Although the Chinese authorities have so far not explicitly said that the donation of masks and other protective equipment to developing countries is part of a formal, coherent strategy, the Chinese government has put significant effort into activating its diplomatic machinery, seemingly taking a leading role in response to the COVID-19 outbreak in Africa. It has created numerous online resources to share its experience, it sent 12,000 testing kits to multiple African countries and organized videoconference sessions with health leaders from 20 African countries. The Chinese billionaire and founder of the e-commerce giant Alibaba, Jack Ma, has also distributed 20,000 testing kits, 100,000 masks and 1,000 protective suits to each of the 54 African states. And on 19 March, Beijing announced plans to build an African Centre for Disease Prevention and Control research facility in Nairobi.

This is not the first international health emergency in which China has played an active role, with the Ebola epidemic in West Africa in 2014 preceding it. However, this time around China finds itself on a rather new global playing field. The US appears unwilling and, more importantly, unable to take the lead, disdaining international cooperation and lacking medical supplies. The Trump administration's response to the COVID-19 crisis contrasts with the Obama administration's response to the 2014 Ebola crisis when Washington mobilised a coalition of 70 countries, international organizations and private sector companies to prevent and mitigate the disease spread around the world. European countries are struggling with their own shortages though recently the European Union rechannelled funding from existing external resources to fight the pandemic in partner countries, 20% of which was allocated to Africa (Eur3.25 bn, of which Eur2.06 to sub-Saharan Africa). Still far from the request made by the Economic Commission for Africa to the international community of $100bn emergency fund. Despite the World Health Organization’s call for unity, the pandemic is taking on a divisive path and breaking down globalism. This can turn out to be particularly damaging for Africa whose preparedness to face the pandemic is currently very low and dependent upon external support.

While China has rapidly moved to provide support, its predominantly bilaterally-oriented health diplomacy, vis-à-vis participation in the multilateral global health system, will hardly put it in the position to coordinate international assistance to Africa, but may nonetheless grant it a leading solo position – not without pitfalls. China’s reasons to step up its health diplomacy in Africa are under scrutiny, with views ranging from the ambition to gain influence over other states through humanitarian gestures, to protecting national security and economic power, and again to being genuinely interested in helping African countries in need, in a sort of global justice framework. To understand China’s logic when it comes to health diplomacy in Africa, and its position compared to other international actors and multilateral organizations, it may be helpful to trace it back to the start.

China-Africa Health Cooperation: From Aid to Trade to Global Health

The engagement between China and African countries in healthcare dates back to the 1960s when China started dispatching Chinese medical teams to Africa. These were composed of Chinese health care practitioners providing direct care to African people, building local capacity, training healthcare personnel, and constructing hospitals, serving as a tangible expression of solidarity among developing countries, against colonial and imperialist powers. In that period China was effectively excluded from all multilateral health governance, until 1972, as international organizations (including the United Nations and the World Health Organization, WHO) recognized Taiwan instead of the People’s Republic of China (PRC) as the legitimate government. China used health aid to achieve foreign policy goals, especially influence over Europe, the Soviet Union and the United States in Africa, and international recognition of the PRC over Taiwan. In 1971, 26 African countries in the UN General Assembly voted to recognize the PRC, and the year after China joined the WHO and so the multilateral global health system. Despite clear foreign policy motivations, China’s assistance to Africa came at a time when China’s domestic resources were limited, making its efforts more commendable and ‘solidarity’ among equals a building block of the Sino-African narrative.

Since then, China’s health diplomacy towards Africa experienced periods of contraction (1980s-1990s) and expansion (since the 2000s). Since the first Forum on China Africa Cooperation in 2000, China’s relations with Africa, in every field, including health, have expanded incredibly. The 2006 China’s African Policy described the evolving relationship and, health-wise, significantly expanded the scope of relations to the flagship anti-malaria campaign, China-supported medications, building and improving facilities and hospitals in Africa, the development of traditional medicine, investments in preventing HIV/AIDS and other infectious diseases, as well as maternal and child health, and emergency response.

