1 Introduction

This chapter identifies the overall trends of Japan’s official development assistance (ODA) policies for the health sector in developing countries from 1990 to 2020 and their prospects, given the COVID-19 pandemic.

The history of Japan’s ODA is directly related to the post-Second World War era when Great Britain was engaged in continued efforts to maintain its influence in the former colonies of the Asia–Pacific region, including Australia, Canada, Ceylon (presently Sri Lanka), India, New Zealand, and Pakistan. In January 1950, a Commonwealth Conference on Foreign Affairs was held in Colombo, Ceylon,1 during which the Colombo Plan for Cooperative Economic and Social Development in Asia and the Pacific was conceived. The Colombo Plan, which evolved from the original group of seven Commonwealth nations into an intergovernmental organization composed of 27 members, including non-Commonwealth countries, was officially launched in July 1951 (The Colombo Plan 2021).

Japan was affiliated with the Colombo Plan in October 1954, launching, at the time, its first international technical cooperation projects. Similar to other countries’ initiatives to institutionalize their foreign aid activities, in March 1961, Japan established the Overseas Economic Cooperation Fund (OECF) as the implementing agency for loan aid, which assumed management over the Southeast Asia Development Cooperation Fund from the Export–Import Bank of Japan (JEXIM). In June 1962, Japan launched the Overseas Technical Cooperation Agency (OTCA) to administer Japan’s technical assistance. In August 1974, the Japan International Cooperation Agency (JICA) was founded to replace the OTCA. In the meantime, several other organizations were established, such as the Japan Emigration Service (JEMIS) and Japan Overseas Cooperation Volunteers (JOCV), which expanded and strengthened Japan’s Official Development Aid (ODA) institutional framework. In October 1999, the Japan Bank for International Cooperation (JBIC) was established by merging JEXIM and OECF. Finally, in October 2008, the “new JICA” was established, merging the former JICA—specialized in technical cooperation—and the JBIC. Today, JICA is responsible for Japan’s technical and financial aid (JICA 2021a).

It is worth noting that, since April 1964, Japan has been a fully-fledged member of the Organization for Economic Development and Cooperation (OECD). The organization was founded in December 1960 during the first half of the Cold War under the leadership of the United States and less than two years after the Cuban Revolution with the explicit purpose of focusing on the twofold objective of achieving sustainable economic growth that could contribute to the development of the world economy and contributing to the expansion of world trade on a multilateral basis (OECD 1960). The OECD plays a major role in guiding and overseeing members’ ODA figures and policies through the Development Assistance Committee (DAC), currently supported by the Development Co-operation Directorate (DCD).

Japan’s ODA scheme can be divided into bilateral and multilateral aid, which is provided through international organizations. JICA, the ODA implementing agency, oversees the former, which includes bilateral technical cooperation, grant aid, and loans. Multilateral aid in the health sector involves contributions to the WHO through government agencies such as the Ministry of Health, Labor, and Welfare, the Ministry of Foreign Affairs, the Ministry of Agriculture, Forestry, and Fisheries, and the Cabinet Office.

Nowadays, JICA’s motto is “leading the world with trust,” meaning that the agency “values the relationship of mutual trust with developing countries and is working with them to rise to the challenges” (JICA 2021b). JICA’s mission is aimed at two basic international development goals: human security, which means “aiming for a society where all people can protect themselves from various threats and live their daily lives in security and with dignity,” and quality growth, which seeks to promote “sustainable growth with less disparity and without harming the environment” (JICA 2021b). The agency’s work worldwide is organized into four main themes or topics: people, peace, prosperity, and planet (commonly referred to as the 4Ps). Under each topic, the agency targets development sectors or areas (see Table 3.1 for a full list). It is important to clarify that the motto and main international cooperation topics and sectors, like any other international aid agency, reveal the agency’s prime concerns and agendas and that they vary or change over time, as we shall see in this chapter, due to several domestic and external factors. Generally speaking, JICA’s main international development themes and sectors/areas are as follows.

Table 3.1 JICA’s main international development themes and sectors/areas
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Since the end of the Cold War, watershed events have constantly changed the landscape of international cooperation and foreign aid in the health sector. Similar to other international aid donors, Japan has devised priorities and strategies for its health projects based on a set of internal and external factors in a perpetually changing world. This chapter explores and analyzes the process to identify overall trends from a perspective that combines conceptual and theoretical notes and debates on international cooperation and foreign aid for health.

The guiding research questions are as follows: What were the major trends in Japan’s ODA policies in the health sector from 1990 to 2020? Which international health debates and international cooperation factors have exerted influence on these trends? What are the prospects for the future of Japan’s ODA, given the COVID-19 pandemic and its impacts?

This study relied on primary and secondary sources. In terms of primary sources, we obtained the Japanese versions of the annual reports on the implementation of Japan’s ODA Annual Reports (1997–1999), Japan’s ODA White Papers (2001–2014), and the White Papers on Development Cooperation (2015–2020), which are available on the Internet as of November 2021.2 Based on these documents, we compiled the relevant information and the overall structure of each report, organized it by chronological order, and then comprehensively tabulated the descriptions of the health sector in each piece. From this, we created a matrix that facilitated the identification and analysis of the overall structure and dynamics of the country’s ODA policies in the health sector over the years. Another primary source that we used to explore Japan’s ODA commitments and disbursements for the health sector from 1990 to 2020 was the online database provided by the OECD’s Development Assistance Committee (DAC). In addition, secondary sources—academic literature on international cooperation and foreign aid for health—helped devised a preliminary and tentative analytical framework.

This chapter is organized into two sections. Section 3.2 briefly introduces historical, conceptual, and theoretical notes and debates on international cooperation and foreign aid, specifically concerning international cooperation and foreign aid to promote health. Section 3.3 explores and analyzes Japan’s ODA in the health sector from 1990 to 2020. Finally, we present final considerations of overall trends and prospects, with a special emphasis on the potential impacts of the COVID-19 pandemic on international cooperation and Japan’s ODA.

2 Toward an Initial and Provisional Analytical Framework of International Cooperation and Foreign Aid for Health

This first section explores current conceptual and theoretical notes and debates on international cooperation and foreign aid for health to devise an initial and provisional analytical framework that can help identify Japan’s overall ODA trends for the health sector and reflect on its prospects. In an attempt to contribute to the joint effort of brainstorming effective partnerships for the future to create a framework of Brazil–Japan cooperation, we purposefully explored specialized Brazilian and Latin American literature on international cooperation aimed at promoting health that raises the current issues of contention and debate.

2.1 Conceptual and Theoretical Notes and Debates on International Cooperation and Foreign Aid

The practice of international cooperation dates back to Thucydides’ classic book “The history of the Peloponnesian War,” which was written more than 2,000 years ago. However, in the academic field of international relations, the expansion of the theory of international cooperation is relatively recent. International relations was first established as an academic field around the 1920s in Europe. Until the mid-to-late-1980s, the initial theory of international cooperation relied primarily on the hegemonic stability theory (HST) hypothesis to explain the occurrence of international cooperation among nations in an anarchic international system. One advocate of this line of thinking stated that “for the world economy to be stabilized, there has to be a stabilizer, one stabilizer” (Kindleberger 1973, p. 305). The prevalence of HST as an undisputable international cooperation hypothesis for more than 60 years can be partly attributed to the lack of academic interest and effort toward theorizing the phenomenon under the unfavorable historical context of crises, wars, and conflicts that marked the twentieth century. Indeed, this context helped maintain HST, which remained uncontested during that period (Pires de Campos et al. 2010).

However, inspired by the development of neorealists’ structural analyses of the international system during the 1970s, from the mid-to-late-1980s, a new generation of international cooperation theorists began to flourish (Keohane 1984; Grieco 1990; Haas 1990; among several others). By incorporating a systemic analytical framework for international cooperation among nations, combined with game theory, a new set of hypotheses beyond HST emerged that explained the phenomenon of reciprocity and reputation among states, different international strategic settings, relative gains among states, number of actors, domestic politics, and international institutions (Milner 1992; Dai et al. 2010).

Regardless of the progress made by the new generation of theorists, HST has retained its explanatory power for international cooperation. In essence, the theory explains the occurrence of international cooperation among sovereign states in an anarchic international system as the result of the action of a hegemony whose outstanding military, political, and economic power under a respective zone of influence guarantees intergovernmental cooperative arrangements in various areas and issues of the hegemon’s interest (Pires de Campos et al. 2010, p. 9). The reemergence of such analytical considerations makes it evident that since recent theoretical efforts indicate that the occurrence of international cooperation among nations in the international system can be directly influenced by several factors other than hegemony, hegemony continues to hold a critical, although not exclusive, explanatory capacity.

Within this context, the practice of international cooperation—defined among academia since the mid-1980s as “mutual adjustment of state policies to one another” (Keohane 1984, p. 31)—can be explained either by the unilateral imposition of policies by hegemonies or by more democratic and multilateral processes supported by other influential, but not hegemonic, states in the international system.

Recently, a number of analysts worldwide have returned to hegemony to explain the current failures in international cooperation to face global issues and challenges. The devastating impacts of the COVID-19 pandemic worldwide at the beginning of the second decade of the twenty-first century, coupled with the nations’ considerable difficulties promoting effective international cooperation to tackle the crisis equitably have led analysts to become more interested and critical of the history of the establishment of the Liberal International Order (LIO) after the Second World War and the history and evolution of Western international institutions in that order (see, for example, Lake et al. 2021; Almeida and Pires de Campos 2020).

In fact, Lake et al. (2021, p. 234) argued that “the LIO has been challenged from the very beginning, from forces both within and without, and by feedback between internal and external dynamics.” According to the authors, four lessons can be drawn immediately: (i) “orders are clubs that include as well as exclude”; (ii) “international orders are not neutral but embody a set of material, ideational, and normative interests congealed into institutions and practices”; (iii) “institutions are social constructs that rest on social foundations”; and (iv) “domestic politics matter for the LIO” (pp. 246–250).

