International Health Development Assistance of BRICS Countries

With the rapid growth of economy and social development among BRICS countries, the role of international health development assistance in state capacity building is becoming more and more significant. This paper described the management system, scale, recipient countries, mechanisms and characteristics of international health assistance among BRICS countries. Aims: Learn about health development assistance of BRICS countries by analyzing its amount, distribution, main characteristics and management system in order to improve the international health development assistance related to BRICS countries. Methods: Data analysis of health development assistance of BRICS countries by using data from 2005 to 2010 of AidData and literature review were the main methods used in this paper. Results: a) from the total amount of international health assistance from 2005 to 2010, China’s total amount of international health assistance ranked first among BRICS countries (excluding 2008), and peaked in 2010, while India and South Africa was slightly higher than the amount of international health assistance in Brazil; b) China's international health development assistance was mainly distributed in 9 countries in Africa; India's was mainly distributed in 16 countries of South Asia and Africa; Brazil’s in around 45 countries depending on language and cultural factors; almost all South Africa’s aid flowed to African countries; c) Brazil’s international health development assistance mainly through technical assistance and its own experience; Russia prefer multilateral financial assistance and cooperation; India conducted technology-based health development assistance to neighboring African countries; China developed a variety of forms of international health assistance; South Africa's international health assistance was mainly carried out through tripartite partnerships; d) the BRICS countries trends to establish unified management agency. Conclusions: a) it is necessary to set up a unified international assistance management agency; b) each BRICS country should use its own comparative advantages and development experience to carry out international health assistance; c) international health assistance data should be more transparent and open.


Introduction
BRICS countries--Brazil, Russia, India, China and South Africa, represent around 25% of the world's gross national income, more than 40% of the world's population and about 40% of the global burden of disease. [1,2,3] Since the outbreak of global financial crisis in 2008, the world's political and economic structure has undergone profound adjustments and traditional donors deal with a financial crisis, and the overall national strength of BRICS countries has been rising.
As respect to health issues, in spite of BRICS' diversity, all countries were able to significantly increase their investments in health care. [4] With the economic growth, hundreds of millions of people of BRICS countries have been lifted out of poverty, which has resulted in marked improvements in health and in substantial progress towards achieving the Millennium Development Goals and Sustainable Goals. [5] Therefore, BRICS countries are developing a new focus on global health issues and playing an increasingly important role in the field of international health assistance. [6] BRICS countries implicitly supported the international health development assistance even though they seem to act more as individual countries rather that as an allied group, their individual involvement in international health development assistance may give greater voice to low-and middle-income countries supporting the emergence of multiple centres of powers in international health development assistance. [7] In addition, on the basis of comparative advantages, cooperation among BRICS countries has the potential to bring about global changes and make a positive contribution to the health of the population, not only in BRICS but also in the rest of the world. [8] The policies and practices of international health assistance have also received more and more attention. Systematic analysis and analysis of the practices and characteristics of BRICS international health assistance are important reference for countries to improve their international health assistance activities and related policies.

The Amount of International Health Assistance of BRICS Countries
BRICS countries are playing an increasingly important role in the global health field. They have become to the donor countries in international health development assistance [9], especially China, Brazil and India. Since the BRICS countries did not publish statistical data on annual health assistance, it is difficult to make quantitative statistical analysis on the amounts of international health assistance. At present, only the AidData could provide the global development community with more granular and comprehensive data on foreign assistance projects worldwide, which was founded when three organizations -William & Mary, Development Gateway, and Brigham Young University -grew frustrated with the informational status quo. The database covered international assistance data of BRICS countries other than Russia through data collection based on media reports. Based on this data, the paper made a brief analysis of the amount and flow of emerging countries' international health assistance.
From the total amount of international health assistance from 2005 to 2010, China's total amount of international health assistance ranked first among BRICS countries (excluding 2008), and peaked in 2010 with a number of US$550 million (excluding the cost of dispatching medical teams). That was mainly because after the China-Africa Forum held in 2006, the Chinese government followed the Beijing Declaration actively and increased the amount of health assistance to Africa. [10] The amount of international health assistance in India and South Africa was slightly higher than the amount of international health assistance in Brazil, as shown in Figure 1.

Distribution of International Health Assistance of BRICS Countries
International health assistance of BRICS countries has highly regional features [11,12]. From the perspective of the distribution of international health assistance in 2010, China's international health assistance (excluding Chinese Medical Teams) was mainly distributed in 9 countries in Africa, of which Ghana accounted for 72.08% of the total amount of China's international health assistance (excluding Chinese Medical Team), Congo accounted for 10.65%, Zambia 7.69%, Zimbabwe 6.70%, Mauritius 1.26%, Liberia 0.78%, Senegal 0.64%, Uganda 0.12% and Tanzania 0.01%. India's international health assistance was mainly distributed in 16 countries of South Asia and Africa, among which, 80% of international health assistance flowed to neighboring countries, mainly concentrated in Nepal (29.54%), Afghanistan (29.33%), Bhutan (12.75%) and Sri Lanka (11.22%). Brazil conducted international health assistance in more countries, around 45 countries, but due to language and cultural factors, it was mainly distributed in countries of the Americas, Africa and South Asia as well as Japan, and the amount of assistance to each recipient country was small. Brazil's international health assistance was mainly distributed in Portuguese-speaking countries such as Mozambique (22.28%), Principe (8.96%), Angola (6.66%), Cape Verde (1.11%) and East Timor (0.79%). Almost all South Africa's aid flowed to African countries.

