McDade KK, Mao W, Making sense of estimates of health aid from China, BMJ Global Health 2020;5:e002261.
The global aid landscape is rapidly changing. So-called ‘emerging’ or ‘non-traditional’ donors (ie, those that have only recently substantially stepped up their development finance support) are pushing the boundaries of existing aid practices. Among such non-traditional donors, China stands out as a major player because of its recent high-profile commitments, like the Belt and Road Initiative, and its major role in establishing new development finance institutions, such as the Asian Infrastructure Investment Bank. Although China is often thought of as a new donor, this categorisation is somewhat misleading: China has provided aid to fellow low-income and middle-income countries for decades. However, China’s role as a major financier of and leader in global development is a relatively recent phenomenon.
Health aid played a major role in China’s external aid even in its earliest days. Chinese medical teams were among China’s flagship foreign policy efforts; China dispatched its first medical team to Algeria in 1963. Chinese health aid typically involves transferring experience and lessons learnt from domestic successes. For example, based on China’s own success in controlling malaria, it sent medical teams to malaria endemic countries to advise on malaria control. Its aid primarily focuses on dispatching medical teams, providing in-kind medical equipment and drugs, building health infrastructure and assisting in the prevention and control of infectious diseases, particularly malaria.
In the last few years, health has played a much more prominent role in China’s foreign engagement. To complement the Belt and Road Initiative’s focus on infrastructure, China signed a memorandum of understanding with the World Health Organization for a ‘Health Silk Road’. Health was also front and centre at the latest Forum on China-Africa Cooperation (FOCAC): global health was one of eight main initiatives committed to by President Xi and African leaders.4 On the sidelines of the latest FOCAC, China’s first lady, Peng Liyuan, led a side event with African first ladies on combatting HIV/AIDS in Africa.
Why we need estimates of aid from China
Given China’s expanding role in the development finance space, there have been many attempts by researchers to better understand the volume and focus of Chinese aid. Such estimates are needed because unlike the 30 traditional donors, who must publish detailed aid information as part of their membership in the Organization for Economic Cooperation and Development (OECD) Development Assistance Committee (see http://www.oecd.org/dac/development-assistance-committee/), China makes very little information available to the public. To give one example, China ranked last in the 2018 Publish What You Fund Aid Transparency Index, an ‘independent measure of aid transparency among the world’s major development agencies’.
There are two documents that the Chinese government released in recent years that give some glimpse into its aid approach: the foreign aid white paper of 20111 and the foreign aid white paper of 2014. These white papers give a high-level overview of the aid landscape, the regions that receive the greatest funds, and some examples of key projects and priorities. While a step in the right direction, the white papers lack disaggregated, detailed information, particularly at the sector level. Additionally, the very definition of foreign aid in China differs from the definition used by other donors, and therefore the reported figures in the white papers are not comparable with those of other donors. If we want to understand the full scope of China’s aid portfolio, and how it compares to the portfolios of other donors, we need a better measuring stick.
Current estimates of the total annual volume of health aid typically exclude donors like China, given the unavailability of Chinese data and the difficulties comparing estimates of Chinese health aid with data on health aid from other donors. Given the lack of official data on China’s aid, several academics have developed estimates of the scope of China’s global development footprint.