Summary
We examine China’s role in the global health arena. At one-fifth of the world’s population, China has an outsized impact on global health statistics but has had an undersized impact on global health outside its borders. The Chinese healthcare system began with a well-developed and well-functioning “barefoot doctors” system but then fell into disorder. The rise of the Chinese economy has had a massive impact on Chinese health. However, as the Chinese adopt a more sedentary and high-calorie lifestyle, the public health challenges are set to be considerable.
China has had many remarkable public health successes, and reforming health care could be next. But, China has been a minnow in the global health arena. This is partly due to the bilateral tradition of Chinese aid, partly because global health holds a low status in China, and because the PRC was, until recently, a net recipient of global health aid. China is beginning to realize the importance of global health and the soft power it brings. By need, China will become a key player in providing solutions for the world’s global health problems. This will serve both China and the world well.
Key takeaways
- China is one-fifth of the global population, so any changes to its public health considerably impact global health statistics.
- China can boast impressive public health feats, such as against infectious diseases like malaria and schistosomiasis, massive poverty reduction, leaps in life expectancy, and infant survival.
- The PCR faces significant challenges with a costly, inefficient, and under-dimensioned healthcare system and an urbanizing population adopting Western lifestyles.
- China has been a lightweight in international global health as it recently went from being a net recipient of aid to a contributor and has focused on small-scale bilateralism.
- Global health requires global solutions, so China must become more multilateral in its global health dealings. As such, China is set to change global health and global health is set to change China.
China’s historical impact on global health
As the world’s oldest civilization, China’s participation in global health has deep historical roots. In the first millennium, the Silk Road transmitted knowledge of medical cures, which facilitated exchange between China, India, the Middle East, and Europe. China has historically been the origin of many infectious epidemics1, the most famous being the “Black Death” of the Middle Ages caused by the bacteria Yersinia pestis that killed over one-fifth of the global population in the 14th century, 1/3 of Europe’s.2 In the recent decade, fears about Severe Acute Respiratory Syndrome (SARS) and the avian influenza A(H7N9) virus have repeated that feat.
We will examine the role of China in the field of global health. What role has China played, does it play, and what functions will it play in the future? China has the world’s largest population and the third-largest surface area. It has arguably been the most dynamic and “world-order-disrupting” country in recent decades. There is a vast and growing amount of literature on every aspect of its internal and external politics. We will limit our focus to the public and global health field and not on other forms of politics or aid.
What is global health?
There has yet to be a universal consensus on the definition of global health1.
Medical Subject Headings (MeSH) is an international standard of keywords and definitions used in medical research and databases. It is managed by the National Institutes of Health (NIH) and the U.S. National Library of Medicine (NLM).The MeSH term Global Health is defined as
“A multi- and interdisciplinary field concerned with improving health and achieving equity in health for all people. It transcends national boundaries, promotes cooperation and collaboration within and beyond health science fields, and combines population-based disease prevention with individually-based patient care.“
In a Lancet review, Liu defines global health as “a framework […] characterized by health and related transnational flows of diseases, people, money, knowledge, technologies, and ethical values” and proposes four domains that capture these global processes.
- Health aid aims to advance global health equity. Traditionally, this has been coordinated by Organization for Economic Cooperation (OECD) countries as official development assistance (ODA).
- Global health security deals with the interdependencies in global health and the shared and transferred risks, such as epidemic diseases.
- Health governance sets the ground rules as mediated by health diplomacy needed for global stewardship.
- Knowledge exchange, the sharing of lessons, knowledge production, ownership, and application worldwide.
Thus, these points provide us with a framework by which to analyze China’s role in global health today.
China, one-fifth of global health
In 2015, China’s population was about one-fifth of the world’s population, and China was classified as an upper-middle-income country.3 As such, any index on global health will be heavily influenced by China. For example, three-quarters of the Millennium Development Goals (MDGs), set by the United Nations, reduction in extreme poverty between 1980-2010, came from China’s economic rise, as 680 million Chinese rose out of poverty, according to the Economist.4 China itself makes up one-fifth of the world’s population. As such, it is relevant first to look at China’s public health system, also keeping in mind that it gives an indication of China’s global health capabilities.
The evolution of china’s health care system
In 2010, China had a doctor-nurse-per-person ratio of 3 per 1000 population, of which half are doctors and half are nurses. In Europe, these numbers are 10 per 1000 population with one doctor per 2 nurses; in the US, these numbers are 12 per 1000 with one doctor to 4 nurses.5 According to the World Health Organization (WHO), 40 % of medicine in China is traditional Chinese medicine (TCM). In some areas, modern medicine is nearly nonexistent6.
