As global health funding retreats, could China reshape the system?

China could play an increasingly important role in global health as traditional donors reduce funding, but experts have warned that simply replacing dependence on Western countries with dependence on Beijing would be a missed opportunity to build stronger and more sustainable healthcare systems.

Writing in The BMJ, global health experts argue that China is well positioned to expand its influence at a time when international health funding is undergoing significant change. However, they say China’s most valuable contribution may not be attempting to replace the money previously provided by countries such as the United States.

Instead, they argue that China’s experience in areas including health infrastructure, workforce development, medical technology, supply chains and disease control could help countries develop greater capacity to meet their own healthcare needs.

The debate comes during a period of major disruption for global health financing. Development assistance for health has fallen sharply, leaving governments and international organisations facing difficult decisions about how programmes previously supported by external donors can continue.

Attention has inevitably turned towards China. Its involvement in international healthcare is not new. Chinese medical teams have worked overseas for decades, while the country has supported the construction of healthcare facilities, supplied medicines and medical equipment and provided training to health professionals.

Its role has expanded into areas including malaria, HIV, maternal and child health, non-communicable diseases, pandemic preparedness and emergency response. China has also pledged an additional $500 million to the World Health Organization over five years.

However, the scale of China’s health assistance remains substantially smaller than the funding historically provided by major Western donors. The BMJ authors therefore argue that expectations that Beijing could simply step in and replace retreating donors are unrealistic.

China also faces pressures of its own. Slower economic growth and competing domestic priorities mean there are limits to how much additional international assistance it may be prepared to provide.

But money is only one part of China’s potential role.

The authors argue that strengthening countries’ own healthcare systems could ultimately prove more valuable than creating another model based primarily on external financial assistance. Building laboratories, developing local healthcare workforces, improving supply chains and supporting countries to manufacture or obtain medicines and medical technology could leave health systems better equipped to respond independently to future challenges.

That raises a much bigger question about how global health has traditionally operated.

For decades, many health programmes in lower-income countries have relied heavily on funding from wealthier donor nations. Those investments have supported enormous advances in areas including vaccination, infectious disease control and maternal and child health, but they have also left some services vulnerable when political priorities change thousands of miles away.

The current funding disruption exposes that vulnerability. When a change of government or policy in a major donor country can threaten healthcare programmes elsewhere, countries can find themselves dependent on decisions over which they have little control.

Replacing Washington, London or European capitals with Beijing as the dominant source of support would not necessarily solve that underlying problem.

China’s growing involvement also needs scrutiny. Global health assistance does not operate separately from foreign policy, economic interests or international influence, regardless of which country provides it.

For China, expanding healthcare partnerships can help protect against infectious diseases crossing borders while supporting economic relationships, technological development and greater international influence. Its Health Silk Road forms part of a much wider effort to strengthen relationships with countries around the world.

That does not make China’s contribution inherently problematic, any more than strategic interests automatically invalidate healthcare assistance from Western governments. But it does mean transparency, accountability and the priorities of the countries receiving support remain important.

The BMJ authors argue that recipient countries should have greater control over deciding what their healthcare systems actually need rather than programmes being shaped predominantly around the priorities of donors.

That could mean the current funding crisis presents an opportunity as well as a threat.

China may be able to contribute expertise, technology, infrastructure and investment while countries develop stronger domestic systems. Other emerging economies and regional partnerships could also play greater roles, reducing reliance on a small number of wealthy donor nations.

International cooperation would remain essential. Infectious diseases do not respect national borders, while pandemics, antimicrobial resistance and other health threats require countries to work together. The question is whether cooperation must continue to operate through a system in which a relatively small group of countries controls much of the money.

China is unlikely to become a straightforward replacement for the traditional global health donors now pulling back, and the BMJ authors suggest it should not try to be.

Its growing role could instead become part of a wider shift towards countries building the healthcare infrastructure, workforce and expertise needed to become less dependent on external assistance.

The changing balance of global health funding will inevitably create new winners, new relationships and new centres of influence. China is likely to be one of them.

But perhaps the most important question is not whether Beijing will become global health’s next major donor. It is whether this moment can be used to create a system in which countries no longer need any single global power to play that role.

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