China, International Society, and Global Health Governance
China, International Society, and Global Health Governance
Abstract and Keywords
China possesses the world’s largest economy, but that economic clout has not necessarily translated into taking leading roles within existing global health governance institutions and processes. It is a country that both contributes to and receives financial assistance from global health institutions. It has incorporated health into some of its foreign policy activities, but it has largely avoided proactively engaging with the values and norms embodied within the global health governance system. This ambivalent relationship reflects larger questions about how and whether China fits within international society and what its engagement or lack thereof might portend for international society’s future. This chapter examines China’s place within global health governance by examining its interactions with international society on global health issues, its use of health as a foreign policy tool, and its relationships with global health governance organizations.
When it comes to global health governance, the People’s Republic of China (PRC) occupies a unique position—a uniqueness derived from its ambiguous relationship to the institution. It is one of the world’s most populous countries with one of the largest economies and a seeming desire to play a larger role in global governance. At the same time, though, China tends to portray itself as a leader of the Third World and has not availed itself of opportunities to take a leadership role on global health governance issues. It is a country that both contributes to and receives aid from global health governance institutions. It has explicitly incorporated health into its foreign policy, deploying medical teams to countries around the world to improve access to health care and promote its own soft power, and it actively promoted the candidacy of Margaret Chan for the role of Director-General of the World Health Organization (WHO) (Chan 2011: 148). That has not translated, though, into a willingness to proactively collaborate with the values and norms embodied within international society’s global health governance structures. It has repeatedly shown a reluctance to collaborate with surveillance systems or engage in other information-sharing activities that are at the heart of contemporary global health governance.
Such ambivalence highlights the importance of figuring out where China fits within the larger global health governance system. China is incredibly important to global health. Huang notes that China possesses one-fifth of the world’s population, contains one-seventh of the world’s disease burden, and has been the origin site for a number of international infectious disease pandemics (Huang 2010: 106–7). The country obviously has a vital role to play—not only in keeping its own citizens healthy, but also in protecting people around the world—but its engagement with international society’s global health governance architecture remains uncertain. A failure to include China in these structures could undermine global health governance’s ability (p.134) to combat disease outbreaks, but such thinking also assumes that the Chinese government has an interest in engaging with global health governance structures as they currently exist. Former Premier Wen Jiabao has spoken of the need to create ‘a model of developing foreign aid with Chinese characteristics’, but it is unclear what exactly this model would look like or how it would relate to the existing global health governance system (Clark 2014: 318). Does engaging with global health governance require China to embrace the system as currently constituted, or can it alter the system in such a way to benefit itself and the rest of international society?
These ambiguities about China’s place in global health governance reflect larger questions about the relationship between China and international society. China has both shown an interest in being an active member of international society and emphasized its difference and distinctiveness from the existing international order. This uncertain relationship with international society writ large reflects the fact that the country is frequently speaking to multiple audiences—the developed, largely Western states that sit at the centre of international society and the Third World states of which China claims to be a leader and exemplar of the benefits of resisting Western models of development (Suzuki 2008: 56–8).
China is hardly the only country to challenge some of the existing norms and practice within international society, nor is it the only newcomer to global health governance. Acharya and Buzan note that many non-Western countries do not fall neatly into existing international relations theoretical categories and that South Korea and India in particular seem uncertain ‘about what sort of place [they] want for [themselves] in international society’ (Acharya and Buzan 2007: 290). Merke (2015) describes how Brazil possesses shared values and institutions with its neighbours, providing the potential foundation for a distinct South American regional international society. Within the realm of global health governance, Fidler (2010b) argues that the rise of Asia—led particularly by China and India—has largely been disconnected from health so far, but that health is likely to become a more important issue. He emphasizes, though, that Asia’s increasing interest in global health is not unique to that region alone; it instead reflects ‘the general increase in global health’s foreign policy, diplomatic, and governance importance over the past 10–15 years’ (Fidler 2010a: 292). Harmer et al. (2013) show that the BRICS economies—Brazil, Russia, India, China, and South Africa—are becoming more important in global health both as funding sources and as institutional and ideational influencers. Kirton et al. (2014) reaffirm this argument, showing that BRICS states are using their regular summits to increase attention to global health governance and bring their influence to the issue.
With all of this interest in how non-Western states attempt to influence international society and global health governance, a specific focus on China (p.135) makes sense for three reasons. First, the sheer size of China’s economy gives it a great deal of power and opens conversations about its role in funding institutions within international society. Second, China holds a degree of political influence within the international system that exceeds other non-Western states. Third, China’s historical experiences mean that these questions about international society and global health governance have featured prominently in Chinese politics since the nineteenth century.
This chapter will examine the place of China within global health governance by examining its interactions with international society on global health issues, its development assistance for health (DAH) spending and priorities, its use of health in its foreign policy objectives, and its relationship with the various institutions of global health governance. It will highlight the fact that China’s ambiguous relationship with international society’s global health governance architecture may actually serve some of its perceived interests, but that this same architecture can and should adjust to incorporate China. International society, in all of its facets, exists within a ‘normatively unsettled condition’ (Clark 2014: 338), and the global health governance elements are no different. In examining China’s place within international society’s norms and values on global health governance, this chapter will pay particular attention to two elements: China’s use of health diplomacy in Africa, and its membership in, diplomatic activities with, and financial contributions to the leading institutions of global health governance.
