Chile’s role in global health diplomacy: a narrative literature review

The international/global is the dominant level of analysis in our article sample, being present in 21 of our sample total of 32 articles. Much of the writing on Chilean GHD focuses on the extent and quality of the Chilean state and non-state actors’ compliance with international health conventions, treaties, regulations, and standards that emanate from international organizations, mainly within the UN system [8‐11]. Indicative of the international/regional orientation of much Latin American GHD, however, some studies compare Chilean policies and practices based on international conventions with reference to more developed countries [12, 13] or other countries in the Latin-American region [14‐23].

The systemic driving forces of GHD invoked most frequently in the article sample is the pursuance of security at the global level, an instrumental framing in which health concerns are used strategically by nation-states to pursue security and other national goals within the international system, which some have called the securitization of health in foreign policy [24]. Several articles frame health as a national, as well as global, security issue, with specific reference in one study to Chile [25]. The authors of this study lay out the current debate between more restrictive and more inclusive definitions of security and suggest that while health issues are not included in narrower conceptualizations of national security, Chile has explicitly adopted a broad concept by including, among others, the following threats in its National Security Strategy: drug trafficking, natural disasters, and gun control [25]. In a similar vein, the United Nations, among other international organizations, has used definitions that include health risks, such as natural disasters and pandemics, in the concept of security. A frequently referenced aspect of global health security is Chile’s obligations under the WHO’s International Health Regulations (IHRs) (2005), and IHR requirements for changes at the Chilean national and regional level [8, 26].

A commonly described international driver of health issues in Chilean foreign policy are the mandates, regulations, and agreements originating from international organizations (IOs) to which Chile is either a formal signatory or an expressed adherent. Frequent reference in the literature is made to the Food Based Dietary Guidelines (FBDG) as a basis for ascertaining best practice options for Chile [13]; it is also worth noting that Chile’s 2017 legislation on front-of-pack food labelling for packaged foods high in fat, salt, sugar, and/or calories is considered a model for other Latin American countries to follow [27]. Another theme, invoking both global and regional analyses, is Chile’s response to WHO and PAHO strategies to ensure an adequate supply of human resources for health, proposing improved policy and practice in human resource management for the country [28]. While these cases indicate an active engagement in Chilean domestic policy in response to international guidelines, Chile was considered slow to take up the social model of health advanced by WHO health promotion declarations, only introducing a social determinants of health approach in 2007 [29]. The reasons for engaging actively with some, but not all, global policy innovations is likely political or due to constrained resources, but could weaken the standing of health in Chilean foreign policy over the longer term [2]. Chile’s docile adherence to some international agreements is consistent with its embrace of free trade agreements (FTAs), but regarded as inimical to health, also received critical commentary. This critique largely relates to intellectual property rights, i.e. the World Trade Organization’s Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement and subsequent free trade agreements with TRIPS+ provisions, and the resulting high costs of essential drugs, even as Chile refrained from taking full advantage of the flexibilization mechanisms regarding public health offered by the Doha Declaration on TRIPS and Public Health [30].

Regional cooperation has always played an important role in Latin American diplomacy, partly to counterbalance US historic dominance in the region. GHD activities are no exception to this general rule, with strong engagement by Chile on health diplomacy at the Union of South American Nations (UNASUR). With the creation of UNASUR in 2008, health policies became a strategic factor in Latin America to collectively balance the negative legacy of neoliberal policies in the region, with regional health diplomacy initiatives proliferating rapidly [31]. The Health Council of UNASUR is actively engaged in establishing health as a regional public good through the promotion of universal and equitable health systems across the region. It also aims to establish trans-border healthcare and access to the health services in each of the member countries for all inhabitants. This would represent an important achievement in a region with intense migration flows and where migrants often remain employed informally in host countries [31]; but it is also seen as an effort to build up an epidemiological shield.

