China’s global health diplomacy through the World Health Organization: a qualitative study

Abstract

Background

Global health governance faces fragmentation following COVID-19 and the 2025 U.S. withdrawal from the World Health Organization (WHO), elevating China’s prominence within the organization. Existing literature has not yet comprehensively examined the China-WHO relationship in the post-COVID-19 period. This study addresses this gap by providing timely qualitative insights from high-level experts.

Results

Using a qualitative descriptive approach, in-depth semi-structured interviews were conducted with 10 high-level experts in global health governance with substantial WHO experience. Five key themes emerged: balancing sovereignty with multilateral cooperation, China’s evolving role within WHO, COVID-19 as a relationship downturn, Chinese contributions to the WHO’s mission, and U.S. withdrawal from the WHO as a cautious opportunity for China. The findings reveal China’s deliberate positioning within the WHO, emphasizing multilateralism rhetorically while engaging pragmatically through bilateral channels. While China remains reserved in making larger voluntary contributions, its strategic engagement through assessed contributions, technical expertise, personnel deployment, and bilateral health programs attest to its growing influence. Importantly, there is consensus that China does not seek explicit dominance within the WHO but aims to position itself more strategically within the evolving global health architecture.

Conclusions

The study reveals that while the U.S. withdrawal creates a leadership vacuum, China does not seek to dominate the WHO but rather to enhance its strategic position through pragmatic engagement. Findings underscore the urgent need for WHO reforms in governance, representation, and financing, alongside enhanced transparency and mutual trust between China and the organization. This critical juncture offers an opportunity to recalibrate the China-WHO relationship in ways that strengthen global health preparedness, contingent on balancing sovereignty concerns with expectations for multilateral cooperation.

Clinical trial number

Not applicable.

Background

The World Health Organization (WHO) serves as the world’s premier forum where all countries have equal representation in addressing transnational health crises, including pandemics and emerging public health threats. However, recent years have witnessed significant disruptions to the global health structure, undermining the foundations of multilateral cooperation. The erosion of trust in the existing governance structure reached a critical juncture with the US withdrawal from the WHO on the first day of the second Trump administration [1]. As the organization’s largest financial contributor—providing $1.28 billion in assessed contributions and voluntary funding during the 2022–2023 biennium [2]—the loss of US participation represents both a substantial funding shortfall and the departure of a founding member’s institutional voice. This development poses serious challenges for the global health community’s capacity to coordinate effective responses to future health emergencies.

Following the completion of the U.S. withdrawal, China will become the WHO’s largest assessed contributor. In 2025, China’s assessed contributions total $87.6 million [3], though its voluntary contributions remain comparatively modest at $41 million [4]. While experts anticipate that China will leverage this position to expand its influence within the WHO [5, 6], Beijing may pursue a dual strategy: maintaining engagement in multilateral forums while simultaneously strengthening bilateral health partnerships with individual nations outside the WHO framework [7]. This approach could enable China to shape global health governance both through formal WHO channels and through direct country-to-country relationships that bypass multilateral coordination.

However, there are several issues facing global health governance and the WHO today. Key obstacles include weak implementation of agreed-upon regulations, vulnerability to global crises, and inadequate coordination mechanisms [8]. Most significantly, multilateral health organizations must deal with inherent tensions between competing interests: state sovereignty versus global collective action, equity versus burden-sharing, and institutional mandates that create overlap, inefficiency, and competition for leadership [8]. Furthermore, the WHO struggles with insufficient collaboration and faces difficulties in identifying and leveraging talent and leadership within its own organizational structure [9].

China, as the world’s second-largest economy and second-most populous nation, played a pivotal role in providing vaccine and mask aid during COVID-19 and will remain critical to future global health emergency responses. Similarly, the WHO—as the world’s largest and most comprehensive multilateral health organization—will continue to serve as a central coordinating body during international public health crises. Despite the strategic importance of the China-WHO relationship, there is surprisingly little that examines how China engages with the organization. Notable exceptions include two commentaries which have examined China-WHO relations post COVID-19 [5, 9]. Existing literature has focused predominantly on China’s bilateral health partnerships with specific countries/regions or its responses to individual public health threats, rather than its engagement with multilateral health institutions [10]. As of 2025, no peer-reviewed study has comprehensively analyzed China’s post-COVID-19 engagement with the WHO, leaving a significant gap in our understanding of contemporary global health governance.

