Just 5 days after COVID-19 was declared a pandemic by the World Health Organisation (WHO) on the 11th of March, China’s President Xi Jinping called Italy’s Prime Minister Giuseppe Conté (16th of March) to reinforce China’s support while also revealing its ambitions in being a central player in global health assistance and governance through the framework of a Health Silk Road1 《健康丝绸之路》 (Cao, 2020, p. 20). Beyond the surface, this example also signifies an existing conceptual model where a bilateral cooperation (China-Italy) is directly related and engaged with a complex multi-lateral framework (the BRI). As Cao explains, on one hand China was able to do this given its relative stability in the control of the virus (Wuhan lockdown was lifted in April) and economic recovery and, on the other, given its increasingly central role in multilateral structures such as the WHO upon America’s “policy to retreat abroad” under the Trump administration (Cao, 2020, p. 27). But within this context and having China been perceived to have more power in the global health settings and institutions, a global cognitive dissonance2 in health discourse arises between China’s calls for solidarity facing the current health crisis, with President Xi Jinping appealing to a “community of common health for mankind” (Huaxia, 2020), the attention and appreciation to its “robust anti-coronavirus diplomacy” and the heated debates and suspicion on its role in the pandemic, namely on health assistance (Cao, 2020, p.20). A question then arises: if China’s increasing importance and central role in multilateral institutions and cooperation, alongside its intervention and assistance in health is not enough to solve this cognitive dissonance, what else is there to be done? To answer this, we may speculate if in this context if, rather than changing the structural aspects of global health, there is instead a need for a more fundamental change related to the thinking informing these structures. However, solving one side of the equation does not solve the problem entirely. Another question to add is whether, despite ambition, China is ready for assuming global health governance and how it will assume it in co-operation with other countries. Based on this understanding, we need then to not so much think about what needs to be done but what needs to be in place to enable cooperation to happen. With COVID-19 this aspect became even more evident as health systems across the globe need to be thinking not only about responding to future global challenges, but essentially how they are going to be developing a new conceptual framework to work with and cooperate together. This paper analyses three possible propositions in this context, departing from a specific case-study of the China-UK Global Health Support Programme (2012-2019) (GHSP hereafter), analysing its possibilities and limitations, while enhancing the lack of a common epistemic point of departure.
1. A triangular conceptual framework
The GHSP started in 2010, was funded by the UK government and created in collaboration between the Chinese government and the former UK’s Department for International Development (Husain, Bloom & McPherson, 2020). Motivated by “the end of UK’s bilateral aid relationship with China in 2011” (Husain, Bloom & McPherson, 2020, p.1) this is yet another example on a bilateral cooperation that engages into a complex framework, but this time operating conceptually on the idea of triangular co-operation3 for development health assistance (DHA). Its main epistemological aim was to move from an understanding of “aid” to a partnership and cooperation framework in global health, in line with the UN 2030 Agenda for Sustainable Development or Sustainable Development Goals (SDGs) (Wang et al, 2019). Triangular cooperation in DHA implies here a working definition that engages a North-South balancing equation4 , whereas this configuration is particularly relevant and directly related to the history of South-South cooperation5. In this aspect, it offers an example on how conceptual frameworks matter to the choice of mechanisms for cooperation, as it brings an understanding of China as an in-between developed and developing equation, pertaining to the idea of “Global South” but with capabilities to