument of Soft Power in Brazil-China Relations

Anabela Rodrigues Santiago, Carlos Eduardo de Andrade Lima da Rocha

297

Belt and Road Initiative (BRI), exemplifies its commitment to improving global health

through international cooperation (Cao, 2020).

Domestically, China’s health policies have focused on expanding healthcare access,

improving healthcare quality, and enhancing the country's capacity to respond to public

health emergencies (Meng et al., 2019). The country has also emphasized the importance

of innovation and technological advancement in its health strategies, investing heavily in

research and development, also as part of its “Made in China 2025” strategic plan.

Abroad, indeed, China's Health Silk Road has been a cornerstone of its health diplomacy

strategy, involving projects to build hospitals, provide medical training, and supply

medical equipment to countries along the BRI routes (Yuan, 2023; Chow-Bing, 2020).

This initiative aims to enhance healthcare infrastructure and improve health outcomes in

partner countries, while also strengthening China's influence in these regions (Gauttam

et al., 2020; Shajalal et al., 2017), a factor which is sometimes associated to the

conception of “aid with strings attached” (Tritto et al., 2024) or “old wines in new bottles”

(Alden, 2006) when compared with traditional donors’ aid. This strategy offers several

potential benefits for China. It may facilitate access to Africa's rich natural resources,

which are vital for China’s expanding economy, and it fosters a sense of gratitude and

dependence towards China. Indeed, by enhancing healthcare infrastructure and

addressing public health challenges, China can generate goodwill and create a sense of

obligation among the recipient nations, both economically and politically (Yuan, 2023).

With or without strings attached, the fact is that the Chinese government has been

proactively engaging in health diplomacy, particularly with developing countries and

notably with the African continent, as part of its wider South-South cooperation strategy.

This commitment was evident, not only before, but also during and after the COVID-19

pandemic (Killeen et. al., 2018; Cabestan, 2022). However, as illustrated in figure 1, the

high volume of Chinese medical aid exports post-COVID-19 was primarily directed

towards Asian countries. This shift is seen by many scholars as part of China's “neighbors’

diplomacy” strategy, aiming to solidify relationships and enhance influence within the

Asian region (Guo et. al., 2024; Aria et. al., 2023).

Figure 1: Distribution of Chinese medical aid exports across regions by quarter from

January 2017 to September 2022, measured by the amount in current US$

Source: Guo et al., 2024

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e-ISSN: 1647-7251

VOL 15 N.º 2, TD 1

Thematic Dossier

Brazil-China relations: The rise of modern International Order

December 2024, pp. 290-308

Global Health Diplomacy as An Instrument of Soft Power in Brazil-China Relations

Anabela Rodrigues Santiago, Carlos Eduardo de Andrade Lima da Rocha

298

Through its multifaceted engagements, China’s health diplomacy highlights the core

principles of South-South cooperation, focusing on mutual benefit, solidarity, and shared

developmental goals. Countries classified as 'emerging' or 'non-traditional' donors, which

have only recently increased their contributions to development finance, are reshaping

and expanding the boundaries of conventional health aid practices (McDade and Mao,

2020). This strategic approach fosters the creation of a more interconnected and

cooperative global community, where developing nations support each other in tackling

common challenges and achieving sustainable development in a more "horizontal"

manner. This stands in contrast to the traditional "vertical" model of cooperation seen in

North-South international aid (Almeida, 2010). Such horizontal cooperation not only

emphasizes development assistance but also promotes equitable partnerships and shared

growth.

In the sequence of the COVID-19 pandemic, China was said to be using what we know

as “mask diplomacy” and “vaccine diplomacy” as tools of soft power, to provide an image

of responsible power, ensuring equitable vaccine distribution, and fostering strategic

partnerships. Partly to mitigate negative perceptions following the initial outbreak in

Wuhan, China aimed to shift its image from a source of the virus to a global health leader

(Wu & Gelineau, 2021; Lee 2023). China’s COVID-19 aid during the first wave of the

pandemic – the phase of mask diplomacy – was largely reactionary and driven by

recipient countries' needs, reflecting traditional norms of non-interference rather than a

coherent strategic plan. The fragmented nature of aid implementation highlights the

challenges China faces in leveraging foreign aid for strategic purposes (Sun and Yu,

2023).

As for vaccine diplomacy, China began with vaccine trials in Brazil in July 2020, expanding

to donations and sales across Asia, Africa, and Latin America (Lee, 2023). In early 2021,

China appeared to gain an advantage with its swift delivery of medical masks and

vaccines, as Western nations lagged behind (Nolte 2023; De Luce, 2021); indeed, early

vaccine deliveries created a perception of Chinese diplomatic success compared to the

U.S. and Europe (von der Burchard, 2021; Stuenkel, 2020). By March 2021, China had

provided millions of vaccine doses to 69 countries and exported to 28 others (Huang,

2021; Lee 2023), as per figure 2. By June 2021, China had participated in COVAX to

support global vaccine distribution (MFA, 2021; Huang, 2021; Kobierecka, 2022).

