This section describes KIs’ perceptions of the most relevant health-related concerns that enter foreign policy in Mexico, the processes that allow such entrance, and their impacts at the national level. We argue that these processes’ outcomes result from an underlying execution of strategies for power influence between sectors and stakeholders at the national level, aimed at prioritizing their own sectoral interests. This seems to be a scaled-down version of the exercise of power between nation-states commonly found in the global arena of multilateralism. The main findings are summarized in Table 2.
Health concerns entering diplomatic and foreign policy
Health Sector (HS)
The most relevant GHD experience for the Mexican HS is found in its leadership to promote bi-national health within the CSFFootnote 1, where health priority setting for border-living populations is jointly conducted by the health ministries of ten border states in Mexico (Baja California, Sonora, Chihuahua, Coahuila, Nuevo Leon, and Tamaulipas) and the US (California, Arizona, Texas, and New Mexico). Another important concern for the HS is healthcare access beyond Mexican national boundaries, aiding the Mexican population living in the US and other Latin American groups. This action has been mainly driven by the Ventanillas de Salud program operating at the 50 Mexican consulates in the US. These two examples have been widely recognized by KIs and in the relevant literature [8] as good practices for regional integration through migrant health promotion.
“The contribution of Mexico in the resolutions on access to health services for the migrant and refugee population has been very important. It represents an example of good practices to make further proposals for attention to immigrants’ health in other countries that have no experience on the matter.“(Informant F, Health Sector).
The HS experience regarding health concerns entering the national level has been channeled through the adoption and implementation of global health initiatives, such as the WHO Framework for Tobacco Control or health securitization, for instance, with its participation in the G7+Mexico Global Health Security Initiative in 2001, mainly due to its geostrategic location in the region of the Americas.
“One of the main issues in which we are interested is global health security. It has allowed Mexico to be part of the G7+Mexico, which would be unthinkable if we did not have a border with the United States. So, we belong to this group called “Global Health Security Initiative” that comprises the seven most powerful countries in the world, plus Mexico.“(Informant E, Health Sector).
Foreign Affairs Sector (FAS)
The FAS in Mexico does not maintain an office, department, or specific representation on health within its organizational structure. For this reason, conflicts and opposite positions on health issues may arise between the SRE and the Secretariat of Health (HS). There are no clear or direct linkages that are openly identifiable between both secretariats for collaboration on specific health issues. Furthermore, the FAS acknowledges that the Mexican HS have limited formal representation in the global UN agency system:
“We do not have a representative from the Secretariat of Health in Geneva; we do all from the Secretariat of Foreign Affairs. Only when the level of complexity of some [health] issues is high, it does make it necessary to have more space for training [capacities].“(Informant C, Foreign Affairs Sector).
One of the informants identified a lack of communication between SRE and HS as a barrier for better coordination. Nevertheless, some intersectoral collaborative opportunities have taken place when responding to sanitary emergencies, such as a dengue epidemic that broke out in Honduras. However, the communication from the Mexican embassy with the HS was not successful at providing the needed response. It was not until the problem was transferred to the SRE in Mexico to deal directly with HS that adequate interventions were carried out.
“I tried to communicate with the Secretary of Health [but] he did not take the call. Then, I resorted to [closer persons] at the [SRE], and I told them about this very serious problem. Then they spoke to the Health Secretariat, and (…) they went to Honduras to start the whole fumigation and made a large donation of insecticide (Abate, temephos larvicide). It was through the SRE that the HS took action.“(Informant A, Foreign Affairs Sector).
Non-Governmental Organizations Sector (NGO)
The NGO sector activities in the realm of GHD have primarily focused on policy issues surrounding food regulations in Mexico. NGOs have managed to lobby for, and position matters on food policy at global and national levels. However, incorporating issues such as pushing for the implementation of a tax on sugar-sweetened beverages or the proposal of food frontal labeling into national agendas were challenging, as NGOs confronted powerful commercial interests that limited or blocked their participation.