become a provider of health assistance to other developing countries. As such, while developing new forms of cooperation between the China and the UK for “global development”, the aim of GHSP was in part to recognise China’s successful initiatives in ameliorating its health system and health of its population and its increasing importance in global health and in part to provide capacity for diversifying its portfolio in health assistance (Husain, Bloom & McPherson, 2020, p.2,3). This is also related to the fact that as Wang and colleagues state “(…) there is still a substantial gap between China’s “strong willingness” and its actual “qualified capacity” to engage in global health” (Wang et al, 2019, p.2). As a result numerous policy briefings and research outputs helped strengthen and define China’s global health strategy, as consistent in national strategies such as the Healthy China 2030 (Itad, 2017; Wang et al., 2019) and in the creation of a China Global Health Network (CGHN), that complemented China’s investment and commitment to global health in establishing international development agencies such as China International Development Cooperation Agency (CIDCA) and partnerships in health such as the Forum for China-Africa Cooperation (FOCAC) (Husain & Bloom, 2020, p.4)
The GHSP achievements are outside the scope of this paper6 but as an example of the potential of collaboration between “East and West” this project brings important reflections to the understanding of conceptual frameworks. In this sense, and beyond its positive benefits, it also helps to reveal the limitations and necessary lessons to draw from in the creation of better mechanisms for engagement, in all sides of the triangular equation and beyond it. In this regard, one of these limitations on the side of the UK, deals with the potential and unexplored cognitive biases in respect to global health and the understanding of the existence of one optimal model strongly based on conceptual premisses of the “Global North”. In a global mental health context, this idea “unidirectional learning” from the High-Income Countries (HICs) to the Low to Middle-Income Countries (LMICs) sometimes implicitly assumed, becomes an impediment to the creation and reimagination necessary for future cooperation (Kola et al, 2021, p. 542). Some of the GHSP projects in some way mitigated this aspect by focusing on research and training and the creation of academic structures in China, promoting these “to become the backbone for global health research and practice in China”, and “nurturing talent” to be an active element in these developments (Wang et al, 2019, p. 8,10). Similar issues appear on the Chinese side of the equation, in need for a deeper engagement in the understanding of local contexts, as realised by the evaluation of the GHSP7 (Husain, Bloom & McPherson, 2020, p.5). In the same vein, the “distillation of Chinese experience” as an aim of the project finds obstacles to implementation and adaptation (Husain, Bloom & McPherson, 2020). This has profound implications for the “Health Silk Road” or health cooperation within the BRI as the latter seeks to “share China’s experience and wisdom with the world” (Cheng & Cheng, 2019, p. 98). This is does not invalidate Chinese experience being valuable in specific contexts- e.g. the Barefoot Doctors program in Tanzania (see Cheng & Cheng, 2019, p.99) but states that this should be defined by local necessities8 rather than top-down overarching structures, assumptions and narratives. Lastly, on the final side of this triangle, both from the UK and from the cooperating countries, there is a conceptual limitation to engagement due to a lack of a “blueprint for building new kinds of partnership with China” (Husain, Bloom & McPherson, 2020, p.3).
The exploration of the limits of triangular co-operation enhances the need for a more pluralistic and granular framework that attests to a world in change, especially during and after the COVID-19 pandemic. As stated in the evaluation of the GHSP in this regard “Rapid change in the international system, and multiple emerging challenges, will require new kinds of relationships, learning, accommodation and adjustment by all actors – China as well as incumbents” (Husain, Bloom & McPherson, 2020, p.5).