China and International Society
Historically, international society has grappled with understanding how and whether non-European states like China fit into its structures. Prior to the nineteenth century, Gillard argues that China was at the heart of its own regional system of states. Though its governmental structures differed from those in Europe, China’s influence over East Asia led other governments in the region to acknowledge the power and importance of the Chinese emperor in establishing and preserving world order. In this way, it maintained a relative degree of stability in the region even in the face of incredible power imbalances with other states like Japan (Gillard 1984: 87–8). During this period, China remained fairly impervious to European influence despite strenuous missionary efforts; rather, Chinese culture had a strong influence among liberal intellectuals in Europe (Watson 1984: 23).
This situation changed during the nineteenth century. China had long asserted that it would engage with Europe along the same lines as it engages with any non-Chinese polity, and this standard generally worked. So long as European interests paid tribute to the emperor, there would be an opportunity (p.136) for negotiation between China and outside governments (Gong 1984: 130–1). As the nineteenth century progressed, though, European states began to emphasize a standard of ‘civilization’ that would alter the terms on which it could engage with China. Instead of being a site for art and enlightened governance, Europe came to see China, and Asia as a whole, as ‘decadent’. No longer was there an allowance for multiple international societies. Instead, European governments equated modern civilization with their own standards and defined those practices as constitutive of international society. Therefore, only those governments that embraced European ideals could be part of international society and therefore worthy of mutual respect (Watson 1984: 27). Gong identifies five requirements for a state to meet this new standard of civilization:
1. Guarantees of basic rights like life, property, freedom of travel, freedom of commerce, and freedom of religion (particularly for foreign nationals)
2. An ‘organised political bureaucracy’ that can operate efficiently and provide some degree of self-defence
3. Adherence to ‘generally accepted international law’ (including laws of war) and the presence of a domestic legal system with equal justice for both foreigners and citizens
4. Maintenance of ongoing and permanent diplomatic exchange and communication with other states
5. Conforming to generally ‘accepted norms and practices of the “civilised” international society’, such as prohibitions on polygamy and slavery (Gong 1984: 14–15).
By and large, though, they reflected European liberal thought in the nineteenth century—and took those ideas as given without consideration of different philosophical traditions. They elevated individual rights, for example, above collective rights and duties (Gong 1984: 20). These standards lacked specificity, allowing European states to manipulate their interpretations of them to deny recognition or respect to non-European states as they saw fit.
As time has gone on, the standard of civilization has continued to evolve to equate political and economic performance with liberal democracy, market economy, and respect for international law as the new benchmarks for post-Cold War international society (Stivachtis 2015: 132–4). Others have argued that the new standard of civilization includes certain human rights standards, as evidenced by their status as a basic requirement for joining international organizations like the European Union (Donnelly 1998; Stivachtis 2008). Zhang describes this as ‘the expansion of international society 3.0’, based more on the expansion of ideological collective judgements rather than a simple geographic expansion (Zhang 2014: 678–9). These standards thus (p.137) continue to be a tool that the West can use to deny recognition or respect to other states.
The development of this standard of civilization for membership in international society in the nineteenth century fundamentally challenged China and began its bifurcated relationship with international society. With the Opium War of 1839–42, Europe’s attitude towards China underwent a dramatic transformation (Hsu 1995: 14). European international society fundamentally rejected China’s existing political, social, and economic practices and denied that China’s practices qualified as civilized (Gong 1984: 146). To be accepted by European states, China would have to conform to European rules and standards. China was ‘able to retain [its] independence at the price of Westernization’ (Watson 1984: 29). While China resisted relinquishing its own vision of civilization as long as it could, it gradually came to adhere to elements of the European standards. In the face of the unequal treaties imposed by foreign states and threats of external force, China began to ‘employ the European standard to enter international society as a “civilised” state’ in a strategic manner that did not entail wholesale acceptance of this standard of civilization (Gong 1984: 147). This is where the bifurcation emerges. China wanted both to be a part of international society and simultaneously to remain aloof enough from it so as to model an alternative path. China did enough for recognition, but it also contributed to and supported twentieth-century efforts by non-Western societies to challenge Western standards for membership in international society (Bull 1984b: 219–23).
China’s inside/outside attitude towards international society has remained remarkably consistent since the nineteenth century. This is all the more remarkable given the radical changes the government has undergone—from the imperial system to the nationalist republic founded by Sun Yat-sen to the proclamation of the communist PRC in 1949 and the shifts in the PRC’s attitude towards international relations throughout its existence. Bell describes China’s ambiguous relationship with international society as ‘a case-study of continuity rather than change’ (Bell 1984: 255).
In its contemporary manifestation, the Chinese government has largely argued that it is not a status quo power within international society because ‘the current rules of international institutions are systematically weighted against the interests of the developing world, with the more powerful states imposing their favoured liberal rules on the weak’ (Lee and Chan 2014: 298). It instead aspires for recognition as an established power on equal footing with Western states, despite the differences in political and economic forms, while maintaining the idea that it is an aggrieved state whose experience allows it to represent the interests of developing states (Lee and Chan 2014: 304). Suzuki describes this attitude as one of ‘Occidentalism’, whereby Chinese officials recognize Western standards as the sole benchmark for success and (p.138) recognition within international society—even while they maintain an ambivalence towards the appropriateness of those standards for themselves (Suzuki 2014). China finds itself caught between a twin dynamic of receptivity and resistance to the institutions of global governance that are at the heart of international society (Tan et al. 2014). It has made some overtures towards engaging more fully with international society, but these efforts tend to be marginal and more concerned with protecting its own domestic interests (Buzan 2010: 14–15).