“[Since the beginning of the Trump administration] there was an initiative by the US government in the renegotiation of NAFTA to include an article that would prevent any of the three countries from implementing a frontal warning type of labelingFootnote 2 (…) [When] we learned about this, we denounced it, but also [we learned that] it was agreed with the Mexican government [and that] these negotiators were the same lobbyists of the industry (…) of food and beverages.“(Informant H, NGO).
The NGO informants argue that health concerns are not considered relevant enough by government actors in global negotiations, especially when the implementation of global policies at the national level, related to prevention policies, conflicts with the economic interests of private actors. Furthermore, there have been situations in which another government agency is the one that promotes negotiations. For example, when the Special Tax on Production and Services for sugar-sweetened beverages was proposed in Mexico, it was surprisingly supported by the Secretariat of Finance and Public Credit (SHCP), who intervened for its implementation. This instance speaks of the competing interests of different government sectors.
Processes allowing actors to influence foreign policy and negotiation
Health sector
The HS’s influence on GHD strongly depends on the area of policy engagement, either at the bilateral or multilateral level, with HS arguably taking a more passive role in the latter than the former. The HS’s involvement with foreign policy processes is largely determined by its relationship with the FAS. When it comes to the multilateral agenda, the FAS usually proposes the initiatives and the HS reacts to them. Consequently, in health-related multilateral agendas, the FAS assigns the HS a technical role for assisting Mexico’s resolutions and official positions in global meetings. This situation limits the work of the HS because generally, there are no representatives from this sector attending high-level international meetings, but the HS can occasionally have some influence, especially when targeting specific topics of national relevancy.
“In the multilateral sphere, the one driving the questions of the integration of the foreign policy and the health components is the SRE so let us say that we are reactive (…) [An example of an initiative by SRE was when] we began to propose approaching trilateral health issues of Canada, [US] and Mexico. They [the SRE] responded to an initiative of [US] in terms of being able to maintain good security, health, epidemiological surveillance, strengthening cooperation, etc., and we (…) added the issue of childhood obesity in this trilateral agenda.“(Informant E, Health Sector).
The agreed coordinated and collaborative work between the HS and the FAS around specific topics was identified as the most effective mechanism for including health topics in the foreign policy agenda. Typically, the HS prepares and provides the FAS with technical information, data, and relevant documents on health topics, allowing the FAS to define a national position in international declarations and multilateral forums.
“The concrete mechanism is that we can develop a document and be able to negotiate it with SRE so that [they] can integrate it into a multilateral declaration. For example, the case of the Mesoamerican Declaration on Health and Migration (…) SRE gives us the information: the background framework, all the documents we have to refer to make this position more solid (…) It is a lot of work where we sometimes provide the substance, but they give us everything (…) the framework in which we must register this specific issue of health and migration in the case of our region.“(Informant E, Health Sector).
In the binational agenda, driven by the CSF, a relationship of greater autonomy regarding national priorities is identified. Although the working plan of the CSF calls for actions aligned to the national health programs of both countries, the health needs specific to the border context and population tend to be prioritized over those of the national agenda.
“Well, the [Federal] Secretary of Health tells me that he wants the CSF in Baja California to work on Zika, [and I respond] -well, let me consult it to the members, right?- And it turns out that the Secretary of Health [of Baja California] is also a member [of the CSF], and he says: –No, I have other priorities, my number one is tuberculosis, not Zika because people are dying of tuberculosis and I want this to be worked bi-nationally because we have drug users who come from [US] to the Rehabilitation Centers in Baja California, and then the number of cases of tuberculosis increases.“(Informant F, Health Sector).
Foreign Affairs Sector
The recognized national-level actors to consult or negotiate decision-making at the global agenda are the HS, SRE, and SHCP. As a rule, the governmental entities make the decisions as they represent the commitments and interests that affect the whole nation, and these decisions must be taken at the highest level by the corresponding federal authorities. Civil society and the non-for-profit private sector are recognized as having little influence, if any, on decision-making processes at the national level. However, one of the informants points out that the process of arriving at a consensus is very complex because there are many economic, political, and ideological interests.