Beyond triangulation – conceptually complex frameworks
Within the GHSP, Husain and Bloom analysis of China’s management of change and its implications is quite revealing of a fast-developing system that wants to assume a leading role in global health governance. Adding to this idea of change, experimentation, adaptation and complexity have been mentioned as key elements to consider in and beyond triangulation (Husain & Bloom, 2020; Husain, Bloom & McPherson, 2020). So, is complexity a more adequate conceptual model for mechanisms of cooperation? The answer is both yes and no. On the one hand, as stated above, there is a need for differential points of view both conceptually and operationally driving the triangular co-operative model and this creates a complex setting to work from. On the other hand, given the current context, this could lead to increasing fragmentation in a time where cohesion is necessary. This is exemplified by the symbolic timing of the GHSP that, being continued beyond 2019, could have further enhanced the need for cooperation in health between China and the UK during the COVID-19 pandemic9. Instead, as a more negative development, we see increasing politicisation which complicates the potentially positive cooperative developments. The GHSP project perceived the health system and sector at the time as “comparatively non-contentious area for developing international collaboration” (Husain, Bloom & McPherson, 2020, p.2). Despite the epistemic truthfulness of this premiss, the triangular relational structure that this project proposes is likely to find more obstacles in an era where the US and the EU, as well as the UK, are taking a stance towards China as demonstrated by the recent G7 Summit (11-13th June) and the creation of its own global health position in the Carbis Bay Declaration (Wintour, Stewart & Inman, 2021). A question to ask, under this context is when bilateral and multilateral relations are potentially menaced, what does this mean for the third element in the triangular equation? Adding to this is the role China may have in global assistance and cooperation in health in neighbouring regions and many other geopolitical and economic strategic positions (see Husain & Bloom,2020, p.4) as this becomes a highly contested conceptual framework, between being complex and complicated and aiming for a pluralistic complexity, in the adaptation to a “pluralistic global order in a context of rapid change” (Husain & Bloom, 2020, p. 9).
Where do we go from here? The case for a synergistic conceptual framework
Within the context of COVID-19 and the reshaping of global governance, China’s own “template” for global health engagement, which was lacking during GHSP (Husain & Bloom, 2020, p. 5), is an important element for cooperation. The idea of a “community of common health for mankind” (Huaxia, 2020) mentioned above is already informing this understanding but it needs to be establishing corresponding operational mechanisms that dialogue effectively with international conceptual and operational frameworks. It became clear under the COVID-19 pandemic that multilateralism is not enough and more robust strategies for international cooperation are needed. Two elements need to be brought together in this respect: diversification of strategies and unification around common causes and needs. As Husain and Bloom stated “Initiatives such as the 2015–2017 BRI health cooperation plan show how highly pluralistic, emergent initiatives across the country are being screened and assessed for their usefulness as potential models for a more diversified Chinese role in global health” (Hussain & Bloom, p.8). However, beyond a diversification of role and despite attempting to a coherent narrative there is an absolute need to understand not only the differential power dynamics but also the specificities of cultural settings. In other words, a common epistemic definition is lacking as shared narratives are fundamental for a common understanding. Thus, beyond complexity, there is an urgent need for a synergetic conceptual framework. In this respect, much has been said about the need to work with China in climate change10 but much less has been argued in working with China in global health. In this context, the GHSP may have functioned as a possible “proof-of-concept”, both in its potential as well as its limitations, to achieving synergy in cooperation. Moreover, and to end on a claim to rethink and reimagine conceptual frameworks, it showed the importance of knowledge sharing and production, while remembering the need to diversify and ameliorate China’s contribution to what Wang and colleagues state as the “global pool of knowledge” and, ultimately to provide alternatives in epistemic11 modes of functioning in the future of Global Health.
Dr Carla de Utra Mendes holds a PhD in Global Studies, undertaken in Macau, S.A.R, China (awarded by the University of Saint Joseph, Macau S.A.R., China and the Catholic University of Portugal), as former fellow of the Foundation for Science and Technology (FCT) of the Ministry for Science, Technology and Higher Education of Portugal. She is currently completing an MA in Psychoanalytic Studies at the Tavistock and Portman NHS Foundation Trust in London, U.K.
Since her Masters degree in Contemporary Culture and New Technologies (Faculty of Human and Social Sciences of the NOVA University Lisbon, Portugal), Carla has been focusing on East Asia. She develops interdisciplinary research on contemporary China. Her interests range from culture and society to global mental health.
Cao J, (2020) Toward a Health Silk Road. China’s Proposal for Global Health Cooperation, China Quarterly of International Strategic Studies, 6(1): 19-35, https://doi.org/10.1142/S2377740020500013.