The Chinese healthcare system has a history of success but struggles with problems and inefficiencies. The same competing forces that have driven the rest of Chinese society in recent decades – state versus free market economy – compete in the public healthcare system and its reforms.
Barefoot doctors
In the 1950s, as the People’s Republic of China (PRC) was created, a centrally planned socialist healthcare system was developed. All healthcare services were owned and provided by the state, and high priority was accorded to equality of service. In the towns and cities, clinics and hospitals were run by the state, as state-owned enterprises (SOEs) or the local governments provided health services, with doctors employed by the state. In the rural areas, the communes formed the healthcare units through a system known as the Cooperative Medical System (CMS), a network of primary healthcare providers. Community health workers, known as “barefoot doctors,” provided medical services. The system was pioneered in the 1930s as village health workers but matured with the 1950s reforms.1,7
Reforms
In 1978, led by Deng Xiaoping, China initiated a campaign of liberalization that resulted in a fiscal crisis. As the commune system was dismantled to privatize the agricultural sector, the commune-based health care system fell with it, and 900 million peasants lost their safety net and became uninsured. Health care was neglected and was left to market forces and individual self-reliance. Massive downsizing of SOEs left laid-off workers uninsured as well. Without adequate government funding, public care facilities began charging for services, creating a system that relied on selling medicines and expensive imaging and laboratory tests. While the state ignored this, it wasn’t until 1992 that the extra charges for these services became formally legitimized, causing them to spiral even more out of control. It created a system that is viewed as being focused on profit rather than patient care, which has considerable disparities between rural and urban quality of service and rampant overprescription of medicines, tests, and examinations.
During the early 2000s, the public discontent with the cost and quality of the healthcare system was starting to grab the attention of the politicians. With the change in leadership in 2003 and the outbreak of SARS, political leaders awoke to the importance of health care and public health. Shallow reforms providing limited social health insurance for most of the population were introduced, called the New Cooperative Medical Scheme (NCMS) and Urban Basic Medical Insurance (URBMI).7,8
In 2009, a grand health care reform was rolled out to provide affordable primary health care for all Chinese by 2020, a more “socialist” vision of health care. Its goals were to expand coverage and make primary health care universal, make all public health care equal (i.e., rural and urban), improve its delivery, provide an elemental medicines system to meet essential medicine needs, and pilot reforms for better governance. All but the last goal seems to be going well.
The blame for the lack of progress in governance is put on public hospitals and their staff. In 2013, with the entry of a new Chinese regime, the pendulum swung once more, and there is currently a pro-market wave of privatization of healthcare facilities and hospitals and an opening to private insurance. Privatization reforms also restrict public healthcare facilities from expanding, implicitly aiming to reform the wasteful, low-quality, for-profit public healthcare system by subjecting it to competition. This process is currently unfolding.7,8
In summary, China has undergone cycles of public health reforms since the founding of the PRC. Early public health revolutions, only some mentioned in the essay, greatly impacted Chinese health outcomes. However, with the lack of reform, the vastly successful healthcare system was neglected. The era of later market reforms turned it into a low-quality behemoth that wastes human and economic capital resources. Subsequent reforms to provide universal coverage are going well, but poor quality and high costs have yet to be controlled. Recent privatization reforms are too current to evaluate.
Looking at the healthcare system of the USA, the most expensive healthcare market in the developed world, the future cost projections for China look bleak as it moves towards a similar system. It is still being determined how offering premium quality private healthcare for the insured in an already high-cost system with fundamentally low confidence in low-quality public care would reduce costs.
Healthcare challenges
With an aging population, rampant pollution, lifestyle (i.e., modern high-carb diet and low physical activity), a changing social order, and successful infectious disease prevention, chronic and lifestyle diseases are growing and have replaced infectious diseases as the leading cause of death. According to WHO statistics, 47% of males (only 2 % of women) aged 15 or above smoked cigarettes in 2011. While not very obese in general, the Chinese population is rapidly growing their waistlines. Waistlines matter in terms of future heart attacks, strokes, and dementia. In cities, obesity rates exceeded 20% of the population and are set to reach the levels of Western developed countries soon.
The lack of social support and healthcare does not bode well for China, and strong measures are needed to deal with the impending noncommunicable diseases bomb set to explode in a poorly prepared healthcare system. With increasingly skewed sex ratios and labor shortages, a result of the controversial one-child policy driving down fertility rates on purpose, China is only causing further injury to insult. Unlike Japan and Western countries in the 20th century, China can look at these countries and extrapolate their situation to see its future woes unless it acts now.