“We are trying to increasingly build more transparent and plural processes towards all these sectors [including] the entities that have some legitimate interest in this, such as NGOs and the industry, so that they can be heard. We listen to them and we decide what to do with what we are told (…) NGOs are influential, with certain groups of countries. Some countries are not so receptive to the voice of civil society. There are political interests, there are ideological visions, and there are economic interests.“ (Informant D, Foreign Affairs Sector).
The representatives of Mexico in international organizations, for example, in Geneva and particularly at WHO, remark that the opinions or recommendations of a technical nature coming from the SRE and the HS are heard. However, the interview data suggest that this cooperation and consultation with the HS seems to be just rhetorical. The incorporation of health issues in international cooperation with South and Central America countries is guided by the 2011 Law of International Cooperation for Development of Mexico. This situation involves a double agenda, one related to US border matters and another linked to Mesoamerica issues.
“From the perspective of how to incorporate any topic into the cooperation portfolio, including health, the 2011 Law of International Cooperation for Development of Mexico, which is established by the Mexican Agency for International Development Cooperation, defines two regional priority areas for Mexico: Central America, and Latin America as a whole, but with the emphasis on Central America and the Caribbean. So, we work with the sense of being able to build a robust portfolio of cooperation from a first instance of the demands of the countries, and that is where we are identifying opportunity niches, including health, specifically in the Mesoamerica Project.“(Informant B, Foreign Affairs Sector).
NGO Sector
Depending on the subject, NGOs establish a dialogue and team up in coalitions with other organizations, such as independent media, that serve as key actors to disseminate information about health issues or initiatives. According to one interviewee, NGOs perceive a lack of knowledge of how health issues should be handled reciprocally by the FAS and HS. For instance, how health issues presented to diplomats should be managed or which diplomatic strategies the HS personnel should be familiar with.
“At least what I have seen in both Geneva and [UN in NYC] is that [personnel from the FAS] are not as specialized in health issues as such. A single person or a team has to analyze different issues and rely on the links with the official representations from the [HS] to strengthen the participation of Mexico [in global fora]. They have much less experience in comparison with trade, economics, or environmental issues (…) I believe that health is still not seen as a priority area within the representatives of Mexico in international organizations.“(Informant I, NGOs).
From the NGOs’ perspective, Mexico as a global actor is prone to sign treaties, conventions, and agreements worldwide but does little to broadly disseminate its international commitments domestically for an effective political impact. Consequently, the possibility for civil society to successfully demand concrete actions, accountability, or transparency from the government is limited. Many of the signed agreements that are not binding, especially those with international organisms such as WHO, are often not implemented at the national level.
“There is a huge distance between the signature of an international agreement and the implementation of public policy at the local level. There is also a need to strengthen accountability mechanisms, including sanctions, so what is agreed at the international level is implemented at the local level (…) The participation of civil society remains a mystery, let us say there are meetings with an area of the SRE, but finally, the Presidency, who coordinates the follow-up work on the agenda, is completely closed to the participation of civil society.“(Informant G, NGOs).
From the perspective of NGO informants, the interests of private companies, such as the pharmaceutical industry, can also influence the actions of governmental bodies like the Federal Commission for the Protection Against Sanitary Risk (COFEPRIS) or intersectoral institutions like the Mexican Observatory of Non-Communicable Diseases (OMENT). It should be noted the existence of vested interests in some of these governmental bodies. At the time of our interviews, for example, half of the OMENT members represented the industry.
As part of the political visibility strategies supported by NGOs, the informants highlighted public campaigns, the use of social networks, and the identification of windows of opportunity within the broad context and the processes the country is going through.