Cheng Y, Cheng F, (2019) China’s unique role in the field of global health, Global Health Journal, 3(4): 98-101, https://doi.org/10.1016/j.glohj.2019.11.004.
Festinger, L (1957) A Theory of Cognitive Dissonance, Stanford CA: Stanford University Press.
Global Health Research and Policy (n.d) The Governance of New Coronavirus Pandemic: Bridging Research and Policy, [Website] https://ghrp.biomedcentral.com, accessed 20.06.21.
Husain L, Bloom G, (2020) Understanding China’s growing involvement in global health and managing processes of change, Globalization and Health, 16(39), https://doi.org/10.1186/s12992-020-00569-0.
Husain L, Bloom G, McPherson S (2020). The China -UK Global Health Support Programme: looking for new roles and partnerships in changing times, Global Health Research and Policy, 5 (26), https://doi.org/10.1186/s41256-020-00156-1.
Harmon-Jones, E., & Mills, J. (2019). An introduction to cognitive dissonance theory and an overview of current perspectives on the theory. In E. Harmon-Jones (Ed.), Cognitive dissonance: Reexamining a pivotal theory in psychology (pp. 3–24). American Psychological Association, https://psycnet.apa.org/doi/10.1037/0000135-001.
Huaxia (01.06.2020) Xi calls for building community of common health for mankind. COVID-19 timeline, Xinhuanet, http://www.xinhuanet.com/english/2020-06/01/c_139105528.htm, accessed 20.06.21.
Itad (March 2017) China’s increasing global health engagement [Website], https://www.itad.com/knowledge-product/chinas-increasing-global-health-engagement/, accessed 20.06.21.
Kola L, Kohrt BA, Hanlon C, Naslund JA, Sikander S, Balaji M, Benjet C, Cheung EYL, Eaton J, Gonsalves P, Hailemariam M, Luitel NP, Machado DB, Misganow E, Omigbodun O, Roberts T,Salisbury TT, Shidhaye R, Sunkel C, Ugo V, van Rensburg AJ, Gureje O, Pathare S, Saxena S, Thornicroft G, Patel V (2021) COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health, The Lancet Psychiatry 8: 535-50, https://doi.org/10.1016/S2215-0366(21)00025-0.
Mignolo WD. Epistemic Disobedience, Independent Thought and Decolonial Freedom. Theory, Culture & Society. 2009;26(7-8):159-181. doi:10.1177/0263276409349275.
OECD, (n.d) Triangular Co-operation [website], https://www.oecd.org/dac/triangular-cooperation/, accessed 20.06.21
Sengupta S, (13.11.20). Biden Wants to Be the Climate President. He’ll Need Some Help From Xi Jining, The New York Times, https://www.nytimes.com/2020/11/13/climate/biden-climate-china.html, accessed 21.06.21.
Sousa dos Santos, B (2016). Epistemologies of the South. Justice Against Epistemicide, Oxon UK, NY:Routledge (Original From 2014).
The Lancet Global Health (2017). Facing forwards along the Health Silk Road. The Lancet Global Health.5(10):e948. doi: 10.1016/S2214-109X(17)30349-2.
United Nations (2016), Framework of operational guidelines on United Nations support to South-South and triangular cooperation. Note by the Secretary-General (English), https://digitallibrary.un.org/record/826679?ln=en#record-files-collapse-header, accessed 20.06.21.
Wang X, Liu P, Xu T, Chen Y, Yu Y, Chen X, Chen J, Zhang Z, (2020). China-UK partnerships for global health: practices and implications for the Global Health Support Programme 2012-2019, Global Health Research and Policy, 5 (13), https://doi.org/10.1186/s41256-020-00134-7
Wintour P, Stewart H, Inman P, (13.06.21) G7’s Carbis Bay declaration: the key pledges, The Guardian, [Website] https://www.theguardian.com/world/2021/jun/13/g7s-carbis-bay-declaration-the-key-pledges, accessed 20.06.21.