China’s growing engagement in Global Health

Background

The purpose of this summary is to review China’s growing engagement as a stakeholder, actor and donor in Global Health. The focus is on sub-Saharan Africa since these 46 countries (which include 33 of the world’s 47 least developed countries, and 17 of its 29 Fragile or Conflict-Affected Situations) still account for a grossly disproportionate fraction of the Global Burden of Disease. Improving health, and advancing health equity worldwide is a core objective for the global health discipline1, and a focus for development assistance for health (DAH). However, many strategies for improving health, and managing health risks relate to “health and related transnational flows of diseases, people, money, knowledge, technologies, and ethical values” that lie beyond the sphere of influence of individual nation states, bilateral or regional partnerships.2 Global health security focuses on collective action for mutual protection against common and transferred risks. Global health governance sets ground rules and oversight (standards, norms, policies and regulations, financing) for actions that advance shared global health goals, and global health diplomacy comprises the international negotiation and policymaking processes that frame responses to acknowledged global health problems.

Three analytical frameworks have been suggested as ways of conceptualizing global health diplomacy.3 These contrast realist versus constructivist motivations for engagement, vertical with horizontal strategies for improving health and healthcare, and bilateral with multilateral approaches to deliver aid and programmes (Table 1). Motivations underlying commitments to development assistance are often mixed, and aid portfolios typically include support for both vertical and horizontal programmes, delivered as part of bilateral and multilateral processes. Nevertheless, the ‘distinctiveness’ of the Chinese approach is often alluded to and it may be instructive to explore this further by contrasting apparent motives, objectives and methods with those of other actors.

Table 1. An analytical framework for global health diplomacy4

China’s recent engagement in Global Health needs to be understood in the context of the remarkable success of its own domestic economic, human and health development agendas. In 1978, after the national calamities of the ‘Great Leap Forward’ (1958-62) and the Great Proletarian Cultural Revolution (1966-76), but before Deng Xiaoping’s open-door reforms, China was one of the World’s least developed countries, with a Gross National Income (GNI) ranked 175^th of 188 economies with available data. By 1997 it was reclassified as a lower-middle income country, and in 2010 as an upper-middle income country. According to current projections it may achieve high income country status by 2025, in the same year that its (exchange rate converted) GDP overtakes that of the US.5 Over 800 million people have been lifted out of poverty, China thereby making the critical contribution to meeting Millennium Development Goal #1 (Eradicate extreme poverty and hunger). China’s progress on health related MDGs has been equally impressive, with targets generally exceeded, ahead of schedule (Table 2)

Table 2. China’s progress towards achievement of the health related Millennium Development Goals

China is justifiably proud of these achievements, and the conclusion of its summative official report reviewing progress is telling

With the tremendous experience acquired with the MDGs, China is well positioned to play a key role with the Post 2015 development Agenda – both in term of implementing the new development agenda domestically but also sharing its knowledge with other developing countries through South-South cooperation.

Historical context of China’s engagement with Africa

It is important to acknowledge the long history of Chinese engagement in Africa in the modern era, dating back at least to the Bandung Asia-Africa Conference of 1955, and the Five Principles of Peaceful Co-Existence drafted by China’s Premier Zhou Enlai and Jawarharlal Nehru: political self-determination, mutual respect for sovereignty, non-aggression, non-interference in internal affairs, and equality. China’s involvement has always had a strong ideological foundation founded upon liberation, decolonization, and a robust rejection of post-colonial hegemonies. Contemporary analysis drew attention to three interactive themes6:

1. the ‘Chinese Model’ comprising an approach to armed revolutionary struggle (a ‘People’s War’), and China’s exemplary post-1949 economic, industrial and social developmental experience – seen at the time as both unprecedented and impressive in its scope and pace

2. Its struggle against the superpowers, the US and the Soviet Union, particularly the latter after the Sino-Soviet split in the early 1960s - most evident in the wars of independence of the 1970s in Angola, Rhodesia (Zimbabwe) and South Africa, and the politicking with the neighbouring frontline states (Mozambique, Zambia, Tanzania).