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e-ISSN: 1647-7251

VOL 15 N.º 2, TD 1

Thematic Dossier

Brazil-China relations: The rise of modern International Order

December 2024, pp. 290-308

Global Health Diplomacy as An Instrument of Soft Power in Brazil-China Relations

Anabela Rodrigues Santiago, Carlos Eduardo de Andrade Lima da Rocha

299

Figure 2: The Belt and Road Initiative and China’s Vaccine Diplomacy

Source: Huang, 2021

The effectiveness of China’s efforts in improving its international standing remains

debated, with mixed perceptions from global audiences (Silver et. al. 2023; Kobierecka,

2022; Silver et al., 2020). As for the case of Latin America, and Brazil in particular, the

pandemic did not dramatically alter the economic and geopolitical landscape. China

remained a major economic partner, but its vaccine diplomacy did not lead to substantial

geopolitical shifts (Nolte, 2023). China's influence in Latin America was constrained by

the effective vaccine diplomacy of the U.S. and Europe in the latter half of 2021 (Nolte,

2023).

All in all, either mask and vaccine diplomacy are part of China’s health diplomacy that,

besides the real effects in the global health landscape, serve as a tool for image repairing

and nation branding (Lee, 2023). In next section, the relation between Brazil and China

in terms of health cooperation will be further discussed within the BRICS context.

Brazil-China Articulation in Health and Science Diplomacies within

BRICS

Crises in general, and health crises in particular, usually prompted discussions about

open science and innovation, emphasizing the need for widespread experimentation and

international collaboration (Chesbrough, 2020; Roehrl et. al., 2020). We analysed the

case of Brazil and China's health cooperation in the contemporary period.

Brazil and China's health cooperation is rooted in the complementary strengths each

country brings to the partnership: essentially, China provides advanced technological and

medical resources, including manufacturing capabilities for medical equipment and

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vaccines; while Brazil, on the other hand, contributes with its deep expertise in global

health, particularly in managing infectious diseases, thanks to its well-established health

institutions, such as the Fundação Oswaldo Cruz (Fiocruz) (Santiago and Rodrigues,

2023).

During the COVID-19 pandemic, China's ability to rapidly produce and supply medical

equipment and vaccines was crucial for Brazil. This included the provision of Sinovac’s

CoronaVac vaccine, which played a significant role in Brazil's vaccination campaign

(Santiago and Rodrigues, 2023). The partnership exemplifies how technological and

resource-sharing can enhance public health responses in times of crisis. Despite political

tensions during Bolsonaro’s administration, the health cooperation between Brazil and

China remained strong, mainly deriving from local authorities' efforts. The steady flow of

medical supplies from China to Brazil during the pandemic underscores the strategic

importance of maintaining robust health partnerships irrespective of political changes

(McBride et al., 2023). However, although Brazil has historically played a leading role in

multilateral forums advocating for the health interests of the Global South (Ventura et

al., 2020), as well as promoted innovative forms of health cooperation (Almeida et al.,

2010), its stance from the pandemic period until very recently changed:

Brazil stands out from almost all other countries for the lack of legislation

seeking to regulate and give an effective response to Covid-19 on the

federal level. In fact, there has been a systematic obstruction from the

Executive branch of government to contain the pandemic, coming from

other actors, such as the National Congress and local governments

(Ventura and Martins, 2020, p. 68).

Here, paradiplomacy plays a crucial role in finding federal and local alternatives. The shift

in relationship with China occurred during Bolsonaro’s administration led to tensions and

difficulties, especially in a pandemic context as China being the foremost producer of

masks and health equipment (Hoirisch, 2020) and also Brazil's largest trading partner

(Alvarenga et al., 2020). Despite these strains, the already referred notable

paradiplomatic efforts between Brazilian regional entities, particularly in the Northeast,

and their Chinese counterparts had a mitigating effect. For instance, the province of

Sichuan donated health supplies to Pernambuco (Alvarenga et al., 2020; Pozatti and

Farias, 2022). The current research agenda on international cooperation needs to

broaden its scope to include these emerging forms of collaboration and their effects on

national and multilateral institutions and alliances. This is particularly pertinent given that

in March 2021, Fiocruz obtained definitive approval from the National Health Surveillance

Agency (Anvisa) for the COVID-19 Fiocruz vaccine, which is produced using Chinese

Active Pharmaceutical Ingredients (API) (Valverde, 2021). The large-scale production of

this vaccine influenced the trajectory of the pandemic in Brazil and across Latin America

(Xing et al., 2023), provided that Brazil enhances its performance in the region and

continues Fiocruz's strong tradition of international cooperation (Pozatti and Farias,

2022).