In a multidisciplinary analysis focused on current issues and future challenges for the WHO regarding multilateralism, world order, and COVID-19, Almeida and Pires de Campos (2020, p. 32) recognized the intensification of disturbing and disruptive events in times of hegemonic transition or inflection. As a sociopolitical space of continuous negotiations, confrontations, and clashes, the WHO is affected in different ways and at different levels during these times by several forces. These include a proliferation of new actors and financing mechanisms, neoliberalism, the erosion of public services provided by states, the ascendancy of the health security agenda and its exclusive emphasis on specific geopolitical “health threats,” among others. These findings indicate that:

[…] the [present-day] fragility of WHO originates from a twofold dynamic: by assuming and incorporating the precepts of the new neoliberal world order, in order to guarantee its survival, [WHO] gradually distances itself from more holistic approaches to collective health, with a public good focus, compromising its performance in the face of contemporary health challenges, internalizing the problems arising from this option and becoming hostage to powerful actors focused on their own interests. (pp. 35–36) (translated by the authors)

Inspired by Ruggie’s (1992) argument that the definition of multilateralism by a number of actors hides the fact that multilateral arrangements can be, in practice, controlled by one or a few members and by Ikenberry’s (2001) argument that institutions freeze the stratification of power resulting from systemic disputes, thus establishing an ordering of norms and decision-making structures favorable to great powers, Lima and Albuquerque (2021) recognized that the COVID-19 pandemic brought to light a critical issue in multilateralism and highlighted the need to deepen the mechanisms of collective action (Lima and Albuquerque 2021, pp. 8–11).

The authors analyze the United Nations (UN) as a universal, governmental, and, above all, political organization that has struggled to ensure a truly inclusive and diverse multilateral system since its creation. Despite some advances achieved by developing countries within the UN General Assembly over the years, the dominance of US interests in the organization before, during, and after the Cold War is paramount. This situation contributed to the current crisis of multilateralism, especially within the context of emerging hegemonic tensions between the two great powers at present: the United States and China. Against this backdrop, Lima and Albuquerque (2021, p. 17) pointed out that:

The diagnosis of a crisis that characterizes the current period is complex since it includes changes of a systemic and structural nature, deficiencies in the functioning of the UN, and a crisis of legitimacy, to cite the most obvious reasons. In this context, the COVID-19 pandemic can be understood as a critical juncture that maximized the effects of pre-existing problems [...]. The paradox is that when collective multilateral regulation is most needed to deal with public evil, institutions such as the UN and WHO are weaker than in the past. (translated by the authors)

International cooperation for development, also known generally as foreign aid, and more strictly as ODA, is defined as necessary “to promote economic development through a transfer of resources and knowledge from industrialized to developing countries” (Feinberg 1993, p. 309). Thus, it bears a close relation to international cooperation among nations, as defined above. In 1984, Robert O. Keohane, an influential theorist of international cooperation among nations, showed that foreign aid is commonly nested within international arrangements derived from international cooperation among nations. According to Keohane (1984), the international trade regime

[…] is nested within a set of other arrangements, including those for monetary relations, energy, foreign investment, aid to developing countries, and other issues, which together constitute a complex and interlinked pattern of relations among the advanced market-economy countries. These, in turn, are related to military-security relations among the major states. (pp. 90–91)

Thus, in defiance of the apparently neutral or positive meaning commonly associated with the term “international cooperation among nations” and foreign aid, it is imperative to consider the phenomenon in historical, cultural, social, economic, and political contexts as complex expressions of domestic and global idiosyncrasies, forces, and movements revolving around several factors, among which hegemony seems to be the gravitational center.

Lastly, a closer look at the theoretical developments in the last 40 years helps us identify the prevalence of international and domestic factors as prevailing hypotheses in international cooperation theory to the detriment of hypotheses based on individual factors. Recently, the individual dimension of international cooperation has become an emerging issue in Japan’s ODA. Sato (2021) indicated that, although changes in the Japanese government’s international cooperation philosophy over time had led to consideration of the individual dimension in foreign aid, the issue suffered from a lack of concern regarding the “Development Cooperation Charter,” approved by the cabinet of ministers, in which the Japanese Ministry of Foreign Affairs still defines “development cooperation as “international cooperation activities that the government and its affiliated agencies conduct for the main purpose of development in developing regions.” According to the author, with regard to policy discussion, “the people” are absent or hidden behind Japan’s philosophy of development cooperation. Even though former JICA president Ms. Sadako Ogata tried to adopt “human security” in the implementation of international cooperation for development, it remains difficult to determine whether ODA was carried out with an awareness of individuals (Sato 2021, p. 190).

Therefore, the current international context demands a closer examination of the interconnections between international cooperation and foreign aid, with special attention given to the role of hegemony and international cooperation. Inspired by Almeida and Pires de Campos (2020, p. 16), who consider the WHO “not as a mere formal and static organization, composed by member-states organized around a set of norms, rules and decision procedures, but rather as a socio-political arena where negotiations and confrontations take place, reflecting the broader dynamics of multilateralism and the world order,” we assume JICA to be more than a formal and static governmental organization but rather a sort of socio-political arena in which academicians and professionals, interest groups, organizations, and institutions’ views are confronted, negotiated, and advanced in constant, dynamic, and complex ways reflecting domestic, foreign, international, and global policies, and, more widely, the world order itself.

This first section clarified some interconnections between international cooperation and foreign aid. In addition, the chapter introduced a wide range of contending theoretical hypotheses that explain the phenomenon of international cooperation and the recent return of hegemony. This leads us to consider Japan’s ODA as predominantly, although not exclusively, aligned with a hegemonic Western effort to maintain its influence and agendas in Asia. In this sense, Japan’s ODA for health does not necessarily reflect developing countries’ needs and demands but rather the prevailing interests and agendas that are more broadly expressed in international and multilateral health cooperation initiatives. The following subsection explores some notes and debates on foreign aid and international cooperation for health.

2.2 Conceptual and Theoretical Notes and Debates on Foreign Aid and International Cooperation for Health

The ongoing debate on international health has led to the emergence of policies that eventually became diffused across countries through international cooperation by “mutual” adjustments3 or associated foreign aid. Almeida (1996, 2017) aptly summarized the historical process and the importance of hegemony in its progression. Health had become a central international cooperation issue, especially from the mid-to the end of the nineteenth century, when countries first established common protocols to fight diseases that were affecting international trade, in particular cholera, plague, and yellow fever. The creation of the Pan American Health Organization (PAHO), an important reference for health cooperation on the American continent, dates back to 1902. Later in the twentieth century between the two world wars, health aid prioritized scientific and technological advances as a result of a clear and direct influence of the United States, an emerging hegemony.

During the 1960s and the 1970s, the decolonization of former African and Asian colonies, international health cooperation focused on community care, prioritization of public health, and health systems based on primary health care (PHC) were inspired by the influence of the post-great war welfare state. From the mid-1970s to the 1980s, a combination of economic, political, and social factors, including national and international debt and financial crises, unequal economic globalization, implementation of structural adjustment programs (SAPs) by UN financial institutions, aggravation of world poverty, the worldwide spread of HIV/AIDS, civil and political turmoil in the fight for democracy in Latin American countries, and independence movements in African and Asian former colonies led to strong criticism of the key foundations of health service systems, primarily medical assistance, and, eventually, to underfinancing and weakening of health service systems and the introduction of a post-welfare agenda for health through health system reforms. The relationship between health and human rights and health and the public good was strongly questioned and challenged and health conditions and indicators worldwide deteriorated rapidly.

During the 1980s and the 1990s, the negative impacts of neoliberal policies on social equity led to the definition of social development as a renewed foreign aid priority. Under this context, social development received greater attention in foreign aid expenditure worldwide (Pires de Campos 1998). Simultaneously, health aid moved away from strengthening healthcare systems.

From the 2000s until the emergence of the COVID-19 pandemic, so-called “public–private partnerships” increased exponentially, questioning the sufficiency of the state as the sole actor, and were interpreted as “a concerted response to address the worrisome increase in the burden of disease in the world.” According to Almeida (2017, pp. 63–67):

This oscillation became the rule over time, and the bilateral or multilateral allocation of foreign aid or international cooperation resources to countries and regions around the world took place in complex political and economic processes permeated by strategic, national, and international considerations. Further, the conditionalities and priorities, always present, have changed over the decades, according to the different conjunctures and tastes of the dominant powers.

The unexpected terrorist attacks on the United States in 2001 eventually led to a new shift in the paradigms of international cooperation and foreign aid for health, increasing concerns about national and global health risks and health security. Almeida (2013, pp. 240–241) asserted that at the turn of the century, the world experienced an unprecedented intense proliferation and dissemination of several health-related risks, such as the emergence and re-emergence of infectious diseases, the emergence of drug-resistant pathogens, the spread of non-communicable chronic diseases, a generalization of the effects of pollution and environmental changes, and an increase in violence. Combined with geopolitical interests, the author argues that these events have led to the emergence of the health paradigm as a national security issue. Despite the relevance of several actors, the United States played a leading role in this shift, motivated by the country’s responses to the 2001 terrorist attacks to influence other countries and international organizations.

Inspired by Franklin D. Roosevelt’s four freedoms that guided the creation of the UN, human security has been broadly defined as “freedom from want and freedom from fear.” The terms “human security” and “health security” gradually became the prevailing paradigms and were included in international reports, declarations, and agreements. The 2003 report entitled “Human Security Now: Protecting and Empowering People,” for example, was written by the Independent Commission on Human Security established at the 2000 UN Millennium Summit, held in New York and was a Japanese governmental initiative4 supported by the Swedish government, World Bank, the Rockefeller Foundation, and the Japan Center for International Exchange. Similarly, the Global Health Security Initiative was established in 2004 a high-level group of experts from the European Union, France, Germany, Italy, Japan, the United Kingdom, the United States, and the WHO joined forces to define activities that could strengthen the capacity of surveillance and promote a rapid response to pandemics. Along with several other initiatives, these movements led to what specialists in global health consider to be the establishment of robust links between health, foreign policy, globalization, security, and development (Almeida 2013, pp. 242–245).