3. China’s ‘Third World’ policy, which aimed to identify with states in Africa, Asia, and Latin America and build political ties in support of common interest, creating new international structures that would balance and control the influence of the superpowers. These objectives were apparent throughout China’s enthusiastic participation in the Non-Aligned Movement

These themes were succinctly expressed in a 1976 Editorial in the People’s Daily, the official organ of the Communist Party of China7:

"Both China and Africa belong to the Third World. In the great struggle against imperialism, colonialism and hegemonism, the Chinese people. will always stand on the side of the fraternal African people and firmly support their just struggle till final victory.”

While the full menu was, perhaps, never wholeheartedly embraced, certain elements of China’s prospectus were felt to be applicable and found favour at different times with many post-independence African leaders - as President Julius Nyerere of Tanzania expressed in 19658:

"The vast majority in both China and Tanzania earn their living from the land or in the rural areas. And both of us have only recently won freedom from that combination of exploitation and neglect which characterizes feudal and colonial societies. We have therefore much to learn from each other”

China’s early engagement with newly independent African states is often described as ‘political’. It is true that in the 1960s there was a focus on securing diplomatic recognition and votes on the UN General Assembly to support PRC’s application to secure the seat still occupied by the nationalist Republic of China government. Nevertheless, there were important links with trade and aid from the outset. In 1976, a US State Department report identified US$1.9 billion of flows in economic credits and grants between 1956 and 1974, to 28 African countries, with US$1.5bn (80%) in the five years between 1970-749. In 1974 grants and concessionary loans to Tanzania alone amounted to US$331 million, including support for the construction of the rail link between Tanzania and Zambia.10 While much early aid was focused on infrastructure development and technical assistance, China sent the first of its medical teams to Algeria in 1963, and donated its first hospital to Tanzania in 1969.11 Zhou Enlai set the terms of Chinese aid (couched as “mutual assistance”) on his 1963-64 tour of 10 African states12, which included five sub-Saharan African nations - Ethiopia, Guinea, Ghana, Mali, Somalia. The key messages were that China:

1. aims for mutual benefit in the relationship, and operates from a principle of equality with the beneficiary respecting its sovereignty and autonomy

2. never attaches any conditions (the ‘no strings’ principle)

3. helps beneficiaries to achieve independent and sustainable development (“in providing any technical assistance, the Chinese Government will see to it that the personnel of the recipient country fully master such technique”)

4. provides the best-quality equipment and materials of its own manufacture

5. focuses on cost-effectiveness and rapid development impact (“less investment while yielding quicker results”)

The early 1980s signalled a change in China’s relationship with Africa, clarified in Premier Zhao Ziyang’s “Four Principles on Sino-African Economic and Technical Co-operation” announced in the context of a tour of 11 African nations in 1982.13 China’s focus was, increasingly on its own economic development. The ‘Four Principles’ emphasised mutual benefits and common development to be achieved through co-operative projects and joint ventures. Rather than large aid commitments and technical assistance projects, China sought co-financing, and increased scope for Chinese companies to bid for contracts in Africa. The strategic aim of Chinese aid delivered on a cost-sharing basis, was to "contribute to the enhancement of the self-reliance capabilities" in both Africa and China14. While China aspired to the status of a major power, the truth was that it remained a developing country, most of whose population lived in poverty; the largesse of the 1960s and 1970s was considered unsustainable. The health sector in China became increasingly marketized, with reduced government funding, fee-for-service, and a new profit driven private sector pharmaceutical industry15. Inequities in access to care became more apparent, and the Chinese people-centred community-orientated health system that was an influential development model for the Declaration of Alma Ata withered. While still relevant to sub-Saharan African needs, scope for implementation was limited by the similar neoliberal reforms to the health sector foisted on African debtor states by the IMF and World Bank as conditions of access to loans and aid .