Characteristics of International Health Assistance in BRICS Countries
Different countries have different characteristics of international health assistance. Brazil actively strengthened cooperation with health sectors of other developing countries, mainly through technical assistance and sharing of its own development experience. Russia would like to conduct multilateral financial assistance and cooperation [13,14]. India, with its geographical and linguistic cultural advantages, provided a large number of technology-based health development assistance to neighboring African countries, including telemedicine, remote diagnosis drug development and research, etc., mainly through bilateral aid channels [15,16,17] and sharing their experiences in development, et al. Since 1963, China has dispatched China Medical Team to African and other developing countries, and has gradually developed into a variety of forms of international health assistance, including Chinese Medical Team, aids of the construction of medical facilities, donation of medical equipment and medicines, human resources development cooperation, public health assistance, population and reproductive health, emergency humanitarian health assistance, and other forms of health assistance, such as the "Bright Journey" free cataract surgery. China is an important global health donor to Africa but contrasts with traditional DAC donors through China's assistance focus on health system inputs and on malaria. [18] South Africa's international health assistance was mainly carried out through tripartite partnerships. For example, South Africa and Cuba have cooperated in dispatching medical and engineering experts to other African countries such as Rwanda and Sierra Leone.

Management Agency of International Health Assistance Among BRICS Countries
Since the 1950s, the BRICS countries began to change from recipient countries to donor countries, being as recipient and donor countries. In order to improve efficiency, Brazil and South Africa have established the Brazilian Agency for Cooperation (ABC) and the South African Development Partnership Agency (SADPA) to manage various forms of international assistance, as shown in Table 1. International assistance from Russia, India and China lacked a unified administrative system and the international assistance was managed by a large number of administrative departments for a long time. In order to optimize the coordination mechanism of international assistance and improve the level of management, the Ministry of Foreign Affairs of Indian established the Development Partnership Administration (DPA) in 2012. Although DPA is not an independent assistance management agency, it meant that India was taking the first step towards a unified assistance management system [19]. China also established its own unified management system of international assistance in 2018, which ended the long history of co-participating international aid management system dominated by the Ministry of Commerce, the Ministry of Foreign Affairs and the Ministry of Finance of China as well as other ministries, local provinces and autonomous regions, and foreign administrative agencies (resident embassies, counseling offices of the Ministry of Commerce).

Conclusion and Suggestions
Affected by the international financial crisis since 2007, traditional aid countries have tightened their international aid budgets, while aid from the BRICS countries has shown an upward trend. The international community also welcomes and hopes that emerging powers will assume more international responsibilities, increase new sources of funding and new aid thinking to address global health issues. The aid model of the BRICS countries has enriched the original international aid structure and content, and also promoted the international community to reflect on the previous international assistance led by the OECD countries. The aid model of BRICS countries actively promotes the transformation from "aid effectiveness" to "development effectiveness", that is, pay more attention to the role of recipient countries' needs and the development of recipient countries.

Establish a Unified Management Agency for International Health Assistance is Necessary
The BRICS countries are facing with many development problems in the field of health care in their countries [20,21]. Although life expectancy has improved, non-communicable diseases [8] and health inequity also remained a prominent issue in all BRICS countries. [22] However, since the 1950s, the BRICS ccountries have begun to become donors of international health assistance from receipt countries. At present, Brazil and South Africa have established specialized aid agencies. China has established a special aid agency in 2018. India has initially established a prototype of a specialized aid agency. And Russia has established a leading agency to coordinate foreign international assistance, although the participation of many ministries has increased the difficulty of coordinating foreign international assistance. The establishment of a unified and specified international aid agency will help to coordinate the overall international assistance activities, avoid duplication and waste of resources in international health assistance, and maximize the most effective deployment and assistance of human, material and financial resources.

Use the BRICS Countries' Development Experience and Advantages to Carry out Health Assistance
The BRICS countries have gradually played an important role in regional and international health issues, have unique experiences and perspectives on addressing health issues in developing countries, and have regarded health as a priority. At the BRICS Health Ministers Meeting since 2011, the five countries indicated that they will jointly address the common challenges in the health area and broadly support and participate in international public health affairs through many forms including "South-South cooperation" and tripartite cooperation. Each BRICS countries has different characteristics in the form and regional distribution of international health assistance, therefore, it is suggested that, in the future, international health assistance activities, the emerging powers could make full use of their own advantages and features as well as strengthen the joint efforts to promote South-South cooperation and health development in developing countries.

Promote International Health Assistance Data to Be Transparent and Open
Currently, international health assistance data is mainly derived from the OECD Development Assistance Committee (DAC) database, which includes classifications in the health sector, covering data since 1960. Despite the start of 2011, Russia has begun to report aid data to the DAC. However, the DAC database does not have assistance data from BRICS countries as donor countries. [23,24] In recent years, AidData has used the data reported by the media to establish a database of international health assistance. However, the data is still incomplete, such as there is bias in estimation methods, there is no classification of health assistance like the DAC database, and there is no total amount of assistance per year (needs users to calculate). However, the database provides at least a reference basis for understanding the profiles of health assistance in different BRICS countries. Therefore, it is proposed that the transparence of international health assistance data is important to help to avoid overlapping waste of health care assistance and help decision-makers in recipient countries to make more effective and fair decisions on how to allocate these funds, and donor countries make cost-benefit assessments of their own aid, learn from other countries' aid experiences, improve aid activities, and play a better aid effect.