This leads to a different vision of global governance and international society for China as opposed to that articulated by Western states. China recognizes that there exists an idea that its rise poses a fundamental challenge and threat to international society as currently known, so it has adopted a two-pronged strategy to counter that rhetoric. First, it aims to join as many major international organizations and treaties as possible to demonstrate that it is a responsible power. Second, it acts as the protagonist within international organizations, using its membership to point out unjust rules, emphasizing the importance of respecting and defending sovereignty, and fostering the formation of an Asian regional community (Chan et al. 2012: 33). It leverages the fact that ‘no global problems can be successfully handled without China’s involvement’ while also recognizing that it lacks the power to alter the rules of the game or change the international agenda on its own (Chan et al. 2012: 1, 33). The key question for China and international society remains, ‘Could the growing power of China, the most populous developing country in the world, be manifested in facilitating progressively greater global social justice and human welfare in the evolving architecture of global governance?’ (Chan et al. 2012: 3).
One issue frequently brought into the conversation when discussing China’s place within international society is how and whether the size of its economy translates into political standing and stature. In 2016, the US Central Intelligence Agency (CIA) estimated the size of China’s gross domestic product at purchasing power parity exchange rates at $21.27 trillion. This makes China the largest economy in the world, outpacing the combined European Union economy by $2 trillion and the United States by approximately $2.5 trillion (CIA World Factbook 2017). This is incredible growth. In 1980, shortly after China introduced a number of post-Mao economic reforms, the International Monetary Fund estimated China’s gross domestic product at purchasing power parity exchange rates at $247.89 billion (Sedghi 2012). In that same year, the US economy was worth $2.82 trillion (Knoema 2017). China’s incredible economic growth has brought with it both a sense that the country is or should be a major player in the international arena and an expectation that it would become a larger contributor of resources and personnel to leading international organizations. Chan et al. argue that this (p.139) growth is what gives China a place at the international table, writing that ‘China’s ability to play a significant role in global governance depends very much on its continuing economic growth’ (Chan et al. 2012: 59). That said, with China’s growing economic stature comes the notion that its increased prosperity should translate into larger contributions to efforts to address transnational problems (Tan et al. 2014: 325). So far, the Chinese government has tried to strike a balance. While it continues to receive loans from the World Bank, the Chinese government has increased its foreign aid to developing countries and suggested that it would agree to raising its World Bank contributions in exchange for more voting power (Chan et al. 2012: 62–3). It has also increased its personnel contributions to UN peacekeeping operations, but it has resisted increasing its financial contributions to support such missions (Chan et al. 2012: 43). Suzuki calls such a strategy one of playing ‘recognition games’, taking actions that demonstrate that China wants to be a part of international society without fully committing to its values and norms (Suzuki 2008: 46).
While China has shown some willingness and interest in engaging with international society, its hesitation to fully embrace the system can be traced back to some of its existential commitments. China’s Five Principles for Peaceful Coexistence summarize these bedrock beliefs in a tidy fashion:
• mutual respect for territorial integrity and sovereignty
• mutual nonaggression
• mutual non-interference in domestic affairs
• equality and mutual benefit
• peaceful coexistence.
Uniting these five principles, though, is the country’s unwavering belief in respect for sovereignty above all else (Lo 2010: 17). Yoon describes China as hypersensitive to infringements on its sovereignty and ever vigilant about external interference in domestic politics (Yoon 2008: 86–7). As a result, China prioritizes sovereignty and nationalism over global governance when it perceives a conflict between these impulses (Yoon 2008: 96). The emphasis on sovereignty also leads to suspicion about the role of NGOs and civil society groups that operate outside the government’s control. The Chinese government views NGOs as lacking in legitimacy, and some elites fear that NGOs could eventually morph into political parties that would challenge Communist Party rule (Chan et al. 2012: 100–1; Lynch 2009: 103). Chan et al. explicitly connect this attitude with English School theorizing:
On a theoretical level, the Chinese notion [of the international system] bears a resemblance to the English School’s pluralist conception of international society, in which sovereign states can maintain international order, in spite of the fact that they hold varying conceptions of human rights and global justice.
(Chan et al. 2012: 37)
(p.140) This would align the Chinese government, or at least some members of the Communist Party elite, with the pluralist camp of English School theorizing (Lynch 2009: 105).
While China’s ambiguous relationship towards international society can lead to an unsettled attitude, it is important to remember that international society itself is not unchanging. International society is not a purposeful reified agent, but it ‘has real-life effects as if it were’ because it ‘acts’ through its socialization processes (Clark 2014: 320–1). Both international society and the PRC (and all other actors within the international arena, for that matter) engage in ‘perpetual co-constitution’ and operate within a space which remains contested and unsettled by design (Clark 2014: 337). This means that the perceived discordance between China and international society is not an unalterable fact. It also suggests that growing ties between China and international society do not depend solely on China embracing international society’s values and norms. Rather, international society can and will change. It would be a mistake to assert that challenges to European dominance within international society are symptomatic of the breakdown of international society or that non-European states are the only ones who want to see the norms and values embedded within international society change (Bull and Watson 1984a: 433). Dunne notes, ‘The future may well belong to the liberal international order, but there is nothing natural or inevitable about this process’ (Dunne 2010: 537). International society’s continued growth and sustenance will depend on moving beyond its roots in modern European political, legal, and philosophical traditions to identify ways to incorporate ‘the others’ into the realm (Zhang 2011: 785).