The expansion in trade with and aid to Africa stemmed from several developments in the early 2000s. China’s economic development was now proceeding apace generating both foreign currency reserves (which increased from USD 0.2 trillion in 2000 to over 3 trillion by 2011, and some of which could be earmarked for ODA), and an ever increasing domestic demand for energy and raw materials (that could, in part, be provided by sub-Saharan African countries). In 2006 Foreign Minister Li Zhaoxing announced a White Paper resetting China’s African Policy 16. It restated the constructivist rationales that informed Zhou Enlai’s Eight Principles (solidarity, friendship, common experience, common interests, and the struggle for national liberation and development). While much of the paper focuses on facilitating trade and investment with Africa, developing its infrastructure, and exploiting its natural resources, sections also allude to China’s willingness to contribute economically - “in light of its own financial capacity and economic situation, China will do its best to provide and gradually increase assistance to African nations with no political strings attached”. Debt relief and development assistance for health were both highlighted. China also undertakes to use its influence through multilateral channels to secure a fairer deal for Africa. China’s accession to the World Trade Organization (WTO) in 2001 set a seal on the economic reforms of the 1980s and 1990s and was a landmark event in China’s more active participation in the ‘world system’ and its intergovernmental organisations. China transitioned from World Bank International Development Association member status in 1999, and became a donor in 2007. It has increased its contributions to the International Monetary Fund (IMF) securing, with other BRICS counties a greater stake in decision-making and governance. It has moved rapidly from being a net beneficiary to a net contributor of funds to UN agencies including the WHO, UNICEF, UNFPA, and UNAIDS. China’s increased economic and trade engagement with Africa provided a platform and important opportunities for greater engagement in global development in general, including development assistance for health17. Since 2000, China’s triennial Forums on China-Africa Cooperation (FOCAC – Ministerial Conferences and Summits) have been used to set and announce Chinese policy and investment commitments, including priority themes for DAH pledges for the coming three years; hospital construction, malaria control, and high education scholarships (2007–09); training of health workers and artemisinin drug donation (2010–12); Brightness Action (eye care) campaign (2013–15); enhancing epidemiological surveillance, including support for the new Africa Centres for Disease Control and Prevention (Africa CDC), strengthening domestic capacity to manufacture drugs, vaccines and diagnostics, with local production by Chinese enterprises (2016-18)18

What is the volume of Chinese Official Development Assistance (ODA)?

It is difficult to estimate China’s total Official Development Assistance (ODA), and the component of ODA that targets improvements in health (DAH - Development Assistance for Health), given the complexity and opacity of the Chinese system. ODA is defined by the Development Assistance Committee (DAC) of the Organisation for Economic Co-operation and Development (OECD). China is not a member of the DAC and classifies itself as a South-South cooperation development partner or provider—not a “donor”, per se19. The Japan International Cooperation Agency (JICA) has been tracking Chinese ODA (according to DAC definitions) annually since 201420. Using the DAC’s currently recommended ‘grant equivalent basis’ total ODA increased from US$5.1 billion in 2015 to US$5.9 billion in 2019. The JICA estimates are not broken down according to beneficiary country or region, but according to other estimates ODA to Africa accounts for around half of China’s total disbursements21. The shares of bilateral grants and interest-free loans, Chinese government concessional loans, and contributions to international organizations in the 2019 total were 48%, 21%, and 30% respectively. The total represents 0.044% of China’s nominal GNI. This falls far short of the 0.7% target enshrined in a UN resolution in 1970. However, this target was intended to apply to the flow of aid from richer Organisation for Economic Co-operation and Development (OECD) countries to poorer countries, deemed necessary to close the development gap. In absolute terms China’s ODA current contributions would place it among the top 10 OECD donors after the USA, Germany, UK, Japan, France and Turkey.

Figure 1 JICA estimates of DAC and 16 leading countries ODA on a grant equivalent basis, 2015-2019. US$ billion (Fig 4 from JICA report⁷)

Over the past two decades, according to the JICA estimates⁷, China is one of a handful of countries substantially to have increased its ODA spend (Fig 2).

Figure 2. JICA estimates of net ODA disbursement from 16 leading countries, 2001-2019. US$ billion (Fig 5 from JICA report⁷)

How significant is China’s DAH as a component of ODA?

