While the West's health diplomacy in Africa tends to be vertical and targeted at diseases, China's has typically been horizontal, infrastructure-based and recipient-led.
In 1941, Mao Zedong called for a "practice of revolutionary humanitarianism". 14 years later in Bandung, Indonesia, China's Premier Zhou Enlai met with other Asian leaders to chart a distinctly anti-colonial approach to humanitarianism and diplomacy on the African continent.
From its first health aid to Algeria in 1964, China has sought to distinguish its diplomatic aid to Africa from that of the "Global North": its political-economic ideology has employed an anti-imperialist discourse, with an emphasis on horizontal interventions that further the development of local health care infrastructure.
Whether purposeful or accidental, the interventions of the People's Republic of China's (PRC) early health diplomacy in Africa were markedly distinct from Western health diplomacy - and possibly more effective in local African contexts.
One wouldn't want to romanticise a period of Chinese history known for producing such atrocities as the largest domestic famine in modern history (during the "Great Leap Forward") and the abuses of the Cultural Revolution, but the PRC's foreign policies were very different to its domestic policies of the same period.
During the first week of May, this theme was brought into a new era at the 4th International Roundtable on China-Africa Health Cooperation, held in Gaborone, Botswana.
International NGOs and multilateral organisations such as the Global Fund, Gates Foundation, the UK's Department for International Development (DfID), UNAIDS, WHO-AFRO and UNFPA were all in attendance as strategies to combat HIV, schistosomiasis, and malaria were plotted out. The presence of these organisations which generally take a different approach to China raises the question of wheter China's health diplomacy is beginning to change.
Health diplomacy: East vs. West
In general, health diplomacy is defined as any health care activity characterised by the underlying intention of improving political, economic, and/or cultural ties between donor and recipient countries in keeping with the foreign policy of the donor state.
Health diplomacy is an example of what Joseph Nye refers to as "soft power", using health to foster international relationships and achieve foreign policy goals.
Although health care transfers have historically been perceived as an inherently beneficent form of diplomacy, it is naïve to assume that all health diplomacy is conducted in the same manner and leads to the same outcomes in different recipient contexts.
According to Adams, Novotny, and Leslie, "the most effective international health interventions are carried out in an ethical manner that is sensitive to historical, political, social, economical, and cultural differences between nations and peoples".
Hence, regardless of the donor's intentions or the value of the particular health care intervention and/or technological transfer, context appropriateness is a key consideration for effective health diplomacy. So what are the key differences between China and the West in terms of their approaches?
The particular interventions and technology transferred from China to Africa have markedly differed from those transferred by the West. Professional human resources have always been a central component of Sino-African health diplomacy.
For example, Youde claims that "since the first medical team arrived in Algeria in 1964, more than 15,000 Chinese medical personnel have served in 47 different African states and treated at least 180 million patients".
Historically, Chinese medical teams (CMTs) have been specifically targeted for rural, under-served communities with limited access to health care.
However, interviewees specified that CMTs were currently being primarily utilised at district hospitals and were usually not to be found at primary or secondary level rural health care facilities. CMTs are also noteworthy for including practitioners of traditional Chinese medicine (i.e. acupuncturists and herbalists), in addition to conventional biomedical personnel.
There are further structural differences between Chinese and Western health diplomacy. Whereas Western health assistance comes from a combination of public, private, and multilateral sources, China's health diplomacy is almost entirely public in nature, and often decentralised to the level of a Chinese province.
The process of health diplomacy is typically initiated by the prospective recipient government. One Chinese informant noted, "If they don't ask, we don't provide".
In general, an African government will propose a health project in accordance with their assessment of the needs of their population. The Chinese government then assesses whether it can fulfil the demands of the proposal in terms of human and material resource availability.
As a result of this structure, interventions are commonly recipient-led from the onset.
They are thus potentially more context-appropriate than if China were to devise a health care intervention according to its own estimation of local need.
The greater specificity of this process is a contrast to Western health diplomacy which is more often led by "experts", who are external to the given context.
China's health diplomacy is structurally distinct not only in terms of planning, but also in its implementation. Chinese medical teams travel as a cohesive group, typically consisting of 20 members, who work together in a single medical facility for a minimum of two years - a rare overall time commitment.