Looking at the current Chinese healthcare system, it is easy to see the flaws in management and the challenges it is facing. One must remember that China is a relatively new member of the middle-income countries and has made a monumental journey by any health, financial, or other indicator, unlike any other nation in history. Never has the lives of so many improved so much and as fast, and no country, bar India, has or will face similar challenges anytime soon. China is a nation capable of mobilizing vast resources, and throughout the history of the People’s Republic, China has been able to perform remarkable feats once it takes decisive action.
Public health successes
In 2003, the Global Fund (the world’s most significant contributor towards programs fighting HIV/AIDS, tuberculosis, and malaria) initiated its program in China. In June 2014, it ended its operations there, declaring success. During this time, the Chinese government was the first to ask for help from the global fund to develop strategies to fight these three diseases.
The most successful campaign ever against schistosomiasis
China has successfully battled some of the world’s chronic infectious diseases and holds important lessons for the world in this field. For example, the PRC has waged the most successful campaign ever against Schistosomiasis, and it is studied as an example of global campaigns against this and other infectious diseases. Schistosomiasis is a globally prevalent chronic disease caused by parasitic flatworms of the genus Schistosoma. It is considered one of several major neglected tropical diseases (NTDs). It is one of the diseases targeted by the Bill and Melinda Gates Foundation (BMGF) and the rest of the global health community. More than 240 million people around the world are infected, and as a result, they suffer an increased risk of morbidity and mortality.9 Since the 1950s, China has been conducting a remarkably successful campaign against Schistosomiasis, with a reduction from 12 million endemic cases to an estimated 326,000 cases in 201010, and is targeted to eliminate the disease from China by 201611.
Malaria eradication
Mao Zedong’s health reforms in the 50s included a specific order by the chairman to find a cure for malaria among known plants. Going through the many TCM remedies, artemisinin, a very potent and today widely used antimalaria substance, was discovered.6 Today, artemisinin and piperaquine, another antimalarial drug discovered during the same period, are used to fight malaria in the Comoros islands with very high success, hoping to eradicate it by 2016.1 In 2011, only 4% of the number of cases of malaria compared to 2005 were reported, a remarkable drop. In Mainland China, the spread of malaria has been stopped, the absolute incidence has been significantly reduced, and the Chinese aim to complete eradication in 2020.12
Fight against HIV/AIDS
The endemic spread of HIV has been stabilized among both sexually active and injection drug users, and the number of people on antiretrovirals has increased 10-fold. The Chinese government has now taken over funding for HIV medication. The Global Fund program, which includes the fight against multidrug-resistant tuberculosis (MDR-TB), has not been as successful in curbing the growing problem of MDR-TB. While screening for TB and MDR-TB has vastly improved, little is currently being done to fight it.12 In a country where 75% of people with a common cold are prescribed antibiotics, MDR-TB is a problem that will worsen, along with many other infections. As 54,000 new cases of MDR-TB are reported every year, and the annual cost of treatment is $8,025 per patient, a strong commitment is needed from the Chinese government. MDR-TB is potentially a significant public health crisis in the making.12
Non-infectious diseases
The early reforms of the Chinese health system were hugely successful in improving the quality of life of the Chinese and served China well for a long time. Between 1950 and 1978, infant mortality fell from 200 per 1000 live births to 57 per 1000 live births, and today, it is estimated at 6.6 per live births.13 Life expectancy rose from 45 to 68 years7; in 2012, it was estimated at 75 years14. By raising 680 million people from poverty, one-tenth of the world’s population entered the middle class. With the arrival of health care for all in China, the long-term effects the Chinese will have on global health will continue to be vast.
China’s role in international global health
So far, the focus has been on China’s internal public health affairs, illustrating that it (alongside India) plays a unique role in global health statistics. There are many more – positive and negative, current and prior – examples that could be highlighted, such as maternal health gains, environmental health concerns, mental health, China as an emerging biotechnology giant, gay rights, skewed gender ratios, and much more. However, we have already shown how China has generally played its role very successfully. We will now shift to a more international and traditional perspective on China’s national role in global health and focus on transnational flows.