As the PRC has sought to demonstrate its desire for some modicum of membership in international society’s norms and values specifically related to global health governance, it has concentrated its efforts in two key areas. First, it has engaged in health diplomacy, building bilateral relationships with African states and deploying medical teams to those countries to improve access to medical care and build stronger relationships. Second, it has taken more deliberative steps to engage with leading organizations of global health governance in recent years. While the Chinese government remains a relatively small financial contributor to most of these organizations, receiving more in aid from them than it gives them itself, and has largely avoided steering the organizations’ overall agendas, it has consciously cultivated membership and sought to demonstrate its engagement on some level. The Chinese government has not necessarily wholly embraced the norms and values embedded within international society’s ideas about global health governance, but its engagement shows an interest in being a part of that same international society and helping to guide the vision of what its norms and values will be.
States are increasingly integrating health into their diplomatic strategies. Health is moving from being auxiliary or an afterthought to a more central location. Governments seek to use health diplomacy to extend both their hard and soft power. Health diplomacy is ‘political activity that meets the dual goals of improving health while maintaining and strengthening international relations’ (Novotny et al. 2008: 41). Others have described it as ‘mechanisms to manage the health risks that spill into and out of every country’ (Drager and Fidler 2007: 162). This approach moves beyond an explicit focus on particular illnesses and instead accentuates how various manifestations of ill health can have negative consequences for the international community. Health diplomacy is not necessarily premised on enlightened self-interest, though. States can engage in health diplomacy to further their own interests—with an added humanitarian benefit. Drager and Fidler (2007), for example, concern themselves a great deal with the connections between health and international economics, but they do so from a perspective that acknowledges that healthier countries are more economically productive and better able to engage with others on that level.
This shift towards emphasizing health diplomacy is perhaps most strikingly illustrated by the relationship between the PRC and African states. China’s support for various African health care systems has ebbed and flowed over the past fifty years, but it has come to assume a prominent place—just as the government has sought to increase its political influence, economic footprint, and access to natural resources throughout the continent. Providing health care resources not only helps China gain favourable trading terms and access to necessary resources, but it also supports the government’s attempts to portray itself as a good international citizen. It is this combination of hard and soft power—economic and ideological benefits—that marks a significant change in China’s health diplomacy strategies. It also allows China to engage with elements of global health governance and international society in its own particular way.
From the beginning of Chinese diplomatic involvement in Africa, it has sought to frame its relationships over time with African governments and anti-colonial movements as a counterweight to the perceived hegemonies of both the United States and the Soviet Union. The Chinese government presented itself as a patron who both rejected the imperial mandates of Western powers and understood the unique struggles of ‘peasant movements’, unlike the Soviet Union. It portrayed itself as challenging the dominant conceptions of international society that existed in the thick of the Cold War.
This diplomatic engagement extended to supporting infrastructural development through deploying medical teams throughout the continent. In 1963, Zhou Enlai dispatched the first Chinese medical teams to Algeria, inaugurating Chinese efforts to support African health care systems by providing (p.142) medical personnel, equipment, and supplies (Eisenman 2007: 43–4). In some instances, the arrival of medical teams coincided with other Chinese infrastructure- or economics-based diplomatic involvement in Africa. More often, though, medical teams were deployed following treaty negotiations between China and the receiving state absent any ostensible economic benefit. The Chinese medical teams frequently were sent because the host country expressed an inability to live up to its health care commitments (Jennings 2005: 461).
In its efforts to support the development of health care infrastructures throughout Africa, China claimed it wanted to avoid imposing its own vision of medical care. Instead, it sought to encourage development based on the country’s own unique characteristics and locally appropriate technologies (Carmody and Owusu 2007: 508; Gill et al. 2006: 20). Chinese medical personnel were generally deployed in the receiving country for a two-year term, often serving in rural, underserved communities. In addition to sending general practitioners, these teams frequently included a broad array of specialists (Hsu 2008: 222–3). While the Chinese national government negotiated the agreements, the actual implementation of these agreements fell to individual provinces. Particular Chinese provinces were linked with one or more particular African countries (Thompson 2005). In this way, the government sought to establish long-term ties between African states and Chinese provinces. It was the provincial government’s responsibility to recruit personnel, send equipment, and ensure smooth exchanges. Since the province was responsible for implementing the agreements, the idea was that establishing ongoing relationships would ease logistical challenges and build long-standing relationships. Under the terms of most of the medical cooperation agreements, the receiving state paid the expenses for the medical team. These included international airfares, stipends for the doctors and support staff, and some of the pharmaceuticals and medical equipment brought by the team. On occasion, the Chinese national government covered these costs through loans or grants. More often than not, though, these costs came directly from the national health care budget (Thompson 2005).