One study has estimated DAH specifically for African countries22, using the China AID Data database. Over the period 2000-2013, 531 projects were identified, for which monetary values were attached for only 206. No account is given of whether, or if so, how, missing data were estimated. The cumulative total health sector contribution between 2000-2013 was nearly US$2.2bn comprising 2.1% of total China ODA to these countries over this period. When projects that were more broadly ‘public health related’ were also included, for example Water Supply, Sanitation and Hygiene (WASH), population and reproductive health programmes, DAH rises to US5.65bn or 5.4% of total ODA. Using period averages to smooth annual variation, DAH for African countries increased rapidly from US$ 66m pa (2000-2004) to US$ 504m pa (2005-2009) and then more slowly to US$ 705m (2010-2013).

In a more recent study23 China’s total DAH contributions to all world regions were estimated using a ‘top-down approach’ based on annual disbursements from the relevant governmental agencies; the National Health Commission (medical teams); Ministry of Commerce (MOFCOM – grants or interest free loans for infrastructure projects, hospital construction, drug and medical equipment donations); Ministry of Education (scholarships to foreign medical and health sciences students); and the Export and Import Bank (EXIM – the only policy bank in China that provides concessionary loans). In this study an attempt was also made to track and disaggregate multilateral contributions, through UN agencies (WHO, UNFPA, UNAIDS, UNICEF), the World Bank, the Global Fund, GAVI and Regional Development Banks. From 2007-2017 China’s worldwide annual DAH contributions doubled from US$323m to US$652m, although most of this increase occurred between 2007 and 2012, and plateaued thereafter. Of the total $5.7bn DAH provided by China over the 11-year period, 64% was disbursed by MOFCOM, 16% by NHC, and 6% each by EXIM and MOE. Only 8% of DAH was distributed through multilateral channels, principally WHO (4%) and World Bank (2%). This proportion had increased significantly from a very low base in 2012 to exceed 10% by 2016. China’s DAH contributions are roughly at expected levels given the relationship that exists internationally between DAH per GDP, and GDP per capita (Figure 3).

Figure 3 Expected and observed development assistance for health (DAH) contribution as a share of gross domestic product (GDP) conditional on gross domestic product per person of donor country.24

Where is China’s DAH targeted?

Most sources agree with the view expressed in a 2014 Lancet Editorial25, that Chinese DAH is provided in five main areas: medical teams, building hospitals, donating drugs and equipment, training health workers, and malaria control. In that study, estimates of the value of these contributions to African countries between 2007 to 2011 were around $60 million annually for Chinese medical teams, and a similar amount for donated facilities. These two components accounted for roughly 80% of total DAH in the region (estimated at $150 million per annum).

Up to 2013, 648 separate medical team visits were documented, assignments having an average duration of 2 years26. The teams typically provide clinical hospital-based services for specialities in short supply including surgery, eye care and obstetrics, often working out of Chinese donated hospitals and clinics. The scope of this work is extraordinary, and is largely focused on sub-Saharan African countries with only 66 visits (10%) to non-African countries. Forty-two of the 46 sub-Saharan African countries had benefited – only South Africa, Nigeria and Kenya (with better developed health systems) and Eswatini (no diplomatic relations with China) had not received a visit. Since 1970, China had also constructed more than a hundred health facilities overseas; this form of assistance was accelerated in the 2010 to 2012 triennium with around 80 construction projects of health facilities27. Most were donated, but some were part of wider infrastructure development projects funded by concessional loans. African countries were the recipients of more than three-quarters of the donated facilities. Most facilities are built by Chinese construction firms and then transferred to local authorities in a so-called ‘turn-key’ operation.

Given the focus of Chinese DAH, it is not surprising that, according to the most recent estimates, 94% of China’s DAH funding is broadly classified as linked to generic health system strengthening, and hence ‘horizontal in character.28 The only significant investments in vertical programs were those in the control of infectious diseases (1.4%) and newborn and child health (1.1%). For African countries 85% of the health sector DAH was horizontal, orientated to improving healthcare in general or strengthening health systems29. 8% of the funding went to support 115 malaria projects, and 7% to support maternal newborn and child health care. Lesser amounts were invested in other infectious disease control projects (cholera, ebola, TB and schistosomiasis) and eye health.30 Consistent with the horizontal approach 78% of the total funding on ‘public health’ DAH was for infrastructure, equipment and medicine.31