Health interventions from the West are usually of a specific duration, and often lack a follow-up from which sustainability can be assessed.
China-Africa expert Deborah Brautigam observes: "For the West, once a project ends, it is turned over to the government, and donor involvement usually ends".
Measuring success
One outcome of the "Western approach" is that even if projects have fulfilled the donors' specific short-term goals, many are unsustainable in the long term.
Both Chinese and African informants report that China will usually maintain a project until it may be viably assumed by the recipient government. Additionally, follow-ups were considered common, particularly in the case of hospitals in need of repair.
But what about the specific health transfers? Were they, in fact, beneficial to local African recipients? According to several informants, distinctly "Chinese" health care transfers appear to have been particularly appropriate for local contexts in Africa, and are well utilised by local communities.
For example, Chinese herbal remedies were welcomed in most African communities, where many local informal health care economies were already dominated by herbal use.
The Chinese herb Artemesia annua provides the starting compound for artemisinin-combination therapies, which have proved particularly successful in treating malaria and are endorsed by the World Health Organisation.
Although there are concerns of drug resistance due to poorly prescribed and fraudulent versions of the drug, the majority of pharmaceutical manufacturers of Artemsinin drugs are not in fact Chinese, but European.
In addition to human resources, essential medicines, herbs, and acupuncture, China has also been integral in the development of health care infrastructure, both through the construction of hospitals and clinics throughout Africa and in the ongoing training of African medical students in China.
According to interviewed informants, these health care provisions have both enhanced China's image in the eyes of ordinary Africans and engendered a trust in Chinese medical products.
Preliminary evidence from interviews and the literature suggests a general satisfaction with the outcomes of China's particular health diplomacy in Africa.
For example, following visits to a number of medical clinics sponsored by the Chinese government throughout the continent, it became clear to one researcher that rural CMTs represented one of the most successful forms of current aid to Africa.
The Chinese medical teams were noted for focusing on disseminating basic preventative care to rural areas that previously lacked proactive public health care.
Sustainable health care development is thus promoted in recipient countries' health care infrastructure through the creation of horizontal primary health care programmes - building infrastructure and establishing primary and preventative health care - which differs sharply from the singular focus on vertical, top-down programmes for the eradication of specific diseases, commonly practised in Western health diplomacy.
Looking toward the future
Although the current sustainability of these practices can be critiqued in several ways, overall, the type of health interventions that China has delivered and the manner in which these interventions are carried out may be considered separate from Western ones.
However, informants note that China's horizontal focus is currently being compromised by collaborations with Western states, international NGOs and multilateral agencies that insist on a more vertical approach to health care.
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One informant observed that "previously aid from China did not value cooperation with NGOs and other governments". And yet, both the 4th and 3rd International Roundtable on China-Africa Health Collaboration appeared to be dominated by organisations such as The Gates Foundation, the World Health Organisation (WHO), and the UK's DfID.
"We want closer collaboration with WHO and other organisations," offered one Chinese informant. As identified, evidence for this development can be found in the growing focus on health diplomacy projects directed toward, for example, malaria and HIV/AIDS treatment. These distinctively vertical programmes do not, generally speaking, effectively strengthen health care systems.
Interestingly, this shift toward more Western programming has been accompanied by a parallel shift in political-economic ideology.
This is evident in many of the speeches presented by Chinese representatives at the 3rd International Roundtable on China-Africa Health Collaboration. One Chinese informant argued: "Our assistance to Africa has been a public economy ... we should tap into liberal markets and the private sector."
It remains to be seen if what has thus far been a marked alternative to Western health diplomacy, will eventually merge with the West.
An African informant representing the African Union asked, "How do we move away from silos [sic] of interventions and begin to address weak health systems?"
It is questionable whether her query will be heard by a China seemingly eager to forge alliances with Western health and development organisations.
Parts of this piece are taken from an earlier article, published here by St. Anthony's International Review.
Dr. Paul Kadetz is Convenor and Assistant Professor of Global Public Health at Leiden University College in the Hague.
He is also an Associate of the China Centre for Health and Humanity at University College London and part of the faculty of the Arizona School of Health Sciences (United States).
He has served as an external expert researcher for the Traditional Medicine Unit of the Western Pacific Region Office of the World Health Organization and assisted in the development of the current strategy for Traditional Medicine for the Western Pacific Region.
