China-Africa Health Cooperation: A New Era?

I got goosebumps of anticipation reading about the first-ever Ministerial Forum on China-Africa Health Development and the released ‘Beijing Declaration’. At this meeting China’s president Xi Jinping heralded a ‘new era’ of China-Africa cooperation on health, while commemorating its 50-year history beginning in 1963 when China first sent its first medical team to Algeria. As Xi noted:

“Human development is at the core of development. We hope this forum will substantially push forward health cooperation between China and Africa.”

Why does this matter? Since 2000, China has hosted six ministerial Fora on China-Africa Cooperation (FOCAC), held every three years, in which health is but one of many areas of attention. In the last FOCAC, the accompanying Beijing Action Plan for 2013-15 listed cooperation in many areas – 6 in political, 9 in economic, 6 in cultural, and 6 in development – of which ‘medical aid and public health’ is one. And, while official figures are hard to come by (see paper by my colleague Vij Ramachandran), it is likely that health has played only a minor role in China’s development assistance to Africa. This inaugural forum on health and Beijing declaration may well mark a turning point in the history of Chinese development and health cooperation to Africa. China’s top-level leadership clearly sees the political, economic, and perhaps health importance of global engagement especially in Africa.  

What did I like about the Declaration? I liked the shout-out to “universal coverage of health services”, “sustainable, long-term health solutions”, “support strengthening of health information systems”, and the focus on vaccine-preventable diseases. I also like how “universal coverage of health services” in Chinese translates to an explicit focus on covering all people of some set of health services (卫生服务的全民覆盖). Universal health coverage has been a recurring theme both in China’s recent major health reforms and at the WHO led by Margaret Chan (see picture). This focus on universal health coverage and, to some extent, on health systems appears to be a marked distinction from the previous Beijing Action Plan.

And there were other things in Chinese, with its typical metaphorical style, that were endearing, like “中非友好源远流长，历久弥新” which was generically translated to “China and Africa enjoy a sustainable friendship for a long time”, but it conveys a feeling of a long flowing river of history, old yet constantly new. In the related news, there was repeated emphasis on mutual benefit, win-win, and equal partnership (平等互利、合作共赢), all echoing Mr Deng Xiaoping’s early principles of foreign engagement.

There are some areas where both the Beijing Declaration and the Beijing Action Plan could improve. For one, the Beijing Declaration listed a whole bunch of African declarations on health (eg, the African Union’s Africa Health Strategy, the African Union Commission and UNIDO’s Pharmaceutical Manufacturing Plan for Africa, and the Addis Statement on African Leadership for Child Survival). But what was missing (perhaps because the African Development Bank wasn’t present) was the Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector, a joint declaration by both ministers of finance and health in Africa. The Tunis declaration gives particular emphasis on the importance of health financing and improving efficiency and value for money. This is an issue we’ve been tackling through our CGD Working Group on Value for Money in Global Health, mainly focused on the Global Fund, but any donor or funder including China could take up these issues. Through savings from improved efficiencies, a national health system can reallocate resources for greater health impacts. 

Second, even with the Declaration’s greater attention to universal health coverage, the Declaration and the Action Plan still risk focusing excessively on providing ‘things’ – sending medical teams, drugs, prefabricated clinics (yep, that’s there too). There’s nothing wrong with focusing on these inputs per se, but there are risks. First, temporary inputs from China, particularly health workers, are just that – temporary. Once they depart or stop flowing in, the system reverts back to what it was previously. Even if the Chinese medical team can build capacity of local physicians or nurses through their visits, such training may tend to focus on tertiary care, which will not reduce major causes of disease in many African countries.

More critical, however, is that a focus on inputs does not necessarily consider the incentives, the systems, and the health outcomes. Are these particular inputs, eg, medical teams, what is needed to improve health status in a particular African country? It’s not obvious. The Chinese should remember and learn the difficult lessons from their own history of health care, recognizing that their “barefoot doctors” provided services in a system with different incentives – through its Cooperative Medical System. In order to realize its aspiration of “sustainable, long-term solutions,” Chinese officials need to put more attention on the incentives within an African health system, the local governance structures, and local health information systems. Without that, all these things may at best be one-off tokens of goodwill, or worse, it may leave a trail of Chinese products and buildings that are ultimately unused and empty. China should consider other options besides input-based aid and instead look to cutting-edge aid tools such as performance-based financing or Cash on Delivery Aid. 

In addition, the Declaration had zero mention of China’s complex aid architecture. China, like the United States, already has a hodgepodge of national-level agencies involved in international cooperation including its health ministry (now called the National Commission on Health and Family Planning). But unlike the United States, the Chinese government has increasingly decentralized foreign affairs to the province level. My coauthor Gordon Shen presented our working paper on China’s provincial diplomacy for health, during the China-Africa Health Young Leaders Roundtable, which coincided with last week’s events. The paper describes the role of Chinese province to African country relationships in health cooperation (for example, Fujian-Botswana, Henan-Ethiopia, etc.), the implications of locked pairings, and how to improve the allocation of such pairings. While lacking data, our paper overall suggests a historical role of provinces in China’s global health diplomacy, which adds another layer of complexity in an already complex aid architecture.

Finally, readers may naturally ask – what about the financial commitments with this Beijing Declaration? This is important. But the problem is that, because of China’s multi-actor and decentralized aid architecture, it is not surprising that even the Chinese national government hardly has a clue of the size of resources being invested to Africa for health. I wrote a blog on this, and the problem still persists. It’s hard to make pledges to increase aggregate commitments if one doesn’t even know what one’s baseline or historical disbursements.

Bottom line: wait and see. To where will the long and flowing river of China-Africa cooperation lead?

Dr Victoria Fan is a research fellow and health economist at the Center for Global Development. The author thanks Lincoln Chen, Yanzhong Huang, LIU Peilong, Jenny Ottenhoff, Gordon Shen, and TANG Shenglan for helpful comments. You can follow her on twitter at @FanVictoria