Introduction
Since the opening up and reforms that began 40 years ago, China’s economy and society
have developed rapidly. It is estimated that between 1978 and 2017, China’s Gross
Domestic Product (GDP) increased on an average of 9.5% annually, and per-capita GDP
growth was about 22.8-fold.1 During the same period, more than 700 million Chinese
people were lifted out of poverty.2 Consequently, China has become a much healthier
nation. The average life expectancy in China rose from 65.2 years in 1978 to 76 years
in 2017.3 China did remarkably well in meeting the Millennium Development Goals of
reducing infant mortality and improving maternal health.4 For example, under-five
mortality dropped from 54·1 death per 1000 live births in 1990 to 12·5 per 1000 live
births in 2015. Similarly, the maternal mortality ratio declined from 111·0 deaths
per 100 000 live births to 21·8 per 100 000 live births during the same time.4 5
China has also established the most extensive universal health insurance network in
the world, covering more than 95% of the population since 2011.6–8 Less than 50% of
the Chinese population had any health insurance in 2005. About 97% of the rural population
(approximately 45% of the Chinese population) have access to health insurance under
the Rural Cooperative Medical Scheme.6 Similarly, since 2008, the vaccination rate
reached more than 90% coverage rate under the National Immunization Program.9 10 As
part of China’s ongoing effort for global engagement, a new China International Development
Cooperation Agency (CIDCA) was launched in 201811; a platform for China to better
participate in global health governance, as its status changed from being a recipient
country to a donor country.11 12 In this editorial, we highlight China’s contribution
to global health in the last four decades and the opportunities ahead as China establishes
itself a major player in global health.
China’s Belt and Road Initiative
The Belt and Road Initiative (BRI) emerged as one of the most significant foreign
policy agenda for China in the last decade.13 14 The BRI emphasises infrastructure
development but also promotes policy dialogue, infrastructure connectivity, unimpeded
trade, financial support and people-to-people exchange between counties in Asia, Africa
and Europe.13 So far, over 70 countries containing about 65% of the world’s population
and around one-third of the GDPs have signed up for this new initiative.15 This new
initiative, which promotes the trading of goods and the movement of individuals among
countries across different continents, will also elevate the risks of diseases.13
16
Notably, as a part of the BRI, the Health Silk Road was created to promote cooperation
in disease prevention, health promotion, policy development, capacity building, training
of healthcare workforce and exchange, and to assist member countries during disasters
and emergencies.17 A survey was conducted among healthcare experts of 29 countries
covered under the BRI initiative to understand the intentions, needs, advantages and
barriers in participating in the BRI Health Cooperation.18 Based on prior evidence,
we have identified critical areas for further collaboration. We also underscore the
importance of establishing long-term partnerships and platforms to facilitate communication
and mitigate cultural differences.18
China’s global health aid
Developmental assistance for health (DAH), including humanitarian aid, is a significant
issue in contemporary international politics.13 14 Throughout the 20th century, China
has actively participated in numerous global health activities. China had provided
nearly ¥400 billion of development assistance to 166 countries and international organisations
and dispatched more than 600 000 aid workers.19 A recent example is China’s role in
containing the 2013–2016 outbreak of Ebola.13 20 China has also offered emergency
aid to several West African countries with weak public health infrastructure and human
resources as well as offer support to WHO and United Nations’ public health governance
system.20 21 As shown in a recent BMJ Global Health paper, DAH from China saw substantial
increase in total funding between 2007 and 2017.
22
Although China’s contribution for DAH is among top 10 for donor countries, its contribution
relative to the population size and the GDP is still far behind the traditional countries
participated in global developmental assistance.22
China’s foreign aid for global health is often provided in five general sectors, medical
teams, hospital development, drug and equipment donations, healthcare employee training
and infectious disease control such as malaria, with the most significant component
of aid being aimed at medical teams and facilities.14 17 In a keynote speech delivered
at the opening ceremony of the 2018 Beijing Summit of the Forum on China–Africa Cooperation,
the Chinese President Xi Jinping announced its decision to revitalise 50 medical and
health aid programs in Africa, including the African Center for Disease Control and
Prevention and China–Africa Friendship Hospitals.23
Although China’s foreign aid contribution is relatively low as compared with other
major donor countries, China has an extensive history of successfully sharing technical
expertise with many other countries, especially small developing countries for infectious
disease management.17 24 In the last few decades, many countries have adopted different
Chinese models for infection control and the elimination of certain diseases like
lymphatic filariasis, malaria and tuberculosis, among others.17 In 2016, China and
WHO signed the China-WHO National Cooperation Strategy (2016–2020), with a focus on
the development of health policies, planning, technology adoption and human resources
management.25 In 2017, China signed a memorandum of understanding with WHO on ‘Implementation
Plan for the One Belt, One Road Health Sector Cooperation’, to work together on issues
such as medical emergencies, infectious disease prevention and traditional medicine
in countries along the BRI.26 One major challenge in estimating China’s health aids
lies in limited data transparency.27
China’s global health influence in the 21st century
China has done remarkably well in improving the health of the Chinese people in the
last few decades. But major challenges lie ahead of China in the quest to establish
itself as a major global health power. To improve its global health engagement, China
needs to:
Develop a clear global health agenda: 21st Century globalisation is inextricably linked
to health. China must determine the position of global health in its national development
strategy with unprecedented priority and clarity. China already has a clear overall
national development strategy, the ‘Chinese Dream’, and cooperation and exchange of
expertise under the ‘Health Silk Road’ is an encouraging start towards a robust global
engagement. However, the commitment can be only sustainable with clearly defined priorities
in both domestic and foreign policies.