“[HS] has taken a position to defend the interests of the big corporations (…) When in 2013 [the President] created the National Strategy for the Prevention and Control of Overweight, Obesity, and Diabetes (…) the Secretary of Health was sponsored by Nestlé and created a special forum [represented] by the industry (…) In fact, there was no representation of the National Health Institutes there, but many industry businesses have a sit on it. HS only participates in those [issues] that do not intersect with the interests of large corporations.“(Informant H, NGOs).
Impact of multilateral negotiations on decision-making at the national level
The implementation of multilateral agreements in Mexico is a complex process that can fail due to political, security, or commercial interests, and so the impact that multilateral negotiations may have at the local level is limited. Some sectors, both private and governmental, might be negatively affected by a decision aimed to protect population health that was taken at a binational level (i.e., food labeling between Mexico and the US), and governance processes may develop as a consequence, including political and civil society pressure or lobbying.
Health Sector
According to some informants, the HS’s role in these circumstances is to reduce the pressure that actors outside the sector can have in order to maintain decisions oriented towards improving population health and well-being.
“Yes, we have sought to ensure that the HS is not influenced by these private actors, which basically are the pharmaceutical industry, but also other non-state actors (…) civil society organizations, sometimes they want to impose their [particular interests like] HIV/AIDS. We started to receive very strong pressure from the industry. Many times (…) these agreements offer the possibility to be gradually implemented, according to national regulations.“(Informant E, Health Sector).
Negotiation processes become more complex when an agreement signed at the international level affects not only local, non-governmental actors, but also other governmental or private sectors. Such is the case of the WHO Framework Convention on Tobacco Control, where the HS advocates against harm to health and the Secretariat of Economy defends producers’ interests.
“Intra-institutional coordination is always challenging. [In such cases] we ask the FAS to take the lead in solving any problem that can happen. Many times we end up opposed. The Secretariat of Economy supported the tobacco producers in Nayarit, and we say that smoking is harmful to health (…) The work of coordination is entirely led by the SRE [and] it is very complicated to agree [with the other Secretariats of] Agriculture, Economy, and Health.“(Informant E, Health Sector).
Foreign Affairs Sector
The role of industry and competing sectoral interests as barriers to GHD implementation was also mentioned by respondents from the FAS. One informant provided an example of the difficulties encountered in attempts to follow WHO recommendations at the national level to regulate the ultra-processed food trade in Mexico.
“The [HS] spoke with the deputies and the senators [mentioning] a serious problem of morbid obesity in the country and the health system cost is brutal (…) the legislators must approve some laws to forbid, for example, junk food selling in the schools, but [some senators and representatives] received money from [junk food industry] (…) There was a decision made two or three years ago that [public drinking fountains in primary schools] must be made available, but the initiative disappeared, I do not think it was accidental (…) and we were not complying with the decisions that were approved at international level.“(Informant A, Foreign Affairs Sector).
Ultimately, the implementation of recommendations at the national level depends on the decisions of congress members who are often influenced by corporate lobbying practices. At this level of decision-making, the informant recognized a limited power of influence coming from the FAS.
NGO Sector
Informants from the NGO sector mentioned that sometimes the HS is reluctant to support the commitments acquired at the regional level fully. This is more frequent when the implementation of global actions conflict with competing interests at the national level, such as those of the food industry.
“At least from the experience that I had with the NGO Contrapeso (Counterweight), being a member of the Advisory Council in the OMENT (…) [in HS or COFEPRIS] we did not see an openness to recognize the flaws in the subject of labeling, or on the issue of the advertising aimed at children (…) I understand to a certain extent the position of [HS] where they say they have to have openness and dialogue with all sectors (…) However, I think that that openness is in excess, in terms of discussing which policy can be modified, which policies cannot, obviously end up to a conflict of interest (…) if it is an interest in protecting health, or is an economic interest of companies, of industrial sectors [this complicates the process and generates] aggressive confrontations.“(Informant H, NGOs).
link