Though China paid less attention to Africa in the 1970s and 1980s, it began a concerted process to re-engage with its African allies beginning in the 1990s. As part of this re-engagement, the Chinese government emphasized its status as a natural leader of developing states and the only viable alternative to neo-imperialist strategies (Youde 2010b: 155–6). Health diplomacy has played a prominent role in these efforts. Government leaders from China and forty-five African states met in Beijing in October 2000 for the inaugural Forum on China–Africa Cooperation (FOCAC). At the conclusion of the meeting, the Chinese government forgave US$1.2 billion in foreign debt owed by African states and pledged to increase its aid contributions to the continent in all realms, including health. Three years later, when the FOCAC re-convened in (p.143) Addis Ababa, the Chinese government made more explicit health diplomacy promises. It specifically highlighted the treatment and prevention of disease as one of its priority areas, pledging additional funds for these efforts (Sutter 2008: 373). Health also featured prominently at the third FOCAC meeting in November 2006. Not only did the Chinese government pledge to double its aid to Africa by 2009 and offer US$5 billion in preferential loans to the continent, but it also emphasized the prominent role of health and education programmes in its African aid efforts (Sutter 2008: 373). At this same meeting, the Chinese government pledged to build thirty hospitals in Africa, provide US$37.5 million in grants for anti-malarial drugs (drugs, incidentally, developed and manufactured in China), and develop thirty demonstration centres for the treatment and prevention of malaria. It also renewed its commitment to continue sending medical teams (People’s Daily 2006a).
Public health and medical care again played a prominent role in the final action plan after the 2015 FOCAC Summit in Johannesburg. The representatives of the assembled African governments ‘expresse[d] [their] appreciation for China’s continued assistance to countries in need…and further appreciate[d] China’s continued support to reconstruct public health, economic, and societal systems of the affected countries during the post-Ebola period’. The Chinese government pledged a number of specific steps that it would undertake to support African health systems, including:
1. Assist with the improvement of disease surveillance and epidemiological systems
2. Strengthen efforts to prevent and treat malaria and other infectious diseases
3. Support cooperation between twenty Chinese hospitals and twenty African hospitals on demonstration projects
4. Continue training doctors, nurses, and other health care workers for Africa
5. Support building an African Union Centre for Disease Control and Prevention and other efforts to enhance the continent’s medical research and diagnostic capabilities
6. Continue sending medical teams from China to African states
7. Encourage joint medical and pharmaceutical efforts between Chinese and African firms
8. Improve health infrastructure throughout the continent
9. Improve access to maternal and child health and reproductive health services
10. Facilitate high-level exchanges between health policy makers (Forum on China–Africa Cooperation 2015a).
(p.144) To support China’s ambitious plans for health and other sectors in Africa, President Xi Jinping announced that his government would make available $60 billion in various funding support programmes (Forum on China–Africa Cooperation 2015b). This is a tripling of the funding that China has previously made available after FOCAC meetings (Sun 2015).
The medical teams China pledged to send are particularly crucial to its health diplomacy efforts. Each Chinese provincial government is paired with one or more African states and is responsible for staffing and supporting medical teams in its partner state. After dwindling in the 1980s, Chinese medical teams have been increasingly deployed throughout the continent. In 2003, 860 Chinese medical personnel were serving in thirty-five teams in thirty-four African states. Two years later, the number of Chinese medical personnel in Africa topped nine hundred (Eisenman 2007: 44). By 2014, researchers estimated that the Chinese government was spending $30 million to $60 million to support forty-three medical teams in forty-two African states (Lin et al. 2016).
When sending these medical teams, the Chinese government strongly emphasizes its solidarity with Africa. China calls upon its self-perceptions as a developing country as proof that it has no grander, hegemonic motivations in deploying medical personnel on the continent. During remarks made with Jose Maria Neves, the prime minister of Cape Verde, then-Premier Wen Jiabao remarked that China is itself a developing country with limited resources. He continued, ‘the assistance we have provided to the best of our ability is therefore sincere and selfless’ (Ministry of Commerce of the People’s Republic of China 2006).
At the same time, the Chinese government has not wholly dismissed the larger international society in its approach. While it may portray itself as an alternative model, it highlights its commitment to the norms, values, and goals of global health governance in international society by connecting its actions to global interests. It has connected the deployment of its medical teams to larger international goals. At a 2009 diplomatic conference, Ambassador Liu Zhenmin, China’s deputy permanent representative to the United Nations, stated that his government’s deployment of medical teams would not only help African states weather the global economic crisis, but also make it more likely that those countries would achieve the targets established by the United Nations in the Millennium Development Goals (Permanent Mission of the People’s Republic of China to the United Nations 2009).
In addition to traditional medical teams, the Chinese government started to include its medical personnel on UN peacekeeping missions in Africa. Nearly nine hundred Chinese medical personnel served on eight UN-sponsored African peacekeeping missions in 2005 (Sutter 2008: 375). In 2016, China’s People’s Liberation Army deployed just over 2,600 personnel on UN peacekeeping operations, and the majority came from engineering, (p.145) transport, and medical teams (Blasko 2016). It now ranks as the largest contributor of medical personnel to UN peacekeeping missions around the world (Van der Putten 2015: 14). These troops contributed both to benefiting health care infrastructures in African states and demonstrating China’s willingness to engage with the international community in a constructive, cooperative manner. More recently, the Chinese government turned to the People’s Liberation Army to provide assistance in West Africa to combat Ebola. Troops worked to construct health facilities, military scientists conducted research on treatments for and vaccines against Ebola, and much of China’s aid to combat Ebola was funnelled through the military (Tiezzi 2014).