Global health aid
There is no official source of data for Chinese global health aid because of the diversity of government stakeholders, the absence of a national strategy or official policy for global health, and an unclear border between aid and health investments. Data needs to be more complete, and the Chinese Government is the only source of information. Chinese aid is predominantly bilateral, giving direct aid to individual countries and projects rather than funding large multilateral organizations that stand for a post-Second World War order China was not part of building. This also means that the distinction between investment and aid is only sometimes apparent by traditional standards. Chinese health aid also differs from conventional aid in that it is almost exclusively provided on a governmental level, with very little involvement from civil society and non-governmental organizations (NGOs).1
The history of Chinese foreign health aid in modern times is relatively recent and began with dispatching medical teams to Africa in 1963. This was done under a special protocol for the dispatch of medical teams signed between China and recipient countries. Since then, this form of aid has spread to other countries in Asia, Europe, Oceania, and South America. Looking at some foreign aid statistics is interesting to give a sense of proportion. According to Liu, between 1950 and 2010, Chinese foreign aid amounted to $40 billion. By 2010, it is estimated to have reached $3.9 billion annually, and $4.8 billion annually between 2010–2012. In the later period, half went to African countries, approximately a third to Asia, and one-tenth to Latin American countries. Europe accounted for 2% from essentially non-existent before. Thus, an estimated $2.4 billion in aid was given annually to African countries in 2010-2012.
The value of health aid is difficult to estimate because Chinese health aid is predominantly provided as in-kind donations of goods and services (rather than funds, loans, or being part of other investment deals, as is usual with other Chinese aid), but amounts to approximately $150 million. It consists of five categories: medical teams, construction of hospitals (often staffed by the provided medical teams), drugs and equipment donations, training of health professionals, and malaria control. The first two categories dominate, but malaria control has recently grown in priority.
The general model of health aid in Africa appears to be that receiver countries are twinned with a Chinese city, according to Liu. The Chinese government pays for hospitals/clinics that Chinese companies build and then fills these hospitals with donated equipment. These sites are then given over to the host countries. The twinned Chinese city then provides medical teams to that country, especially in medical specialties in short supply, which China pays for. On-site, these teams help train locals and medical staff. This is the general predominant picture, but China also gives health aid grants and some indirect health aid that should be included in the above numbers. For example, China had almost 39,000 foreign medical students studying in China in 2011, of which about 10% received Chinese Government scholarships (most of these were from other Asian countries) that could also be regarded as a form of health aid.
Bilateralism vs multilateralism
For the same reason, China prefers to deal bilaterally with countries in trade and politics by dividing groups into individual countries. Compared to other countries, China’s size will overshadow most; China will want to do the opposite and deal with global health multilaterally. Global health problems demand global solutions, and with a disproportionate part of the world’s population, China will suffer disproportionally from many global health problems (for example, pandemics, pollution, etc.)
China has already entered the world of multilateral organizations by joining organizations such as WTO, WHO, UNAIDS, UNICEF, UNFPA, the Global Fund, World Bank, etc. It is also forming its multilateral institutions, like the Asian Development Bank (ADB), that will follow the same best practices as the World Bank.15 These are testaments to China’s understanding of the value of multilateralism, but also that China is being influenced by and learning from these institutions. This is evident in environmental issues where China is involved on an international and multilateral level. In the long run, global health issues have less to benefit from the divide and conquer approach.
Introducing China into the global health system will change the system and China. The SARS epidemic 2003 was a costly crisis generally attributed to poor Chinese management. For example, four and a half months elapsed between the first detected case (almost three months waiting to go public and report it to the WHO) and the setting up of joint investigation teams.16 This allowed the disease and associated panic to spread and made the government look incompetent. The incident had severe political and economic repercussions. What followed was the creation of the world’s most extensive real-time disease surveillance system and unprecedented participation, engagement, and leadership in international global public health forums.1
In 2011, polio was imported from Pakistan to China. The outbreak was stopped within one and a half months of laboratory confirmation.17 In 2013, only two months elapsed between the first reported incident of the Avian Influenza A(H7N5) virus and the start of joint investigations teams.1 In 2014, China joined the fight against Ebola, the first time it offered to help foreign nationals during a public health crisis. It has since delivered humanitarian aid with a combined value of $120 million and sent hundreds of workers to Africa to fight the disease.18
Recently, Chinese medical universities have taken active steps to increase their global health contribution and opened global health centers at several universities,1 among others at Fudan University.19 Opening these centers will eventually raise the understanding and importance of global health within China. It is encouraging and beneficial for the world that the PRC, with its practical experience of successful large-scale health campaigns, is actively entering the field. This increased interest from the government’s side probably comes from the aftermath of the SARS epidemic. However, as we have seen, it also has much to do with realizing China’s impending internal public health problems. Global health and public health are two sides of the same coin, and this is especially true for huge countries like China and India, which each make up almost 20% of the world’s population in a globalized world. Mosquitoes, parasites, migrating birds, pandemics, and pollution do not follow national borders.