However, the link between health, foreign policy and security, as a promoter of development, is problematic for several reasons, among which the following stand out: a) the close link between health and very specific and linked political-ideological, economic, and security agendas to certain interests and values and b) the fact of being at the service of the strategy of hegemony and domination of great powers. On the other hand, there is no clear evidence to support the arguments that defend this association and some studies show fragile correlations between health, economic development, and national security variables, which are devoid, however, of the respective historical, social, and geographical contexts (Ingram, 2005: 537). In addition, many of the justifications used to declare that certain diseases are a threat to national security — the prevalence of HIV/AIDS in the African military, as a sign of destabilization of the new States, and the spread of the disease around the world from the US military in missions (or wars) in Africa, among others — were also not accurate (Feldbaum et al., 2010). (Almeida 2013, p. 245)

The devastating impacts of the COVID-19 pandemic worldwide have created an opportunity to reflect on what kinds of international cooperation for health have been promoted in the world since the establishment of the international liberal order in the second half of the twentieth century. In fact, international cooperation for health has been the topic of intense academic discussion for the last three decades, which the COVID-19 pandemic has reinforced and deepened.

As previously indicated, the COVID-19 pandemic put to the test more than just international cooperation capacity. Indeed, scholars have stressed that it has revealed numerous weaknesses and contradictions that undermine the very foundations of the international (liberal) order. Within this context, Almeida et al. (2013) emphasized the adequacy of adopting a view of health that incorporates the (geo)political dimension of power relations in the contemporary world system, an arena with extensive inequalities and structural violence demanding collective struggles in which there is no place for naivety:

What these authors describe is a way to address health problems that extends worldwide, across borders and bodies, by going beyond the biological and medical focus to address health concerns also as political issues and political options (Fassin, 2010; Lézé & Fassin, 2013). This means considering Global Health with an “attitude.” It also consists of looking at, questioning, and acting with (and sometimes against) some of the unprecedented constellations of international and transnational actors involved in the political field of health. This is so permeated by inequalities and structural violence (Fassin, 1996; Farmer, 2001) that it now demands a collective struggle in both scientific research and political action on health. Accordingly, this struggle is no place for naivety; rather one should be mindful that it is also a locus of power relations and for building political force in order to achieve changes in health priorities. (Almeida et al. 2013, p. 2)

Almeida (2020, p. 22) endorsed a critical understanding of international cooperation in health, especially when one considers that “the definition of global health is variable, both descriptively and prescriptively, and in both cases, its uses are embedded in ‘particular normative frameworks’ that depend on whomever is formulating the problem and its solution […]” for it “constitutes a scientific and political field disputed by different actors, disciplines, and paradigms” (Almeida et al. 2013, p. 1). In short, “[…] health interventions are not neutral, nor based [always] on scientific evidence […]” (Almeida 2017, p. 52). Therefore, in general terms, there appear to be two main approaches to international cooperation for health: “health treated as a disease, in the strict sense and centered on a certain few epidemic or endemic diseases, and the need to control health problems globally, which not uncommonly is bound up with geopolitical objectives” (Almeida et al. 2013, p. 2).

Almeida (2017, p. 55) approaches international cooperation for development from the assumption that

[…] foreign aid and international cooperation for development are historically marked by the social, political, and economic relations and practices of each particular society and by the position that society occupies in the world system. However, the political-ideological projects that guide this aid or cooperation assume particular meanings in specific historical conjunctures permeated by permanent tensions and disputes.

A reflection of this assumption is the continuously changing relevance of health throughout history (Almeida 2017, pp. 44–45). Until Second World War, the US bilateral aid to the world articulated military and research interests in public health and medicine. Immediately after Second World War, the establishment of the UN system under US leadership expanded the country’s aid agenda to world reconstruction and development. A few years later, during the Cold War, health aid was marginalized by security concerns and became a mere instrument for pursuing national interests. After the fall of the Berlin Wall, health aid gradually returned to the forefront of the international development agenda. The end of bipolarity pushed health onto the agendas of the UN Security Council and the G8 as a key issue in the debate on globalization and health security. Regarding the latter point, Almeida (2017, p. 46) argued that “In reality, it is disease, not health that becomes a geopolitical issue.” It is important to note that these variations all favored the prevailing hegemony.

In contrast, Garay et al. (2013, p. 8), in reference to the etymology of the term “global,” articulated three basic principles that should guide true global health: (i) “health for all” (for all people worldwide), (ii) “health by all” (by a representative range of stakeholders and actors), and (iii) “health in all” (multi-sectorial efforts to increase health, with special attention to social determinants of health). These three basic principles rest on several international legal frameworks: the WHO’s constitutional objective refers to “the attainment by all peoples of the highest possible level of health” (i.e., health for all). The 1978 Declaration of Alma-Ata highlights the central role of community participation in improved health (i.e., health by all), as does the Ottawa Charter for health promotion, which recognizes that “the health of individuals and populations is dependent on a host of environmental, economic, social and political factors” (health in all).5

Notwithstanding their relevance, “these principles are not consistently included in discussions about global health, let alone fulfilled” (Garay et al. 2013, p. 8). Health for all has been negatively affected by global inequity and the overall de-funding of the WHO by nation states in the last few decades, which led the organization to focus on private actors’ agendas and priorities. Meanwhile, health by all has been affected by the lack of democratic national and global governance frameworks, which are commonly influenced by market and communication factors and private actors. Last but not least, health in all has been negatively impacted by the lack of assessments on “health actions and relations with other international and trans-territorial policies, agreements, and dynamics.” For example, limitations on access to medicine through trade or migration agreements may hinder health aid activities.

Regarding the ontological dimensions of the term global health, Garay et al. (2013, p. 6) highlighted three types of actors: private and public–private initiatives, international organizations, and national and regional organizations. As for private and public–private initiatives, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the Global Alliance on Vaccines and Immunization, and the Global Strategy on Women and Children’s Health, there has been a focus on “only some health problems, some interventions, or some population groups,” which clearly falls short from the “health for all” principle or dimension. As for international organizations, the term global health “remains undefined, and simply related to some of the factors influencing/improving it.” Finally, for national and regional organizations, it has been verified that the European Union (EU), Japan, the United Kingdom, the United States, and Switzerland “have developed policies on global health” and that “they [do] discuss the globalized and multi-sectorial influence on health and are aimed at improving both the health of their citizens and of those in the wider world.”

As a result, it is argued that “the traditional international health paradigm of a rich country helping a poor country does not adequately address the complex determinants of health in the world today” (Garay et al. 2013, p. 8). Given increasing national health inequities, some propose that foreign aid should concentrate on decreasing disparities by adopting a “wider-than-health approach that targets social determinants [of health]”.6

While the global health agenda aims at a “health-in-all” approach, the democratic governance (“by all”) of this agenda in action is challenged by the current aid architecture and the bias of economic influences. Likewise, the combination of national interest-based foreign policy links to development aid and the agendas of the progressively more influential philanthropic groups result in biased support for some specific diseases or countries, undermining the “for all” principle. (Garay et al. 2013, p. 6)

Garay et al.’s (2013) analysis concerning national and regional organizations working toward global health, summarized in Table 3.2 (white boxes mean the absence of any explicit discussion on the issue), shows that Japan’s global health policy focused on mother and child health and primarily worked toward the “health for all” principle. Due to the country’s support during global public health emergencies, Japan has contributed to the “health in all” dimension of global health.

Table 3.2 Key features of national and regional policies on global health
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In conclusion, Garay et al. (2013) insisted on the need for a collective approach to global health, without which current efforts will continue to impose a great burden on a large part of the world’s population.

While each global actor on its own cannot – and should not – aspire to ameliorate all three global dimensions of health, collective action under strong leadership and governance should progress towards them. […] At present, […] collective action is not clearly progressing on the three global health principles. (Garay et al. 2013, p. 8)

Yuasa et al. (2013) conducted a study on the contributions of JICA health-related projects aimed at strengthening the global health system. They justified their research by indicating that JICA projects “have seldom been evaluated systematically from a health systems perspective” (p. 2). By analyzing more than 105 projects implemented between January 2005 and December 2009, the authors revealed that JICA “has focused its attention on appraising health development assistance projects and redirecting efforts towards strengthening health systems.” Their conclusion is that, aimed at strengthening health systems, “the majority of JICA projects had prioritized workforce development and improvements in governance and service delivery.” In addition, the authors highlighted that “nevertheless, our findings suggest that JICA assistance could be used to support financial aspects of health systems, which is an area of increasing concern.”

According to Labonté (2008), there are five ways in which “governments and multilateral institutions are responding to the increasing asymmetries and health risks posed by globalization” to frame global health to determine which arguments are most likely to promote health for the greatest number: (i) health as security, (ii) health as development, (iii) health as a global public good, (iv) health as a commodity, and (v) health as a human right.

Labonté (2008) explained that despite being the dominant discourse, health as security is the most reductionist approach, directing attention to specific diseases considered threats to national security or simply inconvenient to global trade, finance, and tourism. Besides being reductionist, this discourse opens ways to violate basic human rights and “can slip slowly towards fascism” (p. 469). Nevertheless, human security, as an alternative discourse that expresses concerns with a person’s physical safety, economic, and social well-being, as well as respect for people’s dignity and worth as human beings, is more in line with the “idealized principles of health promotion” (p. 469).

Health as development, in turn, is the second most prominent discourse in global health debates. Under this paradigm, health becomes a “desired outcome of development” (p. 469) and, as such, is commonly associated with foreign aid flows and market performance rather than solidarity-building mechanisms of global redistributive obligations and human potential.

