At the upcoming 8th Forum on China-Africa Cooperation (FOCAC), the multiple dimensions of health cooperation between China and Africa (aid, trade, and high politics) will undoubtedly take centre stage. During the past year and a half, as the Covid-19 pandemic raged through the world, China repeatedly made headlines for its alleged role as a global public goods purveyor. From the distribution of personal protective equipment and testing kits in the first phase of the pandemic to the more recent vaccine provision, China’s proactive — and often timely — global outreach has triggered speculation and concern among world leaders around its wider strategic aims. Covid-19 has put under the spotlight a long-running, yet largely overlooked, three-pronged Chinese strategy to use ‘health’ to: advance soft power through a South-South solidarity narrative; increase trade in health-related products; and strengthen China’s diplomatic role in global settings, such as the World Health Organization (WHO), so as to promote ‘Chinese solutions’ to global health challenges.
‘Health’ is one of the oldest forms of engagement between China and Africa, dating back to the 1960s, when the first Chinese Medical Teams arrived on the continent to provide direct care to African people, build local capacity, train healthcare personnel, and construct hospitals, ultimately serving as a tangible expression of solidarity among developing countries against colonial and imperialist powers. Health cooperation, at that stage, fed into China’s anti-imperialist discourse, helping Beijing to consolidate its network of regional partners. When the first Forum on China-Africa Cooperation took place in 2000, showcasing China-Africa relations to the rest of the world, ‘health’ appeared in both the FOCAC Declaration and Action Plan (the two official documents issued after each FOCAC). Though the focus on the health sector appeared rather limited in content and relatively low in the priority list (the last of a 10-point statement), its soft power dimension - i.e., China's long-held solidarity towards Africa - was crucial in counterbalancing the rise of a new, perhaps less benevolent, logic of interaction based on economic interests, and achieving the associated foreign policy objectives.
Since 2000, ‘health’ has continued to appear in FOCAC documents, taking up an increasingly important role, signalling China’s shifting interests in health cooperation with Africa: from aid (always infinitesimal in Sino-African relations compared to trade volumes) to trade, eventually enabling Beijing’s rise as a global health leader. Flagship aid initiatives — such as the anti-malaria campaign and assistance for maternal and child health — started being sided by commercial interests, with Africa representing fertile ground to expand China’s emerging interests in gaining a foothold in the medical equipment and pharmaceutical industries (for conventional and traditional medicine alike), where China was still, globally, a minor player. The shift came with recognition: in 2013, for the first time, China and African countries held a Ministerial Forum on China-Africa Health Development (while the forum on Traditional Medicine had been ongoing since 2002) eventually acknowledging health’s crucial role in China-Africa cooperation.
One year later, in 2014, China joined the international health response to an epidemic for the first time, when Ebola raged across West Africa. Though China did not manage, then, to act as a global health leader, the West African crisis made the Chinese government all the more aware that public health threats around the world could undermine its security, business interests, and people.
The subsequent FOCAC, in 2015, pledged to include the Ministerial Forum on China-Africa Health Development in the cohort of FOCAC sub-fora, thus elevating its significance. In the same year, China launched the Health Silk Road, aiming to forge closer people-to-people ties, including in Africa. The focus on ‘public health’ became ever more relevant in FOCAC 2018, to improve resilience in the face of ‘the sudden outbreak of major communicable diseases’, a year before Covid-19 broke out.
The 2014 Ebola crisis also marked a major shift for China, as it paved the way for more cooperation with multilateral initiatives and the WHO, complementing China’s largely preferred bilateral approach to health cooperation. Though China’s trademark preference for bilateral settings largely persisted, Africa played an important role in helping Beijing enter the multilateral world, including health-wise. Africa’s support within the United Nations was pivotal for Beijing to acquire recognition over Taiwan in 1971 and join the WHO a year later. More recently, Africa’s support for China-led stances became crucial in the run-up to the WHO endorsement of Traditional Chinese Medicine, finally included in 2019 in the influential 11th International Classification of Diseases, a compendium of world health trends.
These two events signal how important ‘health’ and Africa have been for China’s wider foreign policy aims. However, there is still a 'red line'. Africa is home to two small territories that enjoy close relations with Taiwan, eSwatini and Somaliland, which are crucial to understanding the symbolic limits of Beijing's overall rise, even when it comes to health. These territories’ recognition of Taipei over Beijing undermines China’s aspiration to enjoy full African support. Having the whole continent abide by the ‘one-China policy’ and ‘abandon’ Taiwan — one of China’s traditional foreign policy priorities — would be a sweeping victory for Beijing at a time when the island’s sovereignty remains at the core of contention, with Western powers supporting the status quo. In this context, the 'Taiwan can help!' campaign launched by Taipei to support the health needs of its most fragile partners (such as eSwatini and Somaliland) during the Covid-19 pandemic collided with Beijing’s objective to act as a global public goods provider. Efforts by China’s Embassy in South Africa to convince eSwatini's government to change sides and enjoy the benefits of more robust cooperation with Beijing as well as efforts to forge a medical cooperation pact in mid-June 2021 between Taipei and Hargeisa consolidated Taiwan’s position with its African partners, ultimately complicating Beijing’s efforts to achieve one of its most symbolic — yet sensible — foreign policy objectives.
Nonetheless, Beijing managed to achieve a number of objectives during the Covid-19 pandemic, somehow reinforcing its health strategy. The distribution of vaccines exemplifies this: donations of Chinese vaccines to Africa are significantly lower than commercial sales (6.7 million donations versus 47.5 million vaccine purchases), but Africa remains the second largest recipient of Chinese Covid-19 vaccine donations worldwide (after the Asia Pacific region, which takes up to 65% of the total share), showing Beijing’s commitment to help the continent. At the same time, out of the 33 million doses delivered to Africa thus far, half have gone to China’s strategic allies, Morocco (16.5 million), followed by Zimbabwe (4.4), Egypt (4.1), and Algeria (1.8), with the delivery gaining momentum over the last few weeks. While China has committed 10 million doses of its Covid-19 vaccines to the COVAX Facility — mainly the Sinopharm vaccine — and numerous Chinese vaccine developers have announced their intentions to supply COVAX, the vast majority of vaccines donated and exported by China have passed through bilateral channels, despite Chinese leaders emphasizing that China upholds multilateralism and wants to promote multilateral cooperation in the global response to Covid-19. Beyond sales and donations, China has also emphasised efforts to contribute to Africa by stepping up the manufacturing of Chinese vaccines in the continent (Egypt being the first to do so), with Beijing supporting calls for waiving intellectual property rights.
These dynamics shed light on China’s above-mentioned, long-term strategic vision. During the Covid-19 crisis, China has not merely promptly provided goods and acted as a global health assistance provider, it has also set the pace for a crisis management approach that tackles health security while potentially promoting industrial development in developing countries.
Should the approach gain ground — despite its many shortcomings, including limited transparency — it would reduce healthcare-related inequalities in developing countries, raise China’s international profile, and potentially expand its foothold in the global pharmaceutical market, not only living up to Beijing’s narrative of solidarity but also achieving high-politics, economic, and foreign policy objectives. The jury is still out as to whether implementation will follow suit, but the next FOCAC will certainly chart the way forward.
 Two are the main Chinese manufacturers exporting Covid-19 vaccines to Africa: Sinopharm remains the main supplier for vaccine donations, while Sinovac for sales. Both vaccines were approved by the World Health Organization for emergency use (in May and June 2021 respectively).