Another example which is representative of the paradiplomacy efforts and also of a return

to previous stage of relations between Brazil and China is the signature of a Memorandum

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of Understanding between Fiocruz and CAS-TWAS Center of Excellence for Emerging

Infectious Diseases (CEEID), to establish the Sino-Brazilian Center for Research and

Prevention of Infectious Diseases (IDRPC). The agreement aims to strengthen

cooperation in health-related science and technology, particularly in preventing and

controlling pandemics and epidemics such as Covid-19, influenza, Zika, dengue, yellow

fever, and tuberculosis, among others. This initiative includes developing global public

health goods like rapid diagnostic tests, therapies, vaccines, and medications. The IDRPC

will have headquarters in both Beijing, at the Institute of Microbiology of the Chinese

Academy of Sciences (CAS), and at the Fiocruz campus in Manguinhos, Rio de Janeiro.

The Rio facilities are expected to be completed by the end of 2024 and operational by

2025 (Azevedo, 2023/ Agência Notícias Fiocruz).

The partnership was initiated before the pandemic but faced delays due to health

emergencies and political factors. However, with President Lula's recent visit to China

and the subsequent signing ceremony, the agreement has gained renewed momentum,

highlighting the deepening health cooperation between Brazil and China. The signing

ceremony emphasized the importance of this high-level and bilateral partnership,

underscoring joint research efforts, exchange of expertise, and enhanced epidemiological

surveillance capabilities.

The IDRPC will facilitate joint research projects, training programs at various levels,

technology and material exchange, seminars, conferences, and collaborative efforts in

tropical medicine. It represents a significant shift towards permanent scientific

collaboration by establishing physical centers where Brazilian and Chinese researchers

can work together extensively. This bilateral partnership aims to advance global health

systems and reduce vulnerability to emerging health crises through sustained scientific

cooperation and knowledge exchange (Pereira, 2023/ Exame).

Final Considerations

In this paper, we have explored the roles of health diplomacy as an instrument of soft

power in the context of Brazil-China relations within the BRICS framework. The evolution

of their relationship from 2013 to 2023 demonstrates the dynamic nature of health

diplomacy in shaping international relations and addressing global health challenges.

Health diplomacy has emerged as a crucial tool for enhancing soft power. Both Brazil and

China have leveraged it to strengthen their global influence. Brazil’s long-standing

tradition in health diplomacy, exemplified by its universal health coverage model and

proactive stance in international health forums, showcases its commitment to health

equity, public health and cooperation. China's Health Silk Road initiative, as part of the

BRI, underscores its strategic use of health diplomacy to enhance global health

infrastructure and foster international goodwill.

The COVID-19 pandemic further highlighted the importance of GHD. Brazil and China’s

collaboration in vaccine development and distribution illustrated how health diplomacy

could serve immediate public health needs while reinforcing diplomatic ties. China's mask

and vaccine diplomacies, despite criticisms, managed to position it as a key player in

global health leadership.

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The BRICS platform provides an essential context for these collaborations, promoting

collective action and mutual support among emerging economies. However, the BRICS

management of the Covid-19 pandemic revealed divisions and limitations in their

collective ability to formulate and act upon policies, with limited agency within the WHO

(Moore, 2022). This paper examines BRICS' global health diplomacy also during the

Covid-19 pandemic and finds that multiple dimensions of power are significant in global

health leadership.

Despite the successes, the relationship between Brazil and China in health diplomacy

faces challenges, including political shifts and economic constraints. The period under

Jair Bolsonaro's administration, marked by a nationalist stance and reduced international

cooperation, posed significant hurdles (Trivellato & Ventura, 2022). However, the

resilience of regional and local efforts, as well as the renewed focus under President Lula's

administration, highlights the potential for overcoming these challenges. A signal of this

is the establishment of the Sino-Brazilian Center for Research and Prevention of

Infectious Diseases which represents a significant milestone in China and Brazil’s

collaboration. This center symbolizes a shift towards sustained scientific cooperation,

aiming to develop global public health goods and improve epidemiological surveillance

capabilities. It is a testament to the potential of multilateral efforts in addressing global

health challenges effectively.

Moving forward, Brazil and China must continue to prioritize health diplomacy within their

foreign policy agendas. Strengthening their collaboration through multilateral platforms

like BRICS can enhance their soft power and contribute to global health governance. By

fostering innovative and equitable health partnerships, they can address transnational

health issues more effectively and promote global sustainable development.

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