Health as a global public good, emerges as a response to the limitations found in the health for development discourse. Despite having a rather vague and weak definition of the public good in terms of policy advocacy and a utilitarian approach to international cooperation assuming shared interests as a key rationale for collective action, as in the health security discourse, it undoubtedly places collective benefits above individual gains.

Health as a commodity, as the expression itself suggests, reduces health to goods or services whose main raison d’être is to maximize profit. Irrespective of its relevance in terms of revealing direct relations between health and trade such as TRIPS (Agreement on Trade-Related Intellectual Property Rights) and GATS (General Agreement on Trade in Services), “health can be commodified, but it is not a commodity” (p. 475).

Finally, health as a human right is a strong discourse that directly clashes with health as a commodity, generating several international obligations derived from international declarations, covenants (treaties), and plans of action. Notwithstanding their broad range, such initiatives lack enforcement power and depend on strong, popular mobilizations derived from social awareness efforts. Recent developments, however, indicate that “efforts to advance human rights as the normative guiding frame for twenty-first century global governance are growing […], representing the most widely shared language of opposition to the devaluation of health that results from the globalization-driven spread of markets” (p. 477).

Farmer et al. (2013, p. 10) however, defend collective and holistic approaches to global health toward social changes:

Global health delivery begins with the question “how can a health system efficiently provide health services to all who need them?” More efficient and equitable delivery of existing health interventions could save tens of millions of lives each year. But even the best models of global health delivery cannot alone raise the standard of health care available to people worldwide. The health of individuals and populations is influenced by complex social and structural forces; addressing the roots of ill health — including poverty, inequality, and environmental degradation — requires a broad-based agenda of social change.

Within this context, Almeida et al. (2013, p. 2) noticed that the debate over global health has undervalued wider approaches to health:

Currently, the international debate over global health undervalues the perspective centered on the variables that determine improvements in the health of populations, groups, and individuals, considering the political, economic, social and cultural dimensions in which societies are embedded. This outlook calls for multidisciplinary thinking and action by the health actors who provide the input for scientific endeavors and determine the quality of the knowledge needed for innovation and technological development in health care worldwide.

It is necessary to point out that since the 1990s, within the context of voracious neoliberalism, one of the main international debates around international cooperation and foreign aid for health, particularly for low- and middle-income countries, has revolved around health system reform. The debate has also centered on the topics covered so far in this chapter: geopolitical, hegemonic, neoliberal, social, and cultural issues, thus requiring further critical thinking to analyze its recent impacts on international cooperation and foreign aid for health worldwide.

One should bear in mind that the “right to health” is a widely recognized right in international treaties, conventions, and agreements around the world. This right has been widely recognized in several declarations and resolutions adopted by international organizations since the end of the Second World War. The adoption of the Universal Declaration of Human Rights in 1948 recognized the “right to health” as one of a set of basic human rights. Later in the same year, the Constitution of the WHO also recognized health as a fundamental right of every human being, irrespective of race, religion, political belief, and economic or social condition. In 1966, the UN General Assembly adopted and opened for signature the International Covenant on Economic, Social, and Cultural Rights, which mentions the right to health (Article 12). In 2005, United Nations Educational, Scientific, and Cultural Organization (UNESCO) mentioned the same right in its Universal Declaration on Bioethics and Human Rights. These legal foundations impose obligations on sovereign states7 but are not entirely effective. As Kingston et al. (2010, p. 1) stated, “The scope and meaning of this right have been the subject of debate within the international community, however, the means for achieving it remain similarly contested.”

Although there are innumerable national and international groups worldwide promoting the right to health, each one specific and unique, international cooperation and foreign aid practices in the last 70 years or so have demonstrated the power a nation can exert in the international system by having some of its own experiences labeled as “best practices” or the like. Brazil and Japan have already enjoyed this status at different times in the last 30–40 years in different development policy areas. For decades, Japan has been recognized as a “high technology” country, and that status strengthened and expanded not only Japan’s foreign aid but also foreign trade, foreign investments, etc. (see, for example, Orr 1990). Brazil likewise enjoyed the status of a “social technology” country in the first 15 years of the twenty-first century (see, for example, IPEA 2014, 2017). During that time, Brazilian “best practice” experiences were diffused worldwide, opening avenues for the foreign trade, foreign investments, etc. with the country.

Health systems are a major issue for international cooperation in general. Contending models of health systems were developed and promoted in the initial years of the Cold War reflecting the world’s capitalist–socialist divide. Since then, different health systems and health system reforms have been developed and implemented in different parts of the planet. According to several studies (Reibling et al. 2019; Heredia et al. 2015; O’Connell et al. 2014; Noronha 2013; Kingston et al. 2010; Kutzin et al. 2009), the evolution of these health systems has created two main “models” of health systems around the world: the universal health coverage (UHC) and the universal health system (UHS).8

According to Noronha (2013), the first explicit reference to “universal coverage” in the international cooperation system was made in one of the reports for the 58th World Health Assembly in 2005, entitled “Sustainable health financing, universal coverage, and health social insurance.” The author argues that this sparked the “semiotic transformation” of the right to health and universal and equitable access to “universal coverage,” which is convergent with the (neoliberal) idea of protecting states against financial risks and seeking alternative mechanisms of sectoral financing. The international debate over whether the UHC or the UHS model is more appropriate for health system reforms thus commenced, greatly fueled by Margaret Chan’s, former Director-General of the WHO, proposal of UHC as the “best model to assure the right to health” in 2008.

In 2010, the title of the World Health Report, “Health systems financing: The path to universal coverage,” inverted the logic of the terms, adopting sectorial financing as the key strategy toward achieving universal coverage. Since then, the topic has garnered strong interest among certain circles of conservative thought on health worldwide. In one of many articles published in The Lancet, a prestigious scientific review of the field of health, the author refers to UHC as the “third global sanitary transition.” According to the WHO Director-General at the time, Dr. Margaret Chan:

[…] a response to a need, expressed by rich and poor countries alike, for practical guidance on ways to finance health care. The objective was to transform the evidence, gathered from studies in a diversity of settings, into a menu of options for raising sufficient resources and removing financial barriers to access, especially for the poor. As indicated by the subtitle, the emphasis is firmly placed on moving towards universal coverage, a goal currently at the center of debates about health service provision. […] At a time when money is tight, my advice to countries is this: before looking for places to cut spending on health care, look first for opportunities to improve efficiency. (The World Health Report 2010)

Later in 2012, during the opening session of the 65th World Health Assembly, Dr. Chan claimed that “universal health coverage is the single most powerful concept that public health has to offer” (Noronha 2013). Since then, many researchers and policymakers have jumped into the debate, intent on revealing the strengths and weaknesses of both models and reasons not to employ a one-size-fits-all solution, especially considering the constraints of the UHC in terms of promoting equity, a central concern of the right to health and a principal issue in developing countries (Kutzin et al. 2009; Sachs 2012; Noronha 2013; O’Connell et al. 2014; Heredia et al. 2015; among others).

Although the debate is complex, it is easier to introduce the perspectives in terms of opposites, that is, those who defend the UHC model and those who defend the UHS model. For those who defend the UHC model, social health insurance (SHI)9 (also referred to as the “Bismarck model” after the German chancellor of the same name enacted social legislation destined to protect workers in the nineteenth century) is the right political choice in health financing, particularly for low- and middle-income countries hoping to realize universal coverage. For those who defend the UHS, a general or universal, tax-funded system (often called the “Beveridge model” after the designer of the British National Health Service, NHS) would be the best option:

Advocates of SHI have suggested that in low-income countries, insurance coverage can expand from the formal sector in the entire population, as it has done in many countries that followed the Bismarck model, such as in Western Europe, Japan, and the Republic of Korea. Critics of this view have argued that introducing SHI in economies in which most of the population is in the informal sector runs the great risk of widening existing disparities in access to care and financial protection. (Kutzin et al. 2009, p. 549)

Kutzin et al. (2009) regarded the dichotomic debate between UHC and UHS as reductionist. For the authors, Kyrgyzstan’s experience of successfully introducing an adapted SHI after facing “extreme fiscal contraction in the first half of the 1990s” after the collapse of the former Soviet Union is worth sharing. They argue that the country’s experience reveals a more complex rather than dichotomic reality, calling attention to the need to consider “health financing policy in functional terms, rather than in terms of historical models imported from Western Europe” (Kutzin et al. 2009, p. 549). According to the authors,

[…] it is possible to create a universal health financing system by transforming the role of budget funding from directly subsidizing provision to subsidizing the purchase of services on behalf of the entire population. In other words, universality was designed into the system from the beginning rather than hoping that insurance coverage would simply expand over time. […] By approaching health financing policy from a functional perspective, the Kyrgyz health reformers have demonstrated that it is not necessary to choose between Beveridge and Bismarck: well-defined policy can enable their complementary co-existence in a unified, universal health system. (Kutzin et al. 2009, p. 552)

Although an enthusiast of the UHC model, Sachs (2012, p. 944) recognized that “despite the commitment to universal coverage, in practice, effective access to health care and outcomes depends strongly on economic and social conditions” and that “health outcomes are the result of many complex factors inside and outside the health system.” In this sense, according to the author, analysts and policymakers tend to ignore two issues that constrain people from low-income settings from benefitting from such a model: (1) many households’ lack of means to afford any health care services and (2) inadequate budget for low-income countries’ governments to ensure universal access to health care (pp. 944–945).

Sachs (2012) noted that people usually think that private sector health provision with public financing would offer “the best combination to ensure efficient, high-quality, low-cost primary health care” (p. 945). In response, the author presented three considerations that “point to the importance of public sector provision more akin to the [British] NHS [National Health System]: greater transparency, fewer incentives and pressure to raise costs, and a greater possibility of systematically applying and monitoring best-practice technologies at population scale (pp. 945–946). According to Sachs, “These limitations imply that efficiency, as well as equity, calls for highly systematic and broad coverage of key intervention strategies” (p. 946).