Providing these medical teams appears to be paying off for the Chinese government and its efforts to improve its standing among developing nations. It not only provides much-needed services to a large swath of the population in Africa, but it also reaches far more people than other outreach programmes can. Thompson acknowledges, ‘While university scholarships promote closer ties between China and Africa, China has also promoted “health diplomacy” with African partners, establishing a relationship between Chinese doctors and millions of ordinary Africans, and earning the gratitude of many African leaders eager to be seen providing public goods to their citizens’ (Thompson 2005). Public opinion suggests that these actions have benefited China’s reputation throughout Africa. In 2014 and 2015, 63 per cent of respondents in thirty-six African countries described China’s influence in their country as somewhat or very positive. China’s efforts to promote infrastructure and development were the most important reasons for these positive attitudes (Lekorwe et al. 2016). In this instance, providing health services allows the Chinese government to grow in stature among the people and government leaders throughout the African continent.
Part of what makes China’s health diplomacy strategy so interesting is how it simultaneously pursues insider and outsider strategies. It positions its bilateral appeals to developing states in the context of a shared experience and a commitment to resisting imperialism, but it also emphasizes how its efforts work towards satisfying global health goals. It shows evidence of an interest in participating in international society or at least abiding by some of its norms and values, but without completely rejecting its own traditions and values. China’s health diplomacy efforts in Africa in many ways mirror the government’s larger attitudes towards global health governance and international society.
China and Global Health Governance Institutions
The ambiguous relationship between the PRC and international society replicates itself within the realm of global health governance. On the one hand, (p.146) the Chinese government recognizes the value of participating in global health governance institutions and has taken steps to demonstrate its willingness to embrace some of the norms, values, and expectations that exist within the global health governance architecture within international society. On the other hand, its prioritization of state sovereignty and nationalism has discouraged more active collaboration with these same institutions. Given the realities of combatting transnational health concerns and the history of infectious disease outbreaks in recent years, it is incumbent upon both China and international society to find a way to embrace each other to strengthen global health governance.
Analysts of global health governance frequently lament China’s reluctance to take a stronger leadership and financial role within the international system. Yoon argues that China tends to respond to infectious disease outbreaks with policies that emphasize national protection over international cooperation. The government views disease outbreaks as weakening national power and construes national power as a zero-sum game. As such, sharing information about disease outbreaks with international society would give other states the tools and information necessary to take advantage of China’s situation and usurp its power (Yoon 2008: 93). Stevenson and Cooper note, ‘Although China aspires to be a global leader, it continues to work to constrain the application of exogenous norms’ in global health governance (Stevenson and Cooper 2009: 1380). They argue that global health governance institutions emphasize the notion that health is a human right that should be protected by the state and that public health is key for collective security in a globalizing world. The Chinese government, by contrast, makes health-related policy changes solely based on its own political and economic calculations and invokes a sovereign right to self-determination as it sees fits (Stevenson and Cooper 2009: 1383–5). Lee and Chan echo this view, arguing that China stays on the periphery of global health governance because of its dualistic national identities and its efforts to present different images of itself to different audiences. They describe a group they call Chinese realists or ‘China Firsters’ who interpret any effort to get China to contribute more financially to these institutions ‘is a trap [by the West] to exhaust [China’s] limited resources’ (Lee and Chan 2014: 306). This has discouraged Chinese health experts from collaborating with global health governance, which further isolates the government from the larger global health governance architecture. The result is an attitude where the government is simultaneously fearful about being left behind but also unmotivated to participate in efforts to reshape global health governance institutions (Lee and Chan 2014: 306–9).
Even when there have been conscious efforts to reshape global health governance’s institutions within international society, China has tended to be conspicuously absent. During the 1990s and 2000s, WHO undertook a (p.147) massive effort to fundamentally rewrite the International Health Regulations (IHR)—a process described in Chapter 3. Despite the fact that this was one of the largest global health diplomacy efforts undertaken to this point, China had relatively little involvement in the IHR revision process. It did not take an active role in the IHR negotiations, and it offered little experience or expertise to inform the debates (Lee et al. 2012: 350). What makes China’s minor role in the IHR revision process all the more curious is that much of the final impetus for overhauling the IHR came from China’s experience with SARS. SARS was ‘a good example of an “exogenous shock”’ to international society and global health governance, demonstrating the need for the system to change to respond to new challenges (Price-Smith 2009: 15). In this case, the Chinese government’s efforts to cover up the extent of SARS’ spread, its reluctance to cooperate with international organizations, and its obfuscation to domestic and international audiences provided international society with the final validation that it needed to change its norms and expectations regarding disease surveillance (Davies et al. 2015: 45–58). Thus, the country whose actions compelled the international community to finally complete efforts to rewrite one of the few global health treaties did not offer its experience or expertise to these efforts—not even as a cautionary tale of what states should avoid doing when facing a previously unknown infectious disease.
This reluctance extends to other health-related treaties, too. During the negotiations that crafted the Framework Convention on Tobacco Control, Lee et al. interpret China’s involvement as driven more by industry interests rather than broader public health concerns. China is both the largest producer and largest consumer of tobacco products (Lee et al. 2012: 353). By promoting the concerns of tobacco companies over larger public health interests, China again demonstrated its ambivalent attitude towards the international society of global health governance—though it was not the only country that tried to protect its tobacco industry in the face of criticism of smoking.
While there certainly is space to criticize China’s reluctance to engage with the institutions of global health governance within international society, China has not completely shunned these institutions. Indeed, it is entirely plausible to argue that the government has taken a number of steps to demonstrate its interest and willingness to embrace the norms and values embedded within this regime.
