The People’s Republic of China (PRC) is remarkably transparent about its aim to reform the international order. In this pursuit, Beijing views developing or third states as its main allies with health diplomacy as an essential tool to build international coalitions.

The Covid-19 pandemic revealed China’s capabilities to act globally. Beijing served as a first responder for developing countries and Chinese vaccines played a significant role in immunising the world, despite relatively low efficacy rates. It was geostrategic considerations which guided China’s donation policy as neighbouring and key Belt and Road Initiative (BRI) countries received the lion’s share. The pandemic also highlighted the party-state's ability to promote a streamlined global narrative via digital channels. China has established a parallel Covid-19 information bubble targeting developing states. In this narrative, China is the responsible major power, and the West is in decline. 

The Health Silk Road

Beijing’s health diplomacy did not develop overnight. By sending medical teams, Chinese provinces have been cultivating close relations with individual countries for decades. The PRC also utilised health cooperation when it generated support among former colonies for its UN admission in 1971. After the 2002 SARS outbreak, which challenged China’s economic and political stability, the PRC stepped up its international health cooperation efforts. On a bilateral level, Beijing expanded existing programs. The SARS outbreak also triggered the institutionalisation of regional health cooperation with Southeast Asian and African states. At the multilateral level, the PRC amplified its WHO engagement. 

By 2019, the PRC had established and expanded health cooperations with ASEAN, Central and Eastern European States (16+1) and the Arab League.

The 2015 launch of the Health Silk Road (HSR) marked the beginning of a strategic, centralised, and streamlined health diplomacy. The declared goal of the HSR is to generate ‘soft power and influence in the field of regional and global health governance,’ and to increase China’s ‘status as a major country’. It includes the expantion of health cooperation mechanisms, prevention and control of infectious diseases, capacity building and talent training programs, emergency medical assistance, Traditional Chinese Medicine (TCM), health system reform and health policy coordination, health development assistance (e.g., free surgeries) and health industry development. 

But it was the Covid-Pandemic that served as a catalyst and accelerator for Beijing’s regional HSR outreach efforts. By 2019, the PRC had established and expanded health cooperations within the framework of the FOCAC and China’s regional cooperation mechanisms with ASEAN, Central and Eastern European States (16+1) and the Arab League. Covid-19 also triggered the expansion of regional health cooperation mechanisms to Latin America and the South Pacific. Beijing has attempted to tie Covid-relief to the BRI promises of development and prosperity. But due to political tensions, the 16+1 health cooperation format lost significance, exemplifying that dialogue does not necessarily equal meaningful cooperation.

Regarding multilateral outreach, China’s efforts remain limited. In 2017, Beijing signed a BRI cooperation agreement with the WHO, to explore synergies with the Health Silk Road. Also, it advocated, that collective human rights (incl. the ‘right to health’) are more relevant than individual human rights. During the pandemic, the PRC criticised the US government’s Covid policy through UN platforms, but refrained from significantly increasing its voluntary WHO contributions.

A Western response

Is China successful with its Covid-Diplomacy? Pew polling data indicates that Beijing’s Covid-Diplomacy failed to generate a more positive attitude towards the PRC among Western states. A survey from a Singaporean institute, however, revealed that people from ASEAN states recognise the PRC as the largest Covid aid provider. Nevertheless, they continue to view Beijing’s influence in the region as unfavourable. In the Middle East and Africa, the PRC is generally seen positively, and favourability rates have moderately increased since the pandemic.

The majority of third states welcomed Beijing’s health cooperation. In many cases, they endorsed key policy positions of the PRC in regional and multilateral settings, as for example in regard to Xinjiang and Hongkong. 

Despite Beijing’s quixotical zero Covid policy, decision-makers should recognise the long-term effects of Chinese aid for developing countries. There are a number of recommendations to consider. For instance, the importance of drawing analogies. The PRC's health diplomacy illustrates the functionality of the BRI and the PRC's approach to foreign policy. The BRI is here to stay as a comprehensive vision to establish China-centred networks across a multitude of policy areas, including health.

Beijing understands that support from developing states is crucial to uphold and reform the international order.

Decision-makers should acknowledge the magnitude of the PRC's ambition to win over the hearts and minds of third states. It would also be an error to underestimate the PRC's ability to learn from its mistakes and improve its health diplomacy. Beijing understands that support from developing states is crucial to uphold and reform the international order. For that reason, the PRC targets third countries, offering itself as the natural partner of the developing world. 

While the PRC approaches health cooperation strategically - ‘to gain soft power’ - decision-makers in Europe must do the same and should invest heavily into improving visibility.  As Beijing has been pushing the narrative of Western decline, European decision-makers should promote the narrative of the West’s ability to vaccinate themselves back to normality while extending an open invitation to third countries. Significant resources should be put into social media outreach efforts in recipient countries to counter the PRC’s public narrative monopoly. The European Commission and embassies could hire social media experts with knowledge of the domestic digital landscape to advertise and inform about European health aid. Ambassadors from EU member states could publish joint articles in local newspapers to highlight European health aid in the recipient country. 

It is also important to empathise that developing countries have recognised the PRC's achievement of transitioning from aid recipient to aid provider and Western democracies will not be received with open arms when claiming moral superiority. A bottom-up approach could be an elegant response to the top-down approach of Beijing's HSR. Brussels or EU member states could commission surveys in aid recipient states, to derive needs and demands, which might serve as the foundation for tailor-made health cooperation measures. In doing so, the concrete material interests of the recipients should take centre stage. While donor countries may enable recipient states to achieve their domestic goals, this will not cause them to commit to an ideological camp. The EU's Global Gateway Initiative could play a relevant role if it were to be framed as a post-Covid economic recovery measure. As part of a more strategic approach to health diplomacy, European decision-makers might consider mapping the interests of the recipient states and use health aid as a political bargaining chip. 

Western decision-makers are advised to simultaneously cooperate with like-minded states and the PRC.

In an attempt to replicate Beijing’s strategic outreach method, European states should also apply a multi-level approach. At the bilateral level, the focus should be on identifying fulcrum countries with whom health cooperation has already developed, or which are of key strategic interest for both, Europe, and the PRC (e.g., Nigeria, Egypt, Indonesia, or Serbia). EU+x formats with states from the Indo-Pacific or Africa are another course of action. At the multilateral level, Europe needs to anticipate and match China's increasing level of engagement.

Furthermore, Western decision-makers are advised to simultaneously cooperate with like-minded states, the G7 might be a suitable platform to launch transatlantic health outreach efforts to third states, and the PRC. Despite different values, health cooperation could serve as a high-yield low-risk cooperation area with China.