Heredia et al. (2015) argued that “interest in universal health care has recently risen thanks to the question of Universal Health Coverage as the basis for post-2015 agreements. […] Everybody seems to agree with this objective” (pp. E34–E35). Nonetheless, before adopting the hegemonic UHC model of reform that is unlike European healthcare models, which has been intensely advocated for recently emerging new world development goals, the authors defended a careful and critical examination of both terms, especially in the context of Latin America as “[…] they acquire different connotations according to different social, political, and financial interests” (p. E34). For Latin America, for example, the experience of health reforms must be analyzed in view of the broader picture of the strong influence of structural adjustment reforms imposed by international financial institutions in several countries on the subcontinent during the 1980s and 1990s, as well as their consequences in terms of a dearth of financial resources, which has gradually weakened health ministries and social security institutions.

In their efforts to propose an analytical framework for comparing both models, the authors supported the establishment of a set of uniform criteria to compare each model’s achievements in terms of the right to health in Latin America and around the world. These include population and medical coverage in their categories of universal or segmented access and use of service and possible barriers; health expenditures (both public and private); distribution of costs and amount of out-of-pocket expenditures; impact on public health actions and health conditions; and equity, popular participation, and transparency (p. E35).

One of the assumptions regarding universal health coverage is that “health is primarily a responsibility of the people, with medical care financed by individuals and employers, but not by the state, or at least not as central financial responsibility. For the state, funding could only be extended to groups in extreme poverty or at risk.” According to the authors, this model “is built on principles of the market (internal or external), commodification, managed competition, and pluralism.” Chile, Colombia, and Mexico, three Latin American countries that have adopted this model in their health reform processes, have increased out-of-pocket expenditures yet failed to guarantee the use of health services, provide high population coverage, and avoid increases in health expenditures, leaving millions of people far from their basic right to health. Moreover, and most concerning, “the person-centered insurance model tends to have a negative impact on public health because its pluralist focus weakens epidemiological surveillance and collective interventions” (Heredia et al. 2015, pp. E35–E36).

Some claim that UHC experiences in Latin American countries “have not made substantial improvements because of their commercial orientation and welfare costs” (Heredia et al. 2015, p. E35). In opposition to that model, the authors, on behalf of the Latin American Association of Social Medicine (Alames), defended a universal health system, which they believed “argues for the right to health for all citizens, without distinction, with the state as the guarantor of finance and administration,” as seen in the cases of Cuba and Brazil, where health reforms and emerging policies that expanded the right to health with greater equity were based on state-funded laws and finance. In contrast with the universal health insurance model, “the problems of the single public health system (SPHS) are operational or concern implementation: they are “de-commodified, integrated, and publicly funded health systems, granted by the State”, “[…] the much-discussed pooling of risks and funds is complete since they have a single health fund,” they “offer integrated care [with] better conditions to promote and implement public health actions, such as health education, promotion, prevention, and early detection of disease,” have been the result of extensive institutionalized social participation in some Latin American countries and, for those reasons, “have shown advances in population health and in life security” (Heredia et al. 2015, pp. E35–E36).

In a nutshell,

Intercultural relations are important in the debate over universal health insurance and SHPS because the basic focus on the health insurance model is on the individual and the biomedical, while SPHS is constructed on the basis of the universal well-being of the person, the family, and the community where people live and develop their potential. In the community, ancient and popular cultures and knowledge allow the health sector to build respectful relationships with the population in which promotion and prevention form part of everyday life. (Heredia et al. 2015, p. E37)

O’Connell et al. (2014) considered that the high-level political support to UHC—also referred to as universal health care, universal healthcare coverage, or simply universal coverage—contrasts with the diversity of meanings, lack of clarity, and absence of a consistent framework of the term that can lead, in practical terms, to the inability to promote “equity of access and use of services to achieve more equitable health outcomes.” Taken together, these constraints “can lead to unintended policy consequences” (O’Connell et al. 2014, p. 277).

In a detailed empirical analysis of each term of the expression universal health coverage aimed at establishing “practical boundaries on what policies can achieve, thus creating a normative and operational means by which to gauge national strategies and progress,” the authors asserted that “universal” refers to the noble “legal obligation of the state to care to all its citizens” in an inclusive way. For the authors, the word itself cannot tackle decisions or policies that cause exclusion, diverting health policies from universality (O’Connell et al. 2014, p. 277).

The second term, “health,” is another problematic issue in UHC debates. Although the United Nations General Assembly’s broad definition of health implies the delivery of equitable opportunities “in most countries, the move towards UHC gradually expands access starting from a narrow set of essential health services that are accessible to the public and private sector wage earners,” health inequality increases when a comprehensive social health platform is not established at the very beginning of the reform (O’Connell et al. 2014, p. 277).

Lastly, the authors argued that the term “coverage” is also problematic when it comes to “financial hardships associated with payment” that could guarantee access to essential services (O’Connell et al., p. 277). Here, coverage should be defined beyond “mere accessibility of services to incorporate an assessment of effective utilization” (p. 278). In other words, “two aspects should be made explicit if UHC policies are effective: the appropriateness, and the quality, of coverage” (p. 278). In short,

The term universal necessitates a focus on equity, with the path to UHC explicitly being a gap-narrowing one that prioritizes the attainment of greatly improved health outcomes for those who are currently left behind. Similarly, the term health must consider social determinants, including beliefs, values, and expressed needs of various subpopulations, as well as how actions beyond the health sector can be implemented. For the term coverage, its results must be considered, moving from the measurement of access to the assessment of utilization, appropriateness, and quality. Finally, consistent participation of civil society and the private sector, along with government and development partners, is essential to forge a true consensus about what UHC means within each country so that the relevant causal pathways and mechanisms hindering and enabling UHC can be fully diagnosed. (O’Connell et al., 2014, p. 278)

Noronha (2013) presented a thought-provoking semiotic criticism of the emergence of universal health coverage as the main internationally supported and recommended model for health reforms worldwide. In lines of thinking similar to other authors, the author developed three arguments against the claim that universal health coverage is the “best model for health system reform around the world.” First, he criticized the argument that a specific policy requires a specific finance-pooling mechanism. According to the author, investments and other common services are financed by taxes, contributions, and interests, thereby integrating governments at different levels. The final destination of funds from this fiscal resource pool is detailed in national budgets and investment plans (p. 848).

Second, the term “coverage” does not necessarily mean that individuals are utilizing health services; indeed, the term differs from the actual access and use of health services. In addition, there are several other supply and demand barriers to universal access beyond financial barriers, and which vary according to the service required to address the population’s specific needs (Noronha 2013, p. 848).

Finally, the author wondered why the equity issue is presented in UHC global policies as dependent on the idea of “financial protection” of the poor. This comprehension ignores the major problem of supply segmentation according to social classes and the different kinds of protection guaranteed by different modalities of public or private insurance (p. 849).

Before moving more specifically onto Japan’s ODA for the health sector in developing countries, it is important to know that, as part of the OECD, Japan has a singular health system. Reibling et al. (2019) presented an extended typology of healthcare systems among selected OECD countries by integrating two theoretical frameworks: a comparative-institutional perspective of existing classifications and ideas from the current international health policy research debate. The authors argued that combining these two perspectives “provides a more comprehensive picture of modern healthcare systems and takes the past decade’s dynamic of reforms into account. (…) The results from a series of cluster analyses indicate that at least five distinct types of healthcare systems can be identified” (p. 611).

Based on a theoretical framework that integrates ideas from a comparative-institutional welfare state and comparative health policy research, the authors deduced “five crucial theoretical dimensions for comparing the healthcare systems of OECD countries, including Japan, which are supply, public–private mix, access regulations, primary care orientation, and performance” (Reibling et al. 2019, p. 618). The authors asserted that “instead of assuming the existence of “frozen” regimes that are built on long path-dependent historical trajectories, system types are in fact the result of institutional stabilities and ongoing policy change” (p. 618).

They further recognized the increasing complexity of healthcare systems worldwide over the past three decades and the evolution of healthcare typologies stemming from the scientific community. Hence, for the authors, higher supply and greater access to healthcare do not necessarily lead to good care and improved outcomes (p. 611).

To synthesize the frameworks of both the OECD and the European Observatory on Health Systems and Policies perspectives, the authors developed “an extended typology of OECD healthcare systems.” Utilizing a cluster analysis, the authors identified five distinct types of healthcare systems while suggesting the weakening of dichotomic distinctions between the UHC (Bismarckian model) and the UHS (Beveridgean model) (pp. 611–612).

At the same time, Reibling et al. (2019) recognized that the debate on the “extent to which healthcare is linked to population health outcomes has been central to the health policy community. Prevention—while relatively insignificant in terms of the healthcare budget—is an area with vast potential to improve health outcomes.” Hence, comparisons need to move toward including prevention efforts as significant research variables. Finally, the authors recognized the existence of a “vast difference in quality […] both within and across countries” that needs to be further addressed (pp. 612–613).

The authors’ integrated perspective for healthcare system comparison considers five indicators: 1. supply, 2. public–private mix, 3. access regulation, 4. primary care orientation, and 5. performance. Through a cluster analysis, the authors identified six clusters of countries. Their analysis indicates that Japan and South Korea “have no strong ties with any other country but are both partial members of Cluster Four (Canada, Denmark, the Netherlands, and the United Kingdom), with Japan being more consistently clustered with this group of countries than South Korea” (p. 616). From these clusters, the authors proposed the following types of healthcare systems among OECD selected countries10:

  1. a.

    The supply- and choice-oriented public system

  2. b.

    The performance- and primary-care-oriented public system

  3. c.

    The regulation-oriented public system

  4. d.

    The low-supply and low-performance mixed system

  5. e.

    The supply- and performance-oriented private system

In an overview of cluster characteristics, Japan (along with Finland, South Korea, Norway, New Zealand, Portugal, and Sweden) is included in the second type of healthcare system (the performance—and primary-care-oriented public system), as shown in the second column of Table 3.3.