China may not be the most active member of WHO, but that does not mean that it wholly dismisses the organization’s importance. There is no clearer sign of its willingness to engage with WHO than Dr Margaret Chan, WHO’s Director-General from 2007 to 2017. Chan began her public health career when she became a medical officer with the Hong Kong Government in 1978. She progressed through the ranks of the Hong Kong Department of Health to eventually become its leader in 1994. She joined WHO in 2003 and (p.148) worked on issues like promoting healthy workplace environments, pandemic influenza, and infectious disease surveillance before being elected WHO Director-General. What is significant about Chan’s position is that the Chinese government actively promoted her candidacy and gave her its full backing (People’s Daily 2006b). Analysts took different views of why China would decide to get so involved in an organization that it had previously afforded relatively little attention. On the one hand, China’s actions could be perceived as recognition that working with WHO is the best way to help craft the norms and values underlying global health governance within international society. Lo notes, ‘The presence of Margaret Chan—a Chinese citizen—as Director-General of WHO could give China even more of an opportunity to become the leader in global health governance’ (Lo 2010: 23). Working with the organization from the inside gives China a place at the table, helping it to craft the regime in a way that resonates with its beliefs and bolster its status as a responsible great power. On the other hand, the move could be interpreted as a cynical attempt to block future reforms. After the criticism China received for its handling of SARS, it may have feared being sanctioned by WHO or being subject to more intrusive surveillance efforts. It may have also feared that its own poor relations with WHO during the SARS outbreak could give Taiwan leverage in its efforts to join WHO on its own. By installing one of its own citizens as Director-General, China could theoretically prevent WHO from introducing policies that would challenge China’s sovereignty (Chan 2011: 120). While it is impossible to know the Chinese government’s exact motivation, it is worth noting that China’s increased engagement with WHO is in line with its general trend of joining international organizations and signing up to various treaties and cooperation agreements (Chan et al. 2012: 107).
China’s approach to global health governance has evolved considerably since the 1960s when it started deploying medical teams in developing countries. In the early days, China’s approach could be described as largely defensive. The medical teams were an effort to counter both the Soviet Union and the United States and build alliances with potentially friendly states. The country embraced a bilateral approach to global health issues, preferring to work in a one-on-one relationship with recipient states selected specifically because of their real or perceived strategic importance (Huang 2010: 107–10). Though China eschewed the multilateral approaches of the global health governance institutions within international society, it did not worry about being a responsible power within international society because ‘it regarded the international system as alien and illegitimate’ (Huang 2010: 110). Until the 1980s, then, it would be difficult to argue that China saw much, if any, value within global health governance.
China’s attitude towards global health governance institutions starts to shift during the 1990s. Huang ascribes this change to the government developing a (p.149) new sense of accountability and commitment to the international system, a desire to promote an image as an internationally responsible citizen, and a recognition of human security and non-traditional approaches to security (Huang 2010: 112–14). He also cites SARS as providing an impetus for further engagement with global health governance. The outbreak undermined the country’s long efforts to improve its international image and project an air of legitimacy and competency. As a result, the government eventually demonstrated a willingness to collaborate with WHO and regional Association of Southeast Asian Nations partners for health assistance because it recognized both that it lacked the necessary expertise to handle outbreaks on its own and that it had demonstrated its vulnerability. ‘In an age of globalization,’ Huang argues, ‘it [the Chinese government] can no longer monopolise information or act alone in addressing NTS [non-traditional security] challenges’ (Huang 2010: 121). China has demonstrated a new willingness to engage with regional and international partners to address health concerns, even if it may have some selfish motivations for doing so.
Changes in China’s approach to foreign aid in the mid-1990s facilitated an increase in its DAH budgets. In 1995, the government moved beyond a singular focus on deploying medical teams to provide direct services in developing countries to allow for funding to support improving health infrastructure, developing health-related human resources, and delivering medical services. States that want to obtain such resources from China must make their request known through their local Chinese embassy, which can forward the request to Beijing. Interestingly, since the country lacks specific foreign aid laws, the approval process for health-related aid (or any other form of aid) proceeds in an ad hoc manner and takes one to two years (Huang 2014: 185–90). In general, the Ministry of Foreign Affairs determines the amount of aid to be granted and works with the Ministry of Commerce to make plans for aid disbursement and ensure that political interests are not subordinated to commercial ones. Meanwhile, the Ministry of Finance takes the lead on bilateral and multilateral aid initiatives, and the Ministry of Health oversees the deployment of medical teams. The Global Health Diplomatic Coordination Office works to facilitate cooperation and communication among these different ministries (Florini et al. 2012: 341). Within the language of any agreement to provide DAH to a developing state, the Chinese government highlights its sensitivity towards sovereignty, emphasizing that the recipient government is ultimately responsible for making policy decisions (Tan et al. 2014: 327).
China finds itself in an interesting position within the global economy and global health governance. The sheer size of its economy raises expectations about significant contributions to various international organizations and health campaigns. On a per capita basis, though, China is a middle-income country. It is precisely in these middle-income countries where the bulk of the (p.150) world’s poor live and where the global burden of disease is shifting (Glassman et al. 2013: 2–5). While this means that middle-income states are likely to need additional resources from international society in order to address the health concerns of their citizens, their relative wealth means that many of them are no longer eligible for funding from leading global health governance institutions (Glassman et al. 2013: 6). Economic growth in countries like China increases the pressures on governments to address health concerns, but this occurs at the very time when they are eligible for less funding.