It is hard to believe that as knowledge and awareness of global health increases, China will be able, or want, to hold on to its highly bilateral model. With an aid budget of $150 million, management of relatively small-scale bilateral projects is possible, but as the health aid figure grows, it will eventually be unmanageable and undesirable. That figure must and will grow.
Myths behind the motives
The prevailing idea is that everything China does, including health aid, is done in a cynical attempt to spread its economic tentacles across the globe. Much of this distrust in the field of global health comes from the fact that very little of the already small health aid goes through the traditional channels of large multilateral organizations. It is not a question of whether China has a purpose beyond pure humanitarianism for its aid, health, or other, but how this would differ from the traditional donor countries. No one seriously believes that traditionally large donors – Europe, USA, Japan, France, England, Sweden, etc. – have historically been motivated by pure humanitarian kindness. European countries strike above their weight with soft power, and those postcolonial agendas of maintained political and economic influence and guilt play a huge role.
Missing a global health policy
As said before, China does not have an official global health policy. A post-colonial heritage does not burden China. It has a different global agenda than the countries that are traditional donors. China has other, more direct means to gain political and economic influence. As it has just recently gone from a net receiver to a net donor1, this is likely to give China a different view and is part of the reason it provides aid differently than the traditional way Western countries do. These all explain why health aid is relatively minor in actual value, as a proportion of total foreign aid, and is usually also given as donations, which differs from most other foreign aid China provides. The departments dealing with health aid have relatively low standing in the political hierarchy.1 Liu et al. tried correlating Chinese health aid with commercial indicators (imports, exports, foreign investments, etc.) but found no correlations.
Liu’s numbers do not include the fight against Ebola in East Africa, where the Chinese government claims to have sent $120 million. Given the large numbers China has invested in Africa, as illustrated by the foreign aid to Africa, it is unsurprising that China would almost double its estimated health aid just in that region. The reasons are probably multiple, including getting caught up in the global scare, fear of spreading outside this region, protecting its vast investments, its increased role in the world, and more. It seems clear that China does not prioritize health aid, and there is no indication that it currently views it as a very relevant or influential political tool; instead, it views it as a supportive role.
Conclusion
China is emerging as an increasingly active member of the global health community, and its contributions are set to be considerable and vital. As argued, China makes up one-fifth of global health just by its population count and has some way to secure fundamental public health for its population. However, doing so will significantly impact global statistics. Given the different histories, goals, and sizes of China and traditional donor countries, it is likely that China’s engagement in the future will take a different shape than theirs.
Today, China is still a lightweight in this area, but given that it has just emerged from being a net recipient to a net donor, the fact that China still needs to develop a global health strategy is not surprising. Global health is a soft power approach to politics, and as such, will always be subordinate to security, trade, and traditional “harder” projections of power, which China naturally favors in this time of its history. To China, global health is not essential at first glance, but it seems to have realized that it is crucial, as its response to SARS, health reforms, and the fight against Ebola show. Having vital interests in many parts of the world, China is becoming invested in stability and order in these places. Just as China has been taking a decisive role in environmental issues, it is showing that it will begin taking the lead in many health issues as its stake in the world grows. By necessity, China will become an active participant, a key hub of innovations, and provide solutions for the world’s global health problems. This will serve both the world and China well.
Disclaimer
This post is based on an essay written by the author as a medical student in 2015 for a Chinese Politics and Society course at the Nordic Centre, Fudan University, Shanghai, China. The author does not speak or read Mandarin. It reflects the author’s understanding based on research at the time. It is published in its original form, except for editing based on the improved language skills of the author and some aid from Grammarly. Citations and references are also reformatted for an online format. It is republished here with permission, reflecting our interest in medicine and public and global health.
Update
One month after the original text was finished, Tu Youyou won the 2015 Nobel Prize in Physiology or Medicine “for her discoveries concerning therapies against malaria.” In January 2020, China returned to the global health limelight as the first case of a previously unknown virus from Wuhan, China, was spreading worldwide. The virus, a strain of coronavirus – the same family of viruses that causes SARS, came to be known as SARS Coronavirus-2 (SARS-CoV-2). This virus is the causative agent of Covid-19, which has since spread worldwide. That, however, is an entirely different story.
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