Another central aspect of regional health diplomacy has been the coordination of emergency response in the aftermath of natural disasters. The UNASUR Health Council played an important role in coordinating the emergency response after the 2010 earthquake in Chile [31], while health worker migration has become a regional driver of GHD within Latin America. Most research on the phenomenon of ‘brain drain’ (i.e. the one-way flow of highly skilled/educated workers from one jurisdiction to another) has focused on movement from low- to high-income countries, with the significance of patterns of migration between middle-income countries such as those in Latin America being less clear. Although Chile itself is not experiencing significant international health worker migration (either inwards or outwards), studies on this phenomenon suggest distinctive patterns of migration within the Latin American region that deserve further research, with obvious implications for future regional health diplomacy [32].

A somewhat unique regional health diplomacy issue facing Chile is its shared borders with other countries having a high concentration of indigenous peoples. Convention 169 of the International Labour Organization (ILO) on indigenous peoples has significantly influenced new regional approaches, including Chilean efforts to construct a cross border political space for indigenous populations (primarily Aymaras) in Chile, Peru and Bolivia to reduce conflictual tensions between the three countries [23]. Pressure from both international and regional NGOs, in turn, has led Chile to initiate formation of a field of intercultural health aimed at incorporating indigenous healing practices into the public health system, while proposing pathways to the professionalization of indigenous health knowledge and practice for two indigenous groups in the Chilean territory [33].

Pursuing economic interests in the context of globalization, linked to the hegemonic neoliberal ideology and dominance of global markets, constitutes a major driving force for GHD in Latin America, and especially in Chile. A common theme in the literature references the ongoing tension between the international drivers of foreign macroeconomic interventions in Latin America [34], including Chile’s adoption of neoliberal reforms during the 1970s and 1980s, and the regional drivers of self-consciousness amongst Chilean civil society informed by the problems such reforms brought to the country [21]. A key negative example of such international influences on Chilean health was the entrance of multinational financial capital in the health insurance and healthcare markets since 1981 and the influence foreign investors exercised on the direction of subsequent health sector reform [21]. In the last decades, there were attempts to shift the responsibility of access to care from individuals to the collective, but the results have been mixed. In terms of shifting power, regulations on the private sector were mainly ineffective while implemented reforms at the beginning of the century (a submarket of prioritized services with low copayments and totally funded services) partially “steered the market toward collective responsibility” [35].

As a major exporter of agricultural and livestock products, Chile favours protecting the integration of economic and health interests in its foreign policy, with the latter generally subsumed under and subordinate to the former. At times this has led to Chile being at variance with compliance of international health and environmental standards and regulations, notably concerning use of pesticides in agricultural, particularly fruit, production. Although Chile ratified the Stockholm Convention on Persistent Organic Pollutants (POPs) in 2004, application of this Convention in agricultural production has been challenged by the pesticide sales industry (multinational corporations), Chilean producers, and the Senate House of the Chilean Parliament [36]. Chile, similarly, has vacillated in its adherence to best practices of international pharmacovigilance in relation to veterinary medication products [37]. On a more positive note, Chile enthusiastically joined a sub-regional initiative in animal and human health in the Southern Cone Sub Regional Project on Cystic Echinococcosis (tapeworm) Control and Surveillance, an instance of neighboring countries reaching out to each other to solve a common economic and health problem [19].

The literature reviewed also displays a strong focus on the high degree of social inequity prevailing in Chile and the wider Latin American region, which directly impacts on access to healthcare and quality of life. This is reflective of the emerging global discourse about the detrimental impacts of growing social inequalities, including health inequities. The social approach to health, detailed in the final report of the WHO Commission on Social Determinants of Health [38], after 10 years has yet to produce concrete actions in Chile to achieve greater equality [16]. Despite one of the Commissioners being a former president of Chile, there are important political barriers to advance this approach. For example, the Chilean constitution, written during the dictatorship in the 1980s, only ensures the right to choose the type of health system (mostly public or private) that can be accessed, and not the more commonly constitutionally established “right to health” found in many other Latin American countries. Reducing the heavy weight of social inequalities in Chile, and Latin America more generally, is portrayed as the great pending task to a fuller implementation of the social determinants of health approach promoted by the WHO [18]. While some authors aknowledge that socio-economic development aimed at overcoming social inequities is important to achieve sustainable health gains for the whole population, most of them propose a combination of traditional health promotion interventions and gradual integration of the social determinants of health approach [11, 16, 21, 29, 39]. The Chilean experience in eradicating child malnutrition in the decades of the 60s through the 80s, through targeted, vertical, interventions (e.g. food supplementation), with no major changes in the country’s development process, is cited as such an example of ‘selective’ rather than comprehensive health intervention [29].