It is into this gap that China aims to step. The country finds itself as both a donor of DAH and a recipient of that same aid. China is the most significant foreign aid donor that is not a part of the Organisation for Economic Cooperation and Development’s (OECD) Development Assistance Committee (DAC) (Harman and Williams 2014: 935). DAC member-states are the traditional aid donors, and they are required to have a framework for providing development assistance and engage in monitoring and evaluation activities of their efforts (Organisation for Economic Cooperation and Development n.d.). They have traditionally given the bulk of foreign aid, but this has shifted in recent years. In 2000, non-traditional sources provided 8.1 per cent of all foreign aid. In 2009, these same non-traditional sources were the source of 30.7 per cent of all foreign aid (Harman and Williams 2014: 935–6). This change in which states provide foreign aid means both that more states are trying to demonstrate that they have an interest in being seen as responsible members of international society and that international society itself may be changing to better accommodate these new players.
Before looking at China’s aid flows, it is important to establish that any reported figures are essentially educated estimates based on information culled from a wide variety of sources. It is not that the Chinese government does not account for the total amount that it disburses in foreign aid; rather, foreign aid is part of a tightly controlled government budget reporting system (Brautigam 2009: 166). There are a number of reasons for this. Brautigam cites continued diplomatic tensions with Taiwan, a sense of impropriety in calling attention to delivering assistance, and disagreements over whether China is too poor to give aid to others (Brautigam 2009: 165–6). Florini et al. write, ‘It is more difficult to obtain credible estimates of China’s overseas aid, given domestic political sensitivities in both Beijing and among its aid recipients about publicising aid flows, inadequate inter-ministerial information sharing and limited aid expertise in Beijing, and the absence of a clear development aid system and lexicon within the Chinese government’ (Florini et al. 2012: 338).
Drawing on a variety of sources, Florini et al. derive estimates for China’s DAH for 2007 and 2008. They peg the country’s DAH commitments at slightly more than $300 million. The overwhelming majority of funds went to recipient (p.151) states on a bilateral basis. WHO received $18 million, the UN health apparatus received $15 million, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) received $2 million. Not all of this aid was in cash; a significant portion of it came as in-kind services (Florini et al. 2012: 339–40). China’s contribution to the Global Fund is particularly interesting. In the same year that the Chinese government gave the Global Fund $2 million, it received $1 billion from the same organization (Florini et al. 2012: 340). The fact that China is giving money to global health organizations like the Global Fund when it is receiving funding from them suggests that its contribution may largely be premised on establishing patterns and demonstrating an interest in participating in international society’s global health institutions. Given the country-ownership requirements attached to Global Fund grants, it is clear that China needs the funding from the organization to carry out various programmes. That said, providing some small amount of funding to a multilateral global health organization represents a good faith effort to participate in the organs of global health governance. At this point, though, China has ‘benefited substantially from multilateral initiatives to which their material contributions have been limited and their ideational contributions nonexistent’ (Florini et al. 2012: 345).
It is notable that China’s DAH overwhelmingly goes through bilateral, as opposed to multilateral, channels. It is on the extreme end of the spectrum, but this is not entirely out of step with the rest of the international community. Korea, Portugal, Germany, and Japan all funnel more than 40 per cent of their global health funds through bilateral channels (Institute for Health Metrics and Evaluation 2015: 20). China’s preference for bilateral channels may reflect its relative newness to the DAH realm, its unsettled foreign aid bureaucracy, its interests in increasing the sovereign capacities of its recipient states, and its concerns about the role of civil society organizations and NGOs in service delivery (Florini et al. 2012: 342–5; Huang 2010: 123–9).
As with the deployment of medical teams as part of its health diplomacy strategy, China’s engagement with global health governance within international society embodies a dual insider/outsider strategy. The government has expressed an interest in being a member of international society and taken tentative steps towards active engagement, but it remains a bit aloof to preserve some measure of independence and so that it can portray itself as a bulwark against imperialism and Western hegemony.
Without the involvement of the PRC, the global health governance system within international society will have a serious gap. Given its epidemiological (p.152) history, the sheer size of its population, and its economic wealth, China is obviously an important element in creating and maintaining sustainable strategies to prevent and stop the spread of future epidemics. At the same time, it is of utmost importance that international society be willing to adapt and evolve in such a way that makes it more inclusive of non-Western states.
In many ways, China’s approach towards global health governance mirrors the pluralist conception of international society: state-centric, minimal in its obligations and shared norms, respectful of sovereignty, and a tool for achieving certain specified goals. As much of global health governance walks the line between pluralism and solidarism, this does not necessarily put China’s position far outside the bounds of international society and suggests that international society may possess the adaptability that will facilitate the normative evolutions that will ease China’s full entry into international society.
Perhaps the area of greatest contention will emerge regarding the role of non-state actors such as NGOs and civil society organizations in the provision and maintenance of the global health governance architecture. This is an area that potentially strikes at the heart of the Chinese government’s conception of its own power and legitimacy. That said, and this is important to recognize, the role of non-state actors also challenges some of the base assumptions in English School theorizing of international society. Much in the same way that the Chinese government will likely need to identify ways that it can productively partner with non-state actors in support of global health governance, English School theorizing about international society needs to open itself to recognizing the important role that non-state actors play in the contemporary arena when it comes to the promulgation and support of norms, values, and standards within international society. In this way, China’s stance is less of an outlier position and more a reflection of the theoretical blind spot that currently exists within international society.