A key finding from the Africa focused review was that the monetary value of DAH was highly concentrated to just a few countries, although projects were more widely distributed; 69% was spent on the top four countries Zimbabwe (19%), Angola (18%), Cameroon (17%) and Ghana (15%), and 84% on top 10 (also including Cote d’Ivoire (4%), Sudan (2%), Kenya (2%), Mauritius (2%), Uganda (2%), and Zambia (1%). A detailed sub-national level mapping of the location of hospital and clinics, anti-malarial centres and Chinese Medical teams, found a marked concentration on the more developed northern, western and eastern African coasts, and, for hospitals, in capital cities and major conurbations (Figure 4).32 Chinese medical teams were marginally more likely to be found in less developed areas, but also near to the birthplace of the African country’s current leader. Malaria centres were also clustered in capital cities, and not preferentially allocated to zones of high endemicity or malaria risk. The authors concluded that while the destination of Chinese DAH was said to be “recipient driven” this “was more likely to be “recipient’s government elite driven” rather than “recipient’s local health needs driven””.33

Figure 4. Subnational distribution of China’s Development Assistance for health in Africa34

Several studies have sought to correlate ODA or DAH at country level with indicators that, if correlation were demonstrated, might suggest a realist agenda, specifically based upon economic interest. These included; petroleum imports, China’s foreign investment, and China’s imports from and exports to Africa35; exports36; and African countries’ natural resources37. It seems reasonable to conclude, from the general absence of correlation that China’s assistance is not motivated to an important or obvious extent by such considerations38.

How is China’s aid provided?

One of the factors that makes the value of China’s DAH (and ODA in general) hard to estimate is that almost all of it is made on an ‘in kind’ basis with no direct transfers of funds to the beneficiary country39. Chinese state-owned enterprises or private companies are contracted and resourced to construct hospitals and clinics. Chinese pharmaceutical and other biomedical companies provide drugs and equipment. The Chinese medical teams are supported on enhanced salaries by government hospitals in China, with twinning arrangements between Chinese provinces and African countries. Scholarships are provided to African biomedical students to study in Chinese Universities. However, these DAH contributions are, in effect donations, whereas much of China’s ODA is in the form of interest-free or concessional loans. These kinds of arrangements are not unheard of for bilateral aid for OECD countries, but their complete dominance in the Chinese ODA and DAH portfolios is a distinctive feature. Unlike most OECD and intergovernmental donors, China does not offer general sectoral financing direct to Ministries of Health, which can then be pooled and used with some discretion and flexibility to advance local Ministry of Health strategic agendas. A good example of this is Ethiopia’s ‘diagonal investment’ approach, which has brokered agreement with multiple funders of vertical programmes (GAVI, PEPFAR and the Global Fund), as well as national bilateral donors to allocate some support for primary healthcare system strengthening as part of a unitary health-sector development plan (‘one plan, one budget, one report’) under the strategic control of the Ministry of Health40. Between 2003 and 2016, Ethiopia constructed or renovated 250 hospitals, 3,000 health centres and 12,000 health posts. Investments were also made in laboratories, health information systems, supply chains and logistics and onsite staff training. Just over a quarter of GAVI investments, and a third of Global Fund investments were targeted in this way.