Establish itself as a credible global health actor: the CIDCA is only the first step
towards this goal. China needs to incorporate into its global health agenda all relevant
government departments, state-owned and private enterprises, medical institutions,
public health research centres, healthcare and policy think tanks, private foundations,
charity organisations and religious entities. In addition, China needs to ensure increased
transparency of its health aid data as this will improve tracking of these funds,
increase collaboration between China and other major donors to address high priority
areas, and promote more efficient allocation of these resources.27
Continue its focus on environmental issues: China is playing a proactive role in environmental
issues like climate change. China is the highest producer of wind and solar energy
in the world.28 Although China’s rate of emission per GDP has decreased, China is
still the largest carbon dioxide (CO2) emitter in the world, and the total emission
is increasing.29 Given the centrality of climate change to global health, China should
continue investing in renewable energy sources to mitigate the health risks from pollutions
and reduce global carbon emission.
Increase its focus on food safety standards: food safety is a significant public health
concern.30 Food safety suppressed all other safety concerns, including public security,
traffic safety, medical safety, and so on, in China.31 In the last decades, there
are major incidents reported related to food safety issues in China.32 As China is
exporting many food products globally, food safety is also becoming a major global
health concern. Although the Chinese government has enacted many regulations in recent
years to strengthen food safety in China, including establishing the China Food and
Drug Administration as the central authority in 2013, the challenge remains in the
implementation of these laws due to the fragmented nature of China’s food industry.32
Increase its cooperation with international non-governmental organizations: this would
be necessary for promoting health and well-being in many low-income countries. Prior
evidence suggests that public–private partnership models are useful change agents
in global health.33 China should continue to engage in more public–private partnerships,
both within China and globally, through multilateral initiatives (eg, the United Nations
agencies), and through dialogues and financial assistance to encourage the private
sector innovations and support for the public sector and global institutions.
Support low-income countries connected by BRI to develop electronic health infrastructure:
this would enhance their health systems and sharing health information data to understand
the spread and patterns of diseases better, and also help those countries better respond
to their health challenges. So far, the majority of China’s global health outreach
has focused on infrastructure development.12 But there is a need to focus on ‘electronic
infrastructure’ in addition to providing assistance for physical infrastructures such
as hospitals and research centres.
Train and retain foreign scholars in China: in the last few years, an increasing number
of students and scholars from many low-income and middle-income countries have received
academic scholarships from the Chinese government to attend universities in various
disciplines.34 It is essential to retain some of these global talents in China to
enhance mutual understanding of political, social and cultural issues, and to influence
China’s global health policies and operations.
Develop global health training programs for students in China: this is necessary to
encourage more Chinese students and scholars to visit other low-income and middle-income
countries and study their health systems and policies. Like many schools of public
health in high-income countries, Chinese universities should offer global health courses,35
English language degree programmes in global health (eg, Master of Global Health),
targeting both Chinese and foreign students. As a model of south–south learning and
exchange, the curriculum should be developed, drawing on lessons from China’s experience
and success.
Conclusion
Health is a vital pillar of a knowledge-based economy. As an emerging and increasingly
dominant economy, China is expected to, and will likely take on more responsibilities
and gain more influence in global health governance. But to realise its potential
and enhance its influence, China will need to develop a clear global health agenda,
establish itself as a credible global health actor, continue its focus on environmental
issues, increase its focus on food safety standards, increase its cooperation with
international organisations and multilateral initiatives, support health infrastructure
development in low-income countries with a focus on electronic health infrastructure,
train and retain foreign scholars in China, and develop global health training programmes
for students in China. Even with ongoing challenges, including addressing its domestic
health issues, China has a vital role to play in making the world a healthier place.