Table 3.3 Overview of cluster labels and characteristics
Full size table

Reibling et al. (2019) emphasized that “the low-supply and low-performance mixed system suggests that not all OECD countries currently have sufficient resources for a high-performing healthcare system” and that, among several study limitations, one is the conscious “exclusion of important aspects of healthcare system comparison from the cluster analyses” with several indicators working only as proxies (p. 618).

From the specialized literature on international cooperation and foreign aid for health, it is clear that, at least since the nineteenth century, with a few exceptions, world health has been influenced by emerging issues and debates, from which the most influential countries or a hegemony may have greater opportunities to stake their visions and interests either through regional, such as the OECD, or multilateral institutions, e.g., the WHO. Thus, as part of the so-called “international aid community,” Japan’s ODA for the health sector is an expression of the prevailing domestic and global health visions and interests. In this context, Japan’s UHC, aligned with the WHO’s support for that model, represents a strong force en route for adjusting developing countries’ policies and approaches in the sector.

Concerning health systems, it is clear that the WHO’s decision to advocate exclusively for the UHC model, reinforcing a rather conservative, privatized view of health, fails to promote equity, especially when simply reproduced by foreign aid in developing countries. Here it is worth mentioning that the COVID-19 pandemic has offered a unique opportunity to reflect on hegemonic global health system models and their long-term effects. Within this context, more than ever, critical thinking is crucial to foster debates on health system reform toward the achievement of the universal right to health with equity for all mankind.

In the wake of the COVID-19 pandemic, there may be an increased focus on international cooperation limited to specific diseases, thus contradicting previous discussions about the need to strengthen health systems. Eventually, strengthening health systems, not specific disease control, might become the priority and the basic policy for international cooperation in the health sector would not yield political pressure with short-term results. This is in line with criticism made by Labonté (2008), who explains that despite being the dominant discourse, health as security is the most reductionist approach, directing attention to specific diseases that are considered threats to national security or merely inconvenient to global trade, finance, and tourism.

In an effort to understand what combination of historical factors has brought the world to such crossroads and what future lies ahead, scholars from various fields have provided some relevant insights. To date, findings point to some consensus around international (or systemic) and domestic (or national) factors. These include the intensification of Western liberalism, especially after the fall of the Berlin Wall and the end of the Cold War, and the voracious Western neoliberal capitalism that has marked the world order since then. This has resulted in an overall reduction and weakening of the role of the state at both the domestic and international levels, the rise of China and some countries of the geopolitical South as threats to the American hegemony and their non-Western values and principles (Weiss and Wallace 2021), the securitization of the international development agenda since the 9/11 terrorist attacks in the United States of America, and the deterioration of world social and economic indicators (Goodman and Pepinsky 2021). Moreover, the rise of nationalist movements in different countries that are now strong enough to elect right and far right politicians (in accordance with Lake, Martin and Risse 2021, p. 235) in powerful nations who, in turn, undermine collective action initiatives, cause fear and mistrust that results in tension and rigidifies the international system further, threatening the status quo (Nye and Welch 2014, p. 48).

In brief, the concept of global health that has been promoted in the last few decades has hindered nations from tackling the current COVID-19 pandemic in a collective and equitable way, reflecting that international cooperation for global health is a result of complex political, economic, social, environmental, historical, and cultural factors and contexts that extend far beyond the predominant biomedical approach to health. States and global institutions alone, weakened by decades of neoliberal policies and the rise of nationalistic movements, have failed to guarantee effective international cooperation at a crucial time for humankind. Private and public–private initiatives, in turn, did not contribute much to tackle such a global challenge.

3 Japan’s ODA for the Health Sector from 1990 to 2020

ODA in Japan and other countries is governed by various factors, including world affairs, international events, bilateral and regional international relations, domestic political and economic conditions, the country’s experience in each sector, and individual knowledge and expertise. Japan’s 2014 ODA White Paper, which reflects on the trajectory of 60 years of Japanese ODA, categorizes the period from the 1950s to the 1960s as “Beginnings,” the period from the 1960s to the 1980s as “Expansion and Diversification,” and the period from the 1990s as “Initiatives as a Top Donor.” Finally, the period from the 2000s onward is classified as “Responding to New Development Challenges of the 21st Century” (MOFA 2014).

Health has been treated as one of the principal sectors since the very beginning when Japan agreed to be involved in international cooperation in the 1950s. The early projects in the 1950s and 1960s were implemented as a series of one-off cases without formulating consistent and transparent policies on international health cooperation. From a broad, historical perspective, the establishment of the OECF in 1961, the Economic Cooperation Bureau of the Ministry of Foreign Affairs in 1962, and the inauguration of Japan Overseas Cooperation Volunteers (JOVC) served as domestic preparation for system building in ODA to developing countries. At the same time, a series of international events, such as Japan’s entry into the United Nations in 1956, the foundation of the Organization for Economic Cooperation and Development (OECD) in 1960, the establishment and Japan’s admission onto the Development Assistance Committee (DAC) in 1961, and the foundation of the United Nations Development Programme (UNDP) in 1966 helped boost Japanese involvement in international affairs.

The establishment of the JICA in August 1974 enabled the Japanese government to implement its desire to be involved in international cooperation in the health sector through grant-aid and technical cooperation. During the late 1970s and early 1980s, international cooperation in the health sector was focused on public works such as hospital building and equipment provision. Technical assistance and training to combat diarrhea and infectious diseases such as malaria and tuberculosis was also implemented. However, the lack of alignment between grant-aid and technical cooperation resulted in poor continuity of projects or even abandoned cases in developing countries. Reflecting on these bitter lessons, the government discussed the importance of coordination and effective evaluation of international cooperation projects in the latter half of the 1980s. In 1984, the Ministry of Foreign Affairs issued the first version of Japan’s ODA plan, known as the ODA White Paper.

Around the same period, PHC needs in developing countries had begun to receive significant attention in international health cooperation. PHC was officially mentioned by then Director-general of the WHO, Dr. Halfdan T. Mahler, at a meeting of the executive board in 1975. PHC emphasizes the importance of comprehensive health care at the community level, which must be embedded in the national health system (Fujiya 2013). In September 1978, the Declaration of Alma-Ata was adopted at the First International Conference on Primary Health Care. Article I states that health is a fundamental human right. Article III indicates that economic and social development are of primary importance to attain health for all and reduce the gap between the health status of developing and developed countries.

Japan’s ODA expanded steadily from the 1960s to the 1980s. However, after becoming the top donor in the field of development assistance in the 1990s, it showed a downward trend in the late 1990s and early 2000s. Figure 3.1 shows the trend of Japan’s ODA expenditures by sector based on the information provided in the OECD DAC database. Looking at the breakdown by sector, the economic infrastructure and services sector has been on an upward trend in terms of the absolute amount and share. This trend was particularly pronounced in the 1990s and 2010s. ODA in the social infrastructure and services sector, which includes education, health, and water and sanitation, hovered around 20 percent since the 1990s but fell below 20 percent in the 2010s, indicating a decline in the presence of this sector in Japan’s ODA (MOFA 1997, 1998, 1999). The share of health expenditures out of total ODA has remained less than 4 percent since the 1990s, when Japan was the top donor, and has been relatively modest in terms of quantity in the process of addressing new challenges in the international community against the backdrop of the end of the Cold War and the progress of globalization.

Fig. 3.1
figure 1

(Source Authors’ elaboration based on the OECD DAC database)

Japan’s ODA by sector, commitments, constant-US dollars in millions, 2019 (left y-axis), sector share percent (right y-axis)

Full size image

Figure 3.2 shows the amount of bilateral aid in the fields of health, population policy, reproductive health, and water and sanitation. Notably, the scale of aid for water and sanitation, which involves large-scale facilities, is greater than that for health, which includes basic health and medical services.

Fig. 3.2
figure 2

(Source Authors’ elaboration based on the OECD DAC database)

Bilateral assistance in the fields of health, population policy and reproductive health, and water and sanitation, Commitments [C] and Disbursements [D], US dollars in millions, 2019

Full size image

In developing countries with poverty problems, there is a wide range of issues related to health care. Population, AIDS, child health, and parasite control are representative areas that have been continuously addressed by Japan’s ODA in the field of social development. In many developing countries, the level of and access to health services are insufficient, and preventive and curative disease control measures are lacking. In addition, the economic crises and neoliberal policies experienced in the 1980s and 1990s in Latin America and Asia, have caused long-term, grave consequences for social development, especially in the area of health care. According to Japan’s ODA White Papers, the importance of development cooperation for the health sector needs to be constantly emphasized in developing countries, which are more vulnerable to internal and external shocks (MOFA 1997, 1998).

The need to address global issues in the context of globalization has been discussed since the 1990s. In the ODA Charter , which was first adopted in 1992 to clarify the principles of Japan’s ODA, addressing global issues is listed as a priority. Consequently, health issues covered in Japan’s ODA White Papers have been divided into two categories: health and medical care, which are considered sectoral assistance, and infectious diseases, population, and AIDS, which are considered global issues (MOFA 2001). In the area of sectoral assistance, the perspective of PHC, which aims to provide basic health care services to as many people as possible, has been positioned as important, and both hardware and software support have been provided to facilities that form the core of health and medical systems in developing countries (MOFA 1999, 2001). To address global-scale issues, Japan announced the “Global Issues Initiative on Population and AIDS (GII)” in 1994 and helped develop an international effort to combat AIDS, supporting the leading role of the United Nations Programme on HIV/AIDS (UNAIDS) (MOFA 1999, 2002, 2003).

Infectious diseases have long been considered a global issue. As globalization has facilitated the greater movement of people, infectious diseases have become recognized not only as a health problem that threatens the health and lives of people in developing countries but also as a threat that can spread across national borders to developed countries. At the G8 Kyushu–Okinawa Summit in 2000, for the first time in history, infectious diseases were considered a major issue among developed nations as part of the agenda among developed nations (MOFA 2001, 2002, 2003). On that occasion, the “Okinawa Infectious Diseases Initiative (IDI)” was announced to strengthen support for Japan’s infectious disease control measures and to stimulate international interest in infectious diseases. This trend led to the establishment of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) in 2002, which is expected to continue to play a central role in the global fight against infectious diseases (MOFA 2002).