Several sources draw attention to a lack of strategy and coordination in the planning, allocation and delivery of Chinese DAH41. Part of the problem in the past has been the independent operation of the various funding mechanisms located in or responsible to different ministries. This has led to limited coordination and sometimes competition between ministries; misaligned priorities; problems for MOFCOM’s small in country teams to manage a large number of poorly integrated programmes; and (hence perhaps) limited oversight and accountability42. The creation in March 2018 of China’s International Development Cooperation Agency (CIDCA) is designed to address some of these problems. CIDCA’s remit is “to formulate strategic guidelines, plans and policies for foreign aid, coordinate and offer advice on major foreign aid issues, advance the country’s reforms in matters involving foreign aid, and identify major programs and supervise and evaluate their implementation.”43 In practice there is a three-stage process. First CIDCA appraises and approves or rejects all requests for support, considering fit with strategic and policy priorities, implementation plans and feasibility. Next, approved projects are passed to MOFCOM and their ‘in line’ ministries for contracting and implementation planning, and then to Economic and Commercial Counsellors (ECC) and Ambassadors in country for delivery, monitoring and evaluation. In the final stage CIDCA will carry out an ex-post summative evaluation of all completed projects. There is some doubt as to how CIDCA will be able to deliver effectively on these roles, with a staff of only around 100, and an annual budget of US$18 million. Development expertise is, as yet, limited within CIDCA, most embassies in Africa have a handful of ECCs with much less knowledge of comprehensive impact assessment in the ODA context. Nevertheless, CIDCA’s creation has been welcomed by the international Global Health community internationally, with the hope that this might make China’s contribution to DAH more strategic, coherent, transparent, and evidence/impact orientated. Synergies with the work of other actors and potential partners may be easier to identify, providing opportunities for collaborations and multilateral activities.

With regard to implementation in country, a qualitative evaluation carried out by US Global Health academics of the experiences and perceptions of African and Chinese participants in China-Africa DAH programmes in Malawi and Tanzania provides rare insights into the processes, from the perspectives of Chinese embassy staff, medical team members, their African clinical counterparts, and staff from Ministries of Health, health delivery organisations, NGOs, and academics.44 Narratives from African participants dominate. The themes that emerge are generally quite negative, raising serious questions about the planning, conduct and management of the programmes. Chinese medical team members felt poorly prepared and supported for their roles and reported serious barriers to communication with their African colleagues. This led to frustration, burn out, and rapid turnover of staff. Similar impediments were reported on the African side. More worryingly consistent themes emerged around a lack of consultation, needs assessment, objective setting, monitoring and evaluation. Much wastage was reported when the wrong equipment or drugs arrived at the wrong place or time. Where training was provided by Chinese medical teams, this was appreciated. Some African participants alluded to a lack of Chinese sensitivity to the power dynamics (disparities in political capital, economic resources, institutional and educational development), which, if not discussed openly risked replicating previous colonial relationships.

The Future of Chinese Development Assistance for Heath

The Belt and Road Initiative (BRI), launched in 2013, will be the main driver of Chinese engagement in Asia and Africa for the foreseeable future. BRI links China with 140 countries in Asia, Africa and Europe through investment in roads, railways, bridges, airports, ports, and communications.45 The primary aim is economic development (the countries involved cover 70% of the world’s population, but only 30% of its GDP) through enhanced connectivity, trade and commerce.46 The planned investment is massive, amounting to up to 9% of China’s GDP. Much but not all of this will be on a commercial basis. China has leveraged new investment vehicles linked to the global south (the Asia Infrastructure Investment Bank, the New (‘BRICS’) Development Bank, the Silk Road Fund, the China-Africa Development Fund and the China South-South Cooperation Fund) to generate US$267 billion in pledges. China has from the outset of BRI envisaged investment in health as an important component. The forms that this will take remain unclear. However, China has signed an MoU with the WHO to enhance global health security along the Silk Road. Scientific and technical collaboration, and knowledge exchange will be important elements; the Chinese Government has committed to launch four networks involving BRI countries, focused on public health, health policy research, hospital alliance, and the health industries. Bilateral agreements with BRI countries have covered a range of areas including health security, maternal and child health, health policy, health systems, hospital management, human resources, medical research, and traditional medicine.47

The scope and scale of China’s bilateral and multilateral activity in DAH and global health has expanded with bewildering pace in recent years. Policy agendas are ambitious, aiming to effect transformative change. This has exposed a shortfall in professional and organisational capabilities, particularly the small pool of expertise in specialist administrative, academic, and technical roles, and field experience in programme implementation. These limitations were acknowledged when China first attempted to deliver emergency assistance at scale, during the West Africa Ebola outbreak in 2013-16 [15]. Although China is now a significant financial contributor to WHO, it has not been able to fill its allocated share of technical advisor positions at the Organization. Steps are being taken to address these limitations, among which the creation of CIDCA may be the most important. In 2013 a China Consortium of Universities for Global Health was founded with ten Chinese universities. The aim is to share knowledge and resources, foster collaboration, develop and deliver curricula in global health, promote research, provide advice and facilitate Chinese participation in global health activities abroad. CCUGH also encourages long-term partnerships with established global health institutes around the world.