Another domestic driver of GHD is the occurrence of so-called ‘natural disasters’ (noting that these often arise, in part, from ‘unnatural’ human actions that, in turn, shape how ‘disastrous’ the consequences might be). This driver is unique to the Chilean context due to recurrent earthquakes, tsunamis, volcanic eruptions, floods, and forest fires. Chile has had to develop a set of strategies and policies to respond in the fastest and most effective ways possible to mitigate the damage, although studies have pointed out several weaknesses in the coordination of the international cooperation process, as well as the ‘lack of regulatory criteria for international cooperation in a situation of catastrophe…’ [40]. Health may be the incidental externality in such disasters, but the international dimension of relief efforts obviously invokes a certain degree of diplomacy.

A further domestic driving force for GHD is Chile’s pursuit of influence and leadership in the region. In achieving foreign policy goals, diplomatic efforts surrounding health are often understood in terms of the exercise of ‘soft power’ [41]. While hard power rests on the use of threats and violence, soft power seeks to obtain policy outcomes through leadership and cultural attraction without use of threats or sanctions. One soft power initiative is the 2008 Regional Ministerial Conference for the Eradication of Child Malnutrition in Latin America and the Caribbean, hosted by the Chilean Government, under the auspices of the first Bachelet Administration (2006–2010). The conference report has a strong focus on SSC and triangular cooperation (involving multiple partnering countries) and best practice sharing among countries of the region [42]. A related domestic driver for GHD is Chile’s search for improved relations with its neighbours (Argentina, Peru and Bolivia), a relationship that has been historically strained by border disputes. Chile’s bilateral relations with neighbouring Argentina, for example, has been peaceful and mutually beneficial since the signing of the Vatican mediated Peace Treaty of 1984, with both countries enjoying a sustained period of cooperation and integration in economic and social areas of common interest, including through health collaborations [43].

A more theoretical and less descriptive analysis goes further and suggests that the evolution of international cooperation in the Southern Cone region that began in the mid-1970s was informed primarily by the national security doctrine and, subsequently, by moderate constructivist approaches [44]. The latter approaches began receiving more attention as a way to address regional challenges, and is reflected in the use of concepts such as security communities, relational autonomy, and human security [45] that facilitated cooperation and integration of economic and social initiatives [22]. Chile is also frequently described as an actual or potential technical reference point for other countries of the Region, using its prestigious position in its international relations engagement [9, 12, 42]. Examples include presenting Chileans as ‘experts on public health events of International relevance…’ [8]; portraying Chile as having ‘…more solid institutional credibility’ than some of its neighbours; and that Chile can best ‘manage triangular cooperation… with the aim of teaching public management learned from other OECD (Organisation for Economic Co-operation and Development) members…’ [23]. These examples suggest that GHD activities present an opportunity for Chile to exert regional influence though its use of soft power.

This review included only published documents on a limited set of databases, and thus omitted results from non-published (or non-indexed) works. Through the inclusion of only Spanish and English language documents we might have missed some results published in Portuguese, a language that produces good quality evidence from Brazil. As is common when conducting a narrative literature review, we did not assess the quality of the articles included in the review. Consequently, any conclusion is “open to bias from the potential to omit, perhaps inadvertently, significant sections of the literature or by not questioning the validity of statements made” [5]. We also did not account specifically for the different types of articles reviewed (except by the kind of publication). However, this opening up of the inclusion process made it possible to present a broader perspective on the emerging policy issue surrounding Chilean GHD [60].