The Millennium Development Goals (MDGs),11 adopted in 2000, also set three health-related goals: Goal 4: reduce infant mortality, Goal 5: improve maternal health, and Goal 6: prevent the spread of HIV/AIDS, malaria, and other diseases. These MDGs, together with the Poverty Reduction Strategy Paper (PRSP), agreed with agendas established at the 1999 World Bank/International Monetary Fund Annual Meetings and provided the impetus for the search for results-oriented development assistance (MOFA 2001, 2003). In 2005, the Japanese government announced the Health and Development Initiative (HDI), which aims to contribute to the achievement of MDGs related to the health sector, such as combatting infectious diseases and improving maternal and child health and health care systems, and supporting gender equality, education, water and sanitation, and other areas related to health care (MOFA 2006, 2007, 2008, 2010).

Japan’s ODA since the 2000s has been characterized by the key concept of “human security,” which emerged in the mid-1990s as an alternative to “national security,” i.e., the traditional concept of the state protecting its borders and citizens (MOFA 2001, 2002). Human security is a concept that seeks to protect people from various threats to their survival, livelihood, and dignity and to integrate and strengthen efforts to realize people’s potential based on the perspective of each individual. The ODA Charter , revised in 2003, incorporates the perspective of human security into its basic policy (MOFA 2003, 2005, 2007; among others).

Based on the concept of human security, the new ODA Charter emphasizes the need to address cross-cutting issues in four priority areas: poverty reduction, sustainable growth, addressing global challenges, and building peace. The ODA Charter was revised to reflect changes in international trends surrounding ODA and Japan’s specific circumstances. In the aftermath of the terrorist attacks in the United States in September 2001, developed countries stepped up their ODA efforts with the realization that poverty can be a breeding ground for terrorism (MOFA 2002, 2003, 2007). However, Japan’s ODA budget peaked in FY1997 and has been reduced by more than 30 percent in the seven years since then (MOFA 2003), partly due to public criticism of ODA amid a severe financial situation caused by domestic economic stagnation known as the “Lost Decade.” In 2004, on the 50th anniversary of Japan’s ODA, the role of economic growth and infrastructure in poverty reduction was emphasized and the revival of the economic dimension of ODA was confirmed, including the strategy of securing development funds via private investment through foreign direct investment and linking trade and development.

In 2006, the International Cooperation Bureau was established in the Ministry of Foreign Affairs of Japan to strengthen cooperation between the government and implementing agencies. In 2008, when the new JICA was established, it became one of the world’s leading aid implementing agencies in terms of funding. JICA’s aid reforms in the 2000s clearly reflected its policy of implementing results-oriented ODA, including the strengthening of its strategic focus on “selection and concentration” and the establishment of the Plan–Do–Check–Act (PDCA) cycle for quality improvement (MOFA 2007, 2011).

According to Japan’s official publications on ODA, with the rapid progress of globalization, development issues in the health sector are recognized as issues to be tackled on a global scale. Governments of developed countries that are members of the OECD–DAC, as well as emerging donor countries and private organizations, actively participate in development cooperation (MOFA 2006, 2011). The Global Alliance for Vaccines and Immunization (GAVI Alliance) and the International AIDS and Vaccine Initiative (IAVI), established at the annual meeting of the World Economic Forum in 2000, as well as the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), established in January 2002, have increased the number of foundations and funds that provide global assistance to specific development issues (MOFA 2002, 2004, 2007, 2012; among others). However, as will be discussed later in this section, it is necessary to carefully examine whether the system of international cooperation in the health field involving various actors, e.g., governments of developed countries and emerging countries, international organizations, and private organizations, as well as global efforts such as the GAVI Alliance, functioned effectively during the COVID-19 pandemic.

Discussions at the G8 Hokkaido Toyako Summit in 2008 led to the concept of international health in Japan’s development cooperation in the fields of health and medical care, which emphasizes the need for comprehensive efforts to strengthen health systems, improve maternal and child health, and combat infectious diseases (MOFA 2008, 2009). In 2010, the government formulated the New International Health Assistance Policy for the period 2011–2015, with 2015 being the deadline for achieving the MDGs (MOFA 2010, 2011, 2012). The three pillars of the policy are maternal and child health, control of the three major infectious diseases (HIV/AIDS, tuberculosis, and malaria), and efficient response to public health emergencies. The response to public health emergencies became relevant after the outbreak of emerging and re-emerging infectious diseases, such as severe acute respiratory syndrome (SARS) in 2002 and swine flu (H1N1) in 2009. Accordingly, countermeasures against these emergencies need to be implemented via international cooperation and coordination with international organizations such as the WHO and Food and Agriculture Organization (FAO). Figure 3.3 shows the trend of the Japanese government’s contribution to the WHO. The amount contributed by the Ministry of Health, Labor, and Welfare (MHLW), the Ministry of Foreign Affairs (MOFA), and the Cabinet Office (Cabinet Office) shows a marked increase in the latter half of the 2010s, a reversal of the downward trend that began in 2000. As globalization increases the complexity of human mobility and supply chains as well as the interdependence of economic relationships, strengthening countermeasures against the threat of infectious diseases has become an international issue.

Fig. 3.3
figure 3

(Source Authors’ elaboration based on the documents released by MOFA)

Japanese government contributions to the WHO (JPY thousand)

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In 2012, the Global Health Innovative Technology (GHIT) Fund was established to address infectious diseases in developing countries. It is an international public–private partnership fund originating in Japan that brings together the Japanese government, domestic and foreign pharmaceutical companies, and others to promote the development of new drugs for infectious diseases and to make essential medicines affordable and accessible to people in developing countries. This initiative, which aims to control infectious diseases in developing countries through research and development of low-cost and highly effective therapeutic drugs, vaccines, and diagnostics, may be based on encouraging private companies to become more involved in the field of development cooperation and promoting the diffusion of Japanese companies’ technologies through development cooperation in the field of health care (MOFA 2013).

The “International Health Diplomacy Strategy,” formulated in 2013, sets the promotion of universal health coverage (UHC) as an important policy goal, namely to grant all people access basic health services when they need them throughout their lives at a cost they can afford (MOFA 2014). In promoting human-centered development through ODA, Japan has traditionally emphasized efforts in the field of health care linked to human security and has been focused on strengthening health systems. To meet the health challenges outlined in the 17 SDGs, which were newly formulated as successors to the MDGs, a policy to strengthen efforts toward UHC has been proposed, along with the importance of a cross-sectoral approach and global partnership (MOFA 2015). The possibility of utilizing Japan’s experience and technological capabilities to cope with an aging society and realize the world’s longest healthy life expectancy through the universal health insurance system is also being explored in development cooperation policies (MOFA 2013).

Since the 2016 version of the White Paper on Development Cooperation, the Ministry of Foreign Affairs has emphasized that, in addition to the promotion of UHC, Japan has led discussions in international fora such as the G7 and TICAD on the establishment of a framework of the international community for responding to these health crises, so-called “the global health architecture” (MOFA 2016, 2017, 2018, 2019). The WHO Health Emergencies Program, the Contingency Fund for Emergencies (CFE), and the Pandemic Emergency Financing Facility (EF), established by the World Bank with the support of Japan at the G7 Ise–Shima Summit in 2016, are the principal frameworks mentioned in this context. Through these schemes, the government highlights Japan’s contributions in response to the Ebola virus disease (EDV) outbreak in the Democratic Republic of the Congo in the 2010s (MOFA 2018, 2019).

In 2020, the spread of the new coronavirus disease (COVID-19) severely affected the lives and livelihoods of all people on the planet. The response to the global pandemic will be a turning point that will change the direction of development cooperation among countries in the field of health care. MOFA (2020) briefly mentions in its annual report that, in addition to the EDV outbreak, Japanese financial aid to the CFE and the EFE is to be used to respond to the COVID-19 crisis and contribute to addressing the health crisis. Based on past experiences, weak health systems are factors behind the epidemic or pandemic, and “building a sustainable and resilient health system is crucial to control infectious diseases” (MOFA 2016). It is important to not only pursue a direct response to end the COVID-19 pandemic but also to promote existing frameworks to strengthen the health system and prepare for future emergencies.

Not only in the field of health but also in the field of international cooperation under Japan’s ODA, applications are officially submitted based on the request of the developing country’s government, and the Japanese government decides whether to implement the project. In practice, it is not uncommon for Japanese agents, such as JICA experts, to assist officials from the host government and related organizations in drafting the application form. Looking back at the trajectory of the projects implemented in Brazil,12 it is possible to say that the personal attributes of the experts involved, such as their disciplines and academic backgrounds, work histories, and previous experiences, as well as their personal relationships with their counterparts, the selection of the participants and their awareness and problem consciousness are strongly reflected in the projects. These factors may influence not only the implementation of each project but also the entire series of international cooperation activities through case formation and follow-ups. In the evaluation of international cooperation projects, research that focuses on the people involved in the project and comprehensive analysis of the impact on local communities and stakeholders over a longer period of time that extends beyond one-off project evaluations may reveal contributions that have been overlooked in the past.

JICA aims to implement international cooperation in the field of health in line with the policies proposed by international organizations such as the WHO. Since the development of UHC based on Japanese experience has a high affinity with international discussions, the implementation of international cooperation projects that target achieving health in a broad sense with health promotion as the core has been promoted.

The connection between international cooperation and foreign aid was clarified in our empirical longitudinal analysis of Japan’s ODA in the health sector from 1990 to 2020 within the overall picture of world affairs. Japan’s ODA in the health sector has been influenced by and has itself influenced international cooperation in health. According to the most recent international cooperation theories, influence may be exerted by not only interest groups, organizations, and institutions at domestic and international and global levels but also by individuals.