Conclusions

China’s contributions to development assistance for health (DAH) have increased sharply over the last 15 years, to the extent that they have become globally significant. Nevertheless, they remain relatively modest both as a proportion of overall official development assistance (ODA), and in relation to China’s population size and still rapidly growing economy. There are distinctive features, with respect to the three questions posed at the outset: Why is China pursuing health diplomacy in Africa? What has Chinese assistance sought to achieve? How have initiatives been delivered?

The question of China’s motivation for engagement in Africa; realist of constructivist, trade or aid, soft power and economic advantage or disinterest: has become somewhat sterile, and may miss the important point. There is no doubt that China’s investment in health has, among other things strengthened economic, commercial and political relations, opened new markets for Chinese goods, and facilitated extraction of natural resource in Africa and their export to China.48 In the view of the Chinese authors of a 2014 Lancet review

“Taking advantage of both domestic and international resources and accessing both domestic and international markets is China’s explicit national development strategy. These powerful economic motives drive much of China’s global engagement, including its engagement in Africa, to the point where the dividing line between trade and aid become blurred and hard to demarcate. Health aid is only a very small adjunct to these much larger and more powerful forces.”49

However, China does not recognize the concept of ‘aid’ as defined by OECD DAC. Their contributions, whether, grants, loans or commercial deals are all ultimately orientated to south-south collaboration for mutual benefit with the goal of securing self-reliance through economic and human development. The lesson, learnt the hard way in China, is that development is the only route to freedom and true sovereignty. Given the emphasis on ‘self-reliance’, escaping from dependence on aid (which China has itself quite recently achieved) is one of the freedoms that China would presumably like to see extended to its southern development partners. While the nature and extent of Chinese engagement has waxed, waned and evolved with the times, the essence of the ‘China model’ has been consistently expressed and acted upon throughout. It is heavily influenced by constructivist principles – the shared experience of colonization, poverty, and underdevelopment, and the common desire to achieve independence, security and prosperity. In China’s experience, economic development has been key to the achievement of its domestic goals. But economic development secures health improvements through a variety of mechanisms, mostly outwith the health sector. And effective direct investment in health improvement (promotion, prevention and care) and health security provides a more productive workforce and a more favourable investment environment. Chinese assistance with ‘no strings’ avoids the conditionality and coercion that has characterized much OECD ODA, with the perception, at least, of post-colonial tendencies. China’s model is indeed very distinctive. Its investment in infrastructure provides assistance on a scale and of a type that no other donor nation would countenance. Again, China has perceived, accurately, that economic development will be limited until Africa is better connected, internally and externally, through transport, energy, water and digital technology

China has mainly sought to help by strengthening health systems in general, that is horizontal rather than vertically orientated programmes that focus on the rapid control or elimination of specific diseases through improved access to evidence-based care. It may be that this reflects China’s appraisal of its own capabilities and limitations.50 The focus on health system strengthening is unusual compared with other major donors51, and therefore welcome. However, the limited literature on of these programmes focuses on processes (numbers of medical teams, and hospitals and clinics constructed), with very little apparent evaluation of outcomes and impact. There are reasons to suppose that this may have been limited. Investment seems to have been made mainly at the secondary care level (constructing hospitals and providing specialist clinical care services). Given China’s own development experience there are surprising gaps in the health system strengthening offer; quality improvement in community and primary healthcare, health promotion and prevention services is badly needed in sub-Saharan Africa, alongside technical assistance in health policy, planning and financing. Investments appear to have been doubtfully integrated into countries health systems, and inadequate needs assessment, planning and local stakeholder engagement are all likely to have undercut the sustainability and hence long-term impact of selective investment in one part of the health system infrastructure (hospitals), and substituted services delivered by short term assignments of medical teams.52 Donations of medication can be helpful, but knowledge transfer and co-investment by Chinese pharmaceutical companies to develop independent manufacturing capacity in the Africa region would have huge long-term capacity building significance. This was envisaged as part of the 2015-2017 China-Africa (FOCAC) agenda53, but apparently deprioritized in 2018, with no explanation from the Chinese government.54