Importantly, these relations fast became a springboard for commercial activities, with the Chinese hoping to gain a foothold in African markets, in the context of expanding trade and investment activities on the continent. Hospital construction, supply procurement, drug distribution and production, and other health-related projects in Africa became more and more linked to commercial projects – rather than being merely grant-based. Aid remained a very small percentage of China’s engagement with Africa ($3.3bn in 2018 - $28bn 2008-2018) if compared to loans ($16bn in 2017, down sharply from $29bn in 2016 - $136bn 2007-2017) and trade ($185 bn in 2018 - $1.657bn 2008-2018).

Also, the Chinese government (similarly to the US and the EU) increasingly acknowledged that public health threats around the world could undermine its security, business interests and people. In shaping China’s new approach to global health, the SARS outbreak in southern China in 2003, and the Ebola epidemic in West Africa in 2014 played an important role. With the Ebola crisis, in particular, China joined, for the first time, the international health response to an epidemic, pledging around $125 million to UN agencies, the WHO and other organizations, sending almost 1,500 health workers, building a treatment center with 100 beds, a biosafety lab, operating a mobile testing lab and sending additional supplies, including ambulances, medical equipment and food aid to the West African region. Additionally, existing Chinese Medical Teams (CMTs) in the region trained thousands of local health workers and community-level social mobilizers on Ebola prevention measures. While China was an incredible contributor, insufficient coordination with other development partners earned it criticism.

China’s focus on bilateral health assistance has been pinned to the belief that adhesion to the multilateral system could shift state authority over to intergovernmental or nongovernmental actors. Despite this underlying posture, in the past few years, China’s participation in multilateral health governance grew significantly, contributing to the World Health Organization (with leaders and funds) as well as to specific programmes initiated by the US (such as the Global Fund, The Bill and Melinda Gates Foundation etc.) showing concern and commitment to jointly improving global health. The opening up comes at a time when China is reforming its foreign aid governance with the aim of increasing efficiency and effectiveness, differentiating between foreign aid and commercial packages, and integrating into the foreign aid portfolio socially conscious development projects, also in the area of public health. In that spirit, in 2018 China launched its first agency dedicated to foreign assistance, the China International Development Cooperation Agency (CIDCA). However, the role of the CIDCA is still being fine-tuned and the agency remains, as of today, relatively small and rather inexperienced in coordinating efforts.

The Effectiveness of China's Health Diplomacy in Africa? Not Granted

Although the circumstances – namely the US’ distancing from Africa in the past few years, the EU’s confusion/breakdown over the COVID-19 emergency despite its new commitment to Africa enshrined in the recently launched Africa Strategy, and a widespread retreat of globalism – may leave more room to China to win hearts and minds in Africa (through efficiency, timeliness and generosity), the endeavour is neither simple nor smooth. The effectiveness of health diplomacy depends on the perceptions of recipients and cannot be detached from broader socio-economic dynamics.

This time around (if compared to the Ebola crisis), Beijing is vulnerable to the accusation that the outbreak began because of China's negligence and censorship. Acts of xenophobia were observed in Africa against Asians (and white people) believed to be virus-carriers, adding up to a pre-existing polarized perception of the Chinese on the continent. In addition, the claims, worldwide, that the equipment sent by China is defective, counterfeit, substandard is something that resonates with Africa where perception that Chinese-made goods and medicine are of poor quality is widespread, damaging China's reputation and undermining its attempts to present itself as a benefactor. Though China has strengthened its regulation of medical equipment exports in response to complaints of poor quality, this may not be sufficient, especially in African contexts where robust testing and regulatory infrastructure is often underperforming.

However, health is only one dimension of this pandemic, the economy being the other crucial one. African countries are finding themselves terribly exposed to imports from China, not just in terms of medical equipment and medicines, but also basic commodities such as food. With China’s halt in production and disrupted supply chains, African countries are realizing the hard way the need to accelerate the diversification of partners.

Finally, the financial burden that the COVID-19 health and economic crises are placing on African governments is often much bigger than they can afford. Debt relief measures to prevent the least developed African countries from falling further into poverty may help them open up fiscal space to spend on other health measures as well as economic support measures. Leadership by China on this – as a major lender in many African countries – could cement the country as a global humanitarian leader. But the reality is that it is more likely for China to prioritize credit lines and loan renegotiations over debt forgiveness, thus reducing its chances to effectively contribute to, let alone lead Africa’s crisis management.