In the field of international cooperation, where actors are becoming increasingly diverse, the role and contribution of the Japanese government must be reconsidered. The lessons learned from the spread of COVID-19 go beyond verifying the effectiveness of global health architecture and its underlying frameworks, such as CFE and EF, which focus on responding to health crises. In the pursuit of global health, as recently defined by JICA, it has become necessary to rethink how international cooperation in health should be developed to contribute to strengthening national health systems and what should be considered when implementing such international cooperation.

Data and information extracted from official reports and databases on Japan’s ODA for the health sector from 1990 to 2020 illustrate Japan’s overall ODA trends in the health sector. Japan’s ODA has been strengthening its health systems to address both infectious diseases and the need for maternal and child healthcare. On the one hand, this double priority may lead Japan’s ODA to be criticized for being too specific and hampering the country from truly contributing to global health. On the other hand, Japan’s ODA is concerned with the health system strengthening signals in a different direction, perhaps more in line with equity concerns expressed in much of the extant literature. Nonetheless, the issue, including the assessment of Japan’s UHC at the domestic level, remains to be explored and deserves further research.

4 Final Considerations

This chapter aimed to identify the overall trend of Japan’s ODA policies for health in developing countries from 1990 to 2020 and their prospects given the current COVID-19 pandemic context. The research was guided by the following questions: What were the major trends in Japan’s ODA policies in the health sector from 1990 to 2020? Which international health forces, debates, and cooperation factors have influenced these trends? What are the prospects of Japan’s ODA, given the COVID-19 pandemic and its impacts?

Japan’s official ODA documents indicate that health has been treated as a principal sector since Japan first elected to engage in international cooperation in the 1950s. As the history of foreign aid in the world suggests, Japan’s ODA has also gone through different health paradigms over the decades, during which it has dealt with various health challenges and paradigms. Comparatively, the economic infrastructure and services sector indicated an upward trend in absolute amounts and shares from 1990 to 2020. Simultaneously, the social infrastructure and services sector—which includes education, health, and water and sanitation—has declined steadily. Within this context, in addition to the country’s recognized role and expertise in public health emergencies, Japan’s ODA has focused on two main global issues: health and medical care (mainly maternal and child care, with an emphasis on PHC) and infectious diseases.

Overall, Japan’s ODA has been connected to international cooperation paradigms and movements such as the Millennium Development Goals (MDGs), the human security paradigm, WHO official support to UHC, and WHO and World Bank funds for health emergencies. Connections with international cooperation paradigms in health care must be critically assessed in light of hegemonic interests and the strong neoliberal agenda that has dominated the world since the early 1990s. They also need to be critically evaluated considering Japan’s views and interpretations of emerging health paradigms. In short, if it is true that Japanese ODA cannot be fully understood without considering hegemonies and geopolitics, it is likewise true that it cannot be fully understood without more profound comprehension of the country’s unique views and approaches to international cooperation in health, which sometimes clash with prevailing international paradigms. These considerations highlight the need for further research on Japan’s ODA views and approaches to recent global health issues, such as UHC, infectious diseases, maternal and child healthcare, human security, and an aging society.

In short, Japan’s ODA is part of the domestic and global debates on health policies and systems. As part of these ongoing and dynamic debates, there is evidence that Japan’s ODA has already incorporated the fight against COVID-19 into its global health policies. By October 2021, the COVID-19 pandemic had already surpassed the death toll of the twentieth century Spanish flu. After the outbreak, neither international cooperation nor global health materialized as mandated by international legal agreements, goals, and frameworks (health for all, health by all, and health in all). In contrast, competition, denialism, nationalism, and border politics have prevailed, causing disunity and inequity across the globe.

The COVID-19 pandemic has been teaching us, in the cruelest way possible, the lesson that values, mechanisms, and policies of international cooperation for global health devised with the participation of multiple local, national, regional, and global actors in the international arena in the last decades have not been sufficient to tackle a global pandemic in an equitable way that honors the universal right to health.

At countless moments in history, we, the human species, a collection of peoples, nations, societies, and communities, have come to crossroads. Wars, natural disasters, pandemics, and other events have changed the course of history. In times like these, it is common for humanity to rethink past choices, reflect on the paths taken thus far, and devise new plans for the future. Perhaps it is time for those in charge of organizing Japan’s ODA to think and rethink about past health aid choices and future prospects.

From the discussion above, the simple inclusion of COVID-19 in Japan’s foreign aid agenda does not seem sufficient to promote international cooperation on the issue. On the contrary, it may just reinforce the agency’s trend to focus on infectious disease without contributing, in the longer run, to an actual world collective effort to tackle the current and future pandemics and/or similar challenges. Moreover, maternal and child healthcare, while undoubtedly relevant, may reinforce Japan’s trend of adopting a specific agenda to the detriment of broader and more relevant agendas for health equity around the world. Whether both directions have effectively contributed to strengthening health systems around the world is yet to be analyzed. Moreover, both trends—infectious diseases and maternal and child healthcare—must reflect Japan’s UHC assumptions, unique experiences, and approaches that are yet to be explored in future research.

Recent demonstrations of hesitation on the part of the US government during the Trump administration regarding whether to continue supporting the LIO conceived and implemented by Western powers after the Second World War calls for increased attention to the future of international cooperation and foreign aid for health. Through its UHS model, China has demonstrated an outstanding ability to deal with the pandemic at both the domestic and international levels. Despite a few limitations, Japan has demonstrated the ability to tackle the pandemic at the domestic level. More than ever, it is time to assess strengths and weaknesses carefully and pragmatically based on the experience of the COVID-19 pandemic and all forces and circumstances that have significantly impacted people’s lives worldwide. From there, perhaps it will be possible, like Franklin D. Roosevelt’s Four Freedoms after the Second World War, to have states or their leaders propose and negotiate a new set of ethical consensuses on health that might open new ways of international cooperation for greater health equity in the future.

Finally, this chapter elucidates that international cooperation in general, and more specifically international cooperation for health, especially after the COVID-19 pandemic, cannot be restricted to establishing formal agreements, budgets or fundraising, official reports, approved projects, and other necessary daily bureaucratic actions. If failures in international cooperation can cost lives, the realization of international cooperation requires mutual awareness of the forces at play in the process. In the field of health, more than ever, international cooperation requires the notion of gains and losses caused by past choices, knowledge of global geopolitical forces and prevailing health paradigms, awareness of ongoing international health debates and models, recognition of domestic experiences’ singularities, consciousness of organizations and individuals’ experiences and views.

Brazil and Japan have accumulated enriching experiences of international cooperation and foreign aid in health. Such experiences deserve further studies and analyses based on a broader analytical framework if a true partnership for change is to be devised in the future to deal with the tremendous global health challenges that lie ahead. Simple economic-oriented assessments and evaluations restricted to project effectiveness may not suffice to thoroughly evaluate these initiatives, their complex ramifications, and their implications.

Although it is a simple first research step, the preliminary and tentative analytical framework developed for this study may have elucidated a few aspects that reveal the complexity of thinking about international cooperation and foreign aid for health in the past, present, and future. Admittedly, international cooperation is not an easy task, but it is a collective one that holds the potential to change people’s lives for the better or for the worse.

Notes

  1. 1.

    Currently Sri Lanka.

  2. 2.

    The latest version, White Paper on Development Cooperation (2020), was only available in Japanese in February 2022.

  3. 3.

    At times, “mutual” may reflect the dominant will of a hegemony explicitly or implicitly imposed on other states.

  4. 4.

    The Independent Commission was presided over by Ms. Sadako Ogata, a former member of the UN High Commission for Refugees (UNHCR), and the Ford Foundation’s fellow at the time and Amartya Sen from Trinity College, Cambridge.

  5. 5.

    Ferreira et al. (2013, p. 2) endorsed the idea that “human health is undoubtedly the result of complex biological and socio-historical process.”

  6. 6.

    As reported by Labontè (2008, p. 467), “One of health promotion’s major contributions has been its discursive challenge to biomedical and even behavioral models of health and illness. The concept of social determinants of health is now widely accepted by health authorities in many parts of the world. When health promoters focus on these determinants; however, it is often at local or national scales. Contemporary globalization demands a more critical appraisal of how many health problems have become inherently global in cause and consequence.”

  7. 7.

    See Kingston et al. (2010) for an interesting analysis on the scope of nation states’ obligations concerning the right to health for people who are no longer citizens of any sovereign state or have no legal nationality, also referred to as “stateless people.”

  8. 8.

    There are many expressions to refer to these two health systems, as we shall see in the continuation of the discussion in this chapter.

  9. 9.

    SHI, as explicated below, refers to UHC, according to Kutzin et al. (2009).

  10. 10.

    The authors’ typology is arguably based on distinctions between healthcare systems “according to their institutional characteristics and patterns of financing and service provision,” thus moving away from “the tradition of typologies that have centered on the mode of governance, on the degree of doctor’s autonomy, or— more generally—on the actor in order to distinguish healthcare systems” (p. 617).

  11. 11.

    The United Nations Millennium Development Goals (MDGs) are 8 goals that UN Member States have agreed to try to achieve by the year 2015. The United Nations Millennium Declaration, signed in September 2000, commits world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. The MDGs are derived from this Declaration. Each MDG has targets set for 2015 and indicators to monitor progress from 1990 levels. Several of these relate directly to health. https://www.who.int/news-room/fact-sheets/detail/millennium-development-goals-(mdgs).

  12. 12.

    Authors had opportunities to visit, work, and conduct research on several international cooperation projects implemented in Brazil, including three pioneering international technical cooperation projects between Brazil and Japan in public health: the Public Health and Social Development Center (NUSP) in the Federal University of Pernambuco, developed between 1995 and 2000, the Maternal and Child Health Improvement, Humanization of Childbirth (LUZ) in Ceará State, conducted from 1996 to 2001, and the Healthy Municipality Project in Northeast Brazil, carried out from 2003 to 2008.