China delivers most of its DAH through bilateral agreements. In so doing it controls the destination and use of the aid, even more so since the aid is delivered ‘in kind’. Arguably this provides more scope for political and economic leverage with beneficiary countries. This may also be useful at home, where the value and appropriateness of China becoming a donor, while still having development needs of its own have been questioned in the past.55 Public awareness and approval still needs to be cultivated56. This does not mean that China is averse to working multilaterally. During the Ebola outbreak in West Africa, China and its teams on the ground cooperated extensively and effectively with all other actors, including governments, bilateral donors, UN, multilateral groups, and non-government organisations. In the wake of the outbreak China signed an MoU with the USA to facilitate the collaboration of both countries CDCs to help establish an African CDC57. China’s formal multilateral contributions have increased in volume and as a proportion of DAH, as its spending on aid has increased. It is, however, highly selective and strategic. Most of the recent growth in multilateral contributions is delivered through the WHO, and to a lesser extent the World Bank. Future directions are uncertain. While there has been optimism that the recent growth in multilateral contributions reflected more than mere symbolic gestures, it is also possible that China is leading what may be a partial breakaway from at least some of the established systems of global development collaboration. The Belt and Road Initiative is financed by an alternative international development finance system, which China and its fellow BRICS countries and other southern partners have been instrumental in establishing. WHO is partnering with China in several BRI health-related activities. BRI will itself create opportunities for multilateral investment, but on China’s terms, and consistent with its policy priorities and development model. It is uncertain at present how much of the BRI health-related projects will be delivered multilaterally, and how much would qualify as ‘aid’. It is clear that the major focus is on economic, trade and infrastructure development much of which will be on commercial terms58. China has already signed many bilateral agreements, involving the majority of BRI partner countries.59 In parallel CIDCA is rapidly working on national level Development Cooperation Agreements with individual countries60.

In conclusion, it would be a serious error to presume that the Chinese model for global health engagement and DAH could be improved by making it resemble more exactly the modes, mores and practices that have evolved over the 60 years of the OECD’s Development Assistance Committee. China has taken a somewhat different path, and one well justified both by historical antecedents and the generally accepted need for south-south collaboration. The question then is whether and how ‘two models’ can be effectively integrated within one global health system? It has been pointed out that China’s elision of assistance, research and development, and commercial activities does not and will not conform neatly with current practices of other donors and global health agencies61. More engagement is needed of stakeholders at every level of the global health movement (from what are characterised here as ‘the two models’) to better understand and learn from their objectives, methods and impacts, and to identify points of intersection where collaboration may be mutually beneficial. Greater transparency around DAH activities and funding could be an important part of knowledge exchange, fostering cooperation and synergistic actions in areas and countries of common interest.62 Ultimately, as China’s role expands this will need to be addressed, ideally through consensual modifications to systems of global health governance.63

Professor Martin Prince is Professor of Epidemiological Psychiatry at King’s College London. He trained in Psychiatry at the Maudsley Hospital and in Epidemiology at the London School of Hygiene and Tropical Medicine.

His work is oriented to the salience of mental and neurological disorders to health and social policy in low and middle income countries (LMIC), with a focus on ageing, dementia and other chronic disease. He has coordinated, since 1998 the 10/66 Dementia Research Group, a network of researchers, mainly from LMIC working together to promote more good research into dementia in those regions. The group has published 140 papers covering dementia prevalence, incidence, aetiology and impact and contributed to knowledge of public health aspects of ageing and chronic disease in LMIC.

In the broader field of ageing and health, his work spans chronic disease epidemiology (stroke, hypertension, diabetes, and anaemia), frailty, disability and dependence, social protection and care for older people. He is particularly interested in health service and system responses to the challenges of population ageing, and co-chaired the WHO Integrated Care for Older People (I-COPE) Guideline Development Group

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China Foreign exchange reserves (25 years - 1996-2021)