Examining China’s relationship with the WHO can reveal opportunities for enhanced global health collaboration among China, Western nations, and multilateral institutions. Moreover, this study provides a critical post-pandemic baseline for understanding China’s evolving role and present day issues in global health governance—a reference point that will prove increasingly valuable as member states confront future public health threats.

Methods

A qualitative descriptive design [11] was used for this research study. Qualitative description involves staying close to the data, while providing a rich descriptions of the experiences described by the participants [11]. This approach is beneficial since the situation was changing quickly, and we sought diverse perspectives from both Chinese and non-Chinese sources given the potentially polarizing nature of this topic.

For participant recruitment, we employed purposive sampling, drawing from our personal and professional networks. Participants were contacted through email or LinkedIn. Snowball sampling was then used, where participants were asked to provide contact information of potential participants who meet inclusion criteria. To qualify for this study, participants must have at least 5 + years of professional experience at the WHO, or 10 + years of experience or involvement in global governance (i.e., appointment in an academic institution or think tank). Interviews were conducted in English on Zoom and interview lengths ranged from 28 to 50 min, with an average time of about 40 min. Interviews were conducted between February to May 2025. Verbal consent was obtained prior to the one-time, in-depth, semi-structured interview. Participants were able to stop the interview at any time. Ethical approval for this study was granted by Tsinghua University and all research was done in accordance with the Declaration of Helsinki.

A semi-structured interview guide (Appendix A) was developed a-priori, based on a literature review. Edits were made to the semi-structured interview guide following the first few interviews to maximize flow and ensure clarity of information [12]. The interviews were audio recorded, and the audio files were stored in a secure and encrypted cloud storage, with only the authors having full access. Further, to enhance confirmability and ensure data trustworthiness, the lead author maintained reflexive and analytic memos throughout each interview, documenting assumptions, emergent insights, and decision points [13]. At the conclusion of each interview, the lead author summarized the key findings to the participant and asked whether the findings were representative of the themes discussed, and if not, to ask for further clarifications and explanations.

Following data collection, the audio files were transcribed verbatim. During the transcription, any potential identifying factors (i.e., names or specific work experiences) were anonymized, to protect the privacy of the participants. The interview transcripts were then imported onto Taguette, an open-source data organizer for qualitative coding [14]. The transcripts were then analyzed following the six steps of thematic analysis [15]: data familiarization, coding, theme searching, development, review and definition, and report production. This systematic process facilitated pattern identification and interpretation across the dataset.

Results

Ten interviews were conducted with high-level individuals involved in global governance and the WHO. This resulted in five themes from the interviews, following qualitative data analysis.

Participant Number	Background	Nationality
1	Professor of Global Governance	United Kingdom
2	Current/Former Assistant Director General of the WHO	United States of America
3	Current/Former Assistant Director General of the WHO	Canada
4	Current/former Adviser in the WHO	United Kingdom
5	Associate Professor of Sociology	China
6	Professor of International Relations	China
7	Associate Professor of International Relations	China
8	Current/former WHO country Adviser for China	United States of America
9	Professor of Global Health	United States of America
10	Current/Former Assistant Director General of the WHO	Canada

Theme 1 - Balancing sovereignty with multilateral cooperation

All interviewees discussed the tension between engaging in constructive dialogue that supports multilateralism while maintaining strong sovereignty positions. For nearly all participants, this tension manifested in concerns about information sharing, trust, and transparency. Related issues included the democratization of information and opaque internal control processes. Several non-Chinese participants identified Taiwan as a sovereignty issue that may hinder efficient global health collaboration due to its complicated political status. In contrast, no Chinese participants mentioned Taiwan as a barrier to global health collaboration; all expressed optimism about continued China-WHO cooperation. One non-Chinese participant suggested that China would engage more deeply with multilateralism only when perceiving clear strategic benefits, such as enhanced diplomatic leverage regarding Taiwan. However, other participants minimized Taiwan’s significance, noting that both China and the WHO have responded appropriately and constructively. Participants acknowledged that despite appropriate diplomatic engagement, the practical realities of working with China are far more nuanced and complex. This complexity becomes particularly evident during crises such as COVID-19. As one participant summarized: “China should be acknowledged as having allowed a [WHO] team to come in. But I don’t think the collaboration was open and they could have done a lot better in working with the team from WHO to really understand what had happened”. Nonetheless, another participant notes: “Sovereignty applies to every country, and if you’re a great power, you have more emphasis on that. But the WHO’s role includes encouraging transparency and adherence to international health regulations”.

Nearly all participants noted China’s strong preference for bilateral global health aid over multilateral health aid. Most participants believed that the Chinese side prefers bilateral health aid because of its supposed greater efficiency, increased locus of control, and strategic decision-making aligned with power politics. One participant explained that bilateral engagement allows for more targeted assistance, with the added benefit that this precision allows the aid to be more tailored towards China’s strategic interests. However, many participants had diverging views on China’s exact relationship and contributions to the WHO. Some participants argued that China’s engagement with the WHO is substantial enough, given that it has been providing a consistent amount of assessed contributions and regularly contributes experts for policy-making. However, others argued that these efforts are overshadowed by China’s bilateral aid, suggesting a potential preference for more direct aid over multilateral cooperation. One non-Chinese participant noted that the minimal voluntary contribution challenges the popular narrative that China seeks substantial control over global health governance. Another participant believed that true agenda-setting power comes from voluntary funds, which China has not significantly leveraged. This participant further critiqued the simplistic notion of influence through assessed contributions alone.

Theme 2 - China’s evolving role within the WHO

Every participant noted China’s rapidly evolving role within the WHO. Nearly all commented on China’s gradual shift from recipient to donor country, punctuated by key transitional events. One participant highlighted the strategic nature of this transformation, noting periods when China simultaneously received aid from developed countries while providing assistance to low- and middle-income countries (LMICs). Several other participants characterized this shift as largely historical, emphasizing that China now firmly occupies the donor side, at least within the WHO context.

In general, participants universally affirmed the shift in China’s role but disagreed on the specifics of what it means to be a donor country. Some stated that China is engaging in an increasingly prominent role in the WHO due to increased funding and therefore has increased leverage. However, other participants argued that China’s total funding to the WHO (and multilaterals more generally) is quite unimpressive, especially given that it doesn’t even compare to its direct bilateral aid, nor its development investment in the Belt and Road Initiative. A major shift in most participants’ experience of the WHO’s engagement with China was in reference to the 2002–2003 SARS crisis. All participants who referenced SARS noted that it compelled China to operate with greater transparency, international cooperation, and disease monitoring. The rationale for the change is entirely understandable, as one participant noted that the directives to withhold information and operate with very limited transparency initially did significant damage to China’s overall reputation internationally. This necessitated a more open approach adhering to the framework of international norms. Even though all participants agreed on the long-term impacts of SARS, they differed on the immediate impacts. Some participants emphasized the positive outcomes of increased collaboration and transparency, while other participants discussed the immediate diplomatic tensions and negative repercussions.

Overall, participants attribute China’s evolving role within the WHO due to shifting geopolitics. More recent contributing factors include the U.S. withdrawal and changing expectations within global governance. A few participants identified opportunities for China to fill in the void left by the U.S., however, all were uncertain about China’s willingness to step up. The reasons behind this are multifactorial and complex, as China’s strategic calculus involves optic risks, preference for personnel placements, large amounts of existing bilateral aid projects and WHO institutional limits. Most participants anticipated that China would maintain its current trajectory, characterized by incremental engagement within stable global governance frameworks. Participants identified multiple reasons for this transformation, including reciprocating past assistance from international organizations, expanding global influence, and advancing broader diplomatic and economic goals, such as those related to the Belt and Road Initiative. Notably, all Chinese participants and one non-Chinese participant emphasized China’s “South-South cooperation” model, through which China positions itself as an equal partner to developing countries rather than a traditional donor. As one Chinese participant explained: “China understands their challenges and difficulties also because China itself experienced a lot of similar situations. So, China has more sympathy with them”. However, this framing may provoke criticism in some circles. One non-Chinese participant suggested that “constantly bringing that up in discussions is not very politically mature”.

In sum, one participant synthesized it as: “China seems to be playing a very steady role…the argument from the American side is if the US withdraws, it’ll cede the role to China. Whether China sees it that way or not, I don’t know. China has a posture of commitment to multilateralism”.

Theme 3 - COVID-19 as a relationship downturn

The COVID-19 pandemic marked the next critical turning point. All participants agreed that COVID-19 deteriorated relations between China and the WHO, with tensions centered primarily on transparency and the virus’s origins. Most participants identified the WHO COVID-19 origins investigation as a major source of contention. One Chinese participant perceived the WHO as succumbing to Western political pressure, particularly during the pandemic’s later stages—a view no other participant shared. Another Chinese participant noted Beijing’s displeasure when the WHO shifted from praise to subtle criticism, contrasting sharply with the previously cordial relationship with Dr. Tedros. Collectively, participants observed conflicting statements and shifting narratives from all parties (China, the WHO, and the U.S.), which undermined multilateral governance norms and fostered mutual distrust. Notably, some Chinese participants cited this divergence as evidence that China does not wield undue influence over the WHO, suggesting instead that China’s goals are straightforward and its influence derives from being a major contributor rather than a hegemon.

Most participants agreed that prior to COVID-19, China and the WHO maintained a steady increase in engagement and relationship development. Two of the three Chinese participants highlighted Dr. Margaret Chan’s appointment as WHO Director-General as politically significant, signaling China’s growing interest in multilateral health affairs. Following COVID-19, Chinese participants acknowledged the challenges facing WHO leadership in balancing Chinese and U.S. interests. Among Chinese participants, one attributed the mistrust to Western media and political rhetoric, while another pointed to broader geopolitical conflicts. Chinese participants characterized these issues as temporary setbacks that would not alter the fundamental trajectory of China-WHO relations. In contrast, non-Chinese participants largely disagreed with their Chinese counterparts regarding the root causes of tensions. Non-Chinese participants predominantly framed the issues around transparency concerns, viewing COVID-19 as a missed opportunity for China to demonstrate openness and multilateral engagement. However, two non-Chinese participants attributed the problems to various geopolitical factors and mutual misunderstandings rather than exclusively to Chinese transparency failures.

Participants disagreed on the severity and significance of these tensions. Among those who discussed this issue in depth, opinions diverged. Some believed the tensions would result in lasting mutual distrust between China and the WHO, while most viewed these setbacks as temporary and expected China to remain an engaged WHO member. All participants expressed disappointment over the deterioration and hoped for improved relations among China, the WHO, and the U.S. moving forward.

Theme 4 - Chinese contributions to the who’s mission

All participants acknowledged China’s positive contributions to the WHO’s mission, including human resources support, vaccine production and distribution through WHO frameworks, and collaborative scientific and epidemiological information sharing. All participants viewed China’s overall influence on the WHO as positive, particularly given the organization’s current challenges. Two participants highlighted China’s robust drug and vaccine manufacturing capabilities, advocating for WHO-China collaboration to make global pharmaceuticals more affordable while addressing quality assurance and transparency concerns. Another participant noted China’s expertise in disease eradication, suggesting that both the WHO and other countries could learn from Chinese experiences. Overall, participants recognized China’s potential contributions in technical and scientific domains and expressed desire for greater alignment with the WHO.

Several participants emphasized the benefits of Chinese technical expertise, particularly in vaccine manufacturing capacity and rural health systems support, noting significant potential for infectious disease prevention and eradication. Some participants suggested that China could expand its capacity-building initiatives within the WHO and increase involvement in technical training, such as deploying more experts knowledgeable in emerging communicable diseases. One participant cited China’s collaboration with the WHO during the Ebola crisis as an exemplary model. Regarding Traditional Chinese Medicine, participants maintained a neutral stance, agreeing that more clinical trials and safety evaluations are necessary before further integration into WHO initiatives.

All Chinese participants consistently affirmed China’s continued commitment to multilateral institutions, emphasizing diplomatic presence, personnel deployment, and increased engagement in multilateral decision-making processes. One non-Chinese participant highlighted China’s systematic investment in health diplomacy training, such as the program at Peking University, as a unique strength that distinguishes China from countries lacking similar professional training programs. One Chinese participant acknowledged that financial contributions might be constrained by political sensitivities but expected non-financial engagement to continue unimpeded. Overall, participants believed China could engage in mutually beneficial collaborations with the WHO by sharing experiences in poverty reduction and health system strengthening, contributing to global disease surveillance and pandemic preparedness, and expanding its role in funding and supporting WHO initiatives.

Theme 5 - U.S. withdrawal from the WHO as a cautious opportunity

All participants expressed regret regarding the U.S. withdrawal from the WHO, citing the significant funding void it created. Some participants noted that China remains largely the only major player capable of filling this gap, as European countries face funding constraints due to the Russia-Ukraine war. Ironically, many participants observed that some countries, particularly Western nations, have expressed concerns about China’s growing influence. In response, participants reported that Chinese officials emphasize their commitment to multilateralism and the Sustainable Development Goals. All participants believed China would not assume the U.S. role. One participant proposed structural reforms to the WHO’s constitution to deter abrupt member withdrawals, suggesting that departing countries maintain financial commitments during a transitional period to mitigate operational disruptions.

Participants noted that China has increased its WHO funding in recent years. However, unlike the U.S., China provided minimal voluntary contributions beyond its assessed dues. Chinese participants characterized the financial void left by the U.S. as politically symbolic, signaling an abandonment of global health norms and straining the WHO’s operational capacity. As a result, all participants agreed that China would adopt a cautious, measured approach rather than aggressively replacing the U.S. One participant explained: “No, China doesn’t think about this because China doesn’t see this as a power game, but more like a construction of an equal partnership or a common project.” Another participant noted that the WHO, as a UN institution, inherently resists domination by any single country due to its consensus-based structure.

On this issue, the three Assistant Directors-General framed the China-WHO relationship primarily through formal processes—budget categories, treaty negotiations, and Secretariat constraints—noting that without increased or targeted voluntary contributions, China’s influence remains structurally limited. Chinese participants focused more on practical geopolitical measures, including converting bilateral aid into coalition support and expanding technology and human resource contributions. Notably, one Chinese participant argued against increasing voluntary contributions at present, cautioning that such action could signal China’s attempt to dominate the WHO. Similarly, participants acknowledged inherent structural inefficiencies within the WHO bureaucracy, where financial resources alone cannot resolve all challenges. Thus, participants believed this situation presents an opportunity for China to demonstrate steady, legitimate leadership within the WHO without overextending its influence. Some suggested China could explore innovative funding mechanisms, with one participant citing the International Finance Facility for Immunisation (IFFIm)—which raises funds by issuing bonds backed by long-term donor pledges—as a successful global health financing model.

Discussion

This qualitative study explores the state of China-WHO relations following COVID-19. Understanding this relationship is critical, as the U.S. withdrawal has created a leadership void in global health governance, and China is increasingly viewed as the primary candidate to fill this gap, given its economic capacity, sustained engagement with the WHO, and significant geopolitical influence. To better understand Chin’s role amid tumultuous geopolitical shifts and broader challenges facing global health governance, in-depth semi-structured interviews were conducted with ten high-level participants, including three current or former Assistant Directors-General of the WHO. Overall, participants believed that China’s evolving role in the WHO mirrors its broader transition on the world stage. All participants acknowledged China’s contributions to global health. However, they also noted emerging complexities that both China and the WHO must navigate. Consequently, China faces the challenge of balancing its role in the WHO with both its national interests and the priorities of the broader global health community.

Experts interviewed for this study strongly agreed that SARS represented a critical turning point in China-WHO relations, consistent with previous scholarship [16, 17]. However, characterizing it simply as a watershed moment would be oversimplified. The initial period, marked by secrecy and reluctance to accept international assistance, damaged China’s international reputation and exposed significant weaknesses in its domestic disease surveillance and public health response systems [16, 18]. The normative conflict between China and the WHO during SARS led to behavioral contestation, wherein both parties challenged each other’s preferred norms through actions rather than explicit debate [19]. China’s subsequent shift toward greater transparency and closer collaboration with the WHO was driven by both pragmatic necessity and strategic intent [17]. Nonetheless, the findings suggest that while SARS catalyzed reforms in China’s health system, it did not fundamentally transform its underlying governance structures.

China often employs the rhetoric of South-South cooperation to frame its global health engagement. This aligns with China’s broader foreign policy discourse, which positions the country as a leader among developing nations [20] and offers an alternative to Western-dominated development models. This framing is also consistent with China’s diplomatic principles emphasizing non-interference and respect for sovereignty [21]. However, non-Chinese participants interpreted this approach as limiting the openness of China’s cooperation with the WHO. These tensions stem not from cultural misunderstandings but from normative divergence between China’s emphasis on sovereignty and the international community’s expectations for transparency and information sharing.

Another major point of discussion has been China’s vocal commitment to multilateralism, while engaging more with bilateral global health projects. The results from the interviews mirror what various experts are commenting, especially with regard to the Health Silk Road [6]. Similarly, experts viewed China’s global health diplomacy during COVID-19 as tied to its geopolitical ambitions, not out of Global South solidarity [6]. Conversely, Chinese participants noted that China is doing this in the spirit of equal partnership and South-South cooperation. While discerning China’s true intentions remains challenging, available evidence suggests that China will maintain its formal multilateral commitments while prioritizing its bilateral aid model for strategic reasons.

This pattern became evident during the COVID-19 pandemic, when China provided $4.6 billion in bilateral aid, including $4.17 billion worth of COVID-19 vaccines (over 239.1 million doses), predominantly to Global South countries [3]. This substantial bilateral engagement contrasts sharply with China’s current $87.6 million annual assessed contribution to the WHO, particularly given China’s resistance to planned increases in assessed contributions for the 2026 financial year [22]. This disparity raises questions about whether China’s bilateral aid program will compete with or complement the WHO’s multilateral efforts. While interview responses varied, all Chinese participants believed the relationship would be complementary rather than competitive. Interestingly, there has been a recent shift, where in May 2025, China pledged an additional US$ 500 million to the WHO over the next 5 years, significantly increasing its financial stake in the organization [23]. The reasonings behind such a large contribution are complex, but most likely indicate a greater desire to portray itself as a responsible global power, liaise further with Global South countries and indirectly influence agenda setting and norm shaping within the WHO. Overall, it can be a hint that China will continue to purposively engage with the WHO following COVID-19, at least within the near future.

On a related note, Chinese participants unanimously rejected the notion that China seeks to dominate the WHO, contrasting sharply with recent predictions by Western global health experts [5, 6]. The reasons for this divergence are multifactorial and complex, likely reflecting a combination of information asymmetry and differing perspectives. Specifically, Western experts tend to view China through the lens of its rising global influence, whereas Chinese interlocutors emphasize sovereignty and pragmatic contributions, while potentially facing constraints imposed by political sensitivities. Although overt dominance appears unlikely, China may pursue alternative strategies for influence, including leveraging the flexibility of the Health Silk Road framework, more strategic personnel placements, and strengthening bilateral health partnerships [5].

Balancing China’s interests within the WHO with overarching global health goals remains critical. Potential pathways forward include enhanced negotiation around obligations, representation reform, and depoliticized cooperation [21]. Specifically, this could involve differentiated obligations and equity measures for developing countries, alongside strengthened capacity-building through financing, technology transfer, and local manufacturing support [21]. On the Chinese side, more measured responses to perceived politicization could prevent straining China-WHO relations. In addition, greater transparency in Chinese actions within the WHO—such as personnel appointments—could reduce accusations of undue influence. This could be through publishing appointment rationales and clearly outlining the candidate’s qualifications to ensure merit-based appointments. Conversely, Western nations must engage constructively and in good faith with China within the WHO framework, rather than treating it primarily as a competitor.

Many challenges identified by participants—including counterproductive competition, vulnerability to global crises, bureaucratic inefficiency, and insufficient transparency—were recognized by experts a decade ago [8, 24]. Major reforms in governance, developing country representation, and financing mechanisms are urgently needed. Furthermore, depoliticizing cooperation and implementing confidence-building measures (such as joint investigations) are essential within the global health context. All of these reforms are necessary for the WHO to adequately fulfill its mandate in a post-COVID-19 world. A more effective WHO would foster more productive collaborations among China, Western nations, and the organization itself, ultimately benefiting all parties and advancing global health security.

This qualitative study has several notable strengths, including the high-level representation of participants—three Assistant Directors-General of the WHO and several leading global health scholars. Another key strength is the study’s timeliness: interviews were conducted during a period of significant upheaval in global health governance, with President Trump’s announcement of the U.S. withdrawal occurring just days before the first interview. Consequently, critical issues, particularly China’s evolving role in the WHO, remained highly salient for participants. Combined with qualitative methodology, this study captured the complexity and nuance of an emerging phenomenon, providing a foundation for future qualitative, mixed-methods, or quantitative research.

This study also has important limitations. Notably, the Chinese participants lacked professional diversity; all were academic professors, and the inclusion of Chinese diplomats with WHO experience would have enriched the findings. While the high-level participant panel constitutes a significant strength, it also represents a limitation, as the findings may not reflect the perspectives of mid- or lower-level personnel who engage with China-WHO relations in different capacities. Nonetheless, an elite sampling approach is justified for examining high-level decision-making dynamics, and the study’s timeliness—capturing real-time expert reactions during a critical juncture—outweighs concerns about sample size. Lastly, as with most qualitative research, the findings are context-specific and not intended to infer generalizability.

Conclusion

The post-COVID-19 era has fundamentally reshaped China’s relationship with the WHO. A major recent disruption has been the U.S. withdrawal from the organization. This study is among the first to investigate China-WHO relations in the post-COVID-19 context. Since the U.S. announcement of its withdrawal, China has expressed its continuous support for multilateralism. However, in practice, its global health engagement remains predominantly pragmatic and bilateral. This distinctive approach reflects China’s unique development trajectory and its identity as a major power that positions itself as first among equals within the developing world.

The semi-structured interviews reveal that China does not seek to formally replace the U.S. as the dominant power within the WHO. Nonetheless, it actively pursues a more favorable position for itself within the organization. The findings underscore the urgent need for WHO reform, particularly in governance, representation, and financing mechanisms, to better navigate an era of intensifying great power rivalry between China and the U.S. Such reforms are also essential for the WHO to effectively address emerging global health challenges, including novel pathogens, climate change, and antimicrobial resistance.

While China may encounter tensions between sovereignty concerns and transparency expectations, outside major crises such as COVID-19, collaboration can be enhanced through institutional reforms and increased mutual trust. Incremental successes in joint China-WHO initiatives can gradually reduce mutual suspicions and build confidence. The current moment represents a critical juncture for China and the WHO to recalibrate their relationship in ways that strengthen global preparedness for future health emergencies and advance the shared goal of health equity worldwide.

Appendix A – Semi structured interview guide

Role & Context

• Briefly describe your role and how it relates to the WHO or to China’s global health work.

Evolution & Strategy

• How would you describe China’s overall evolution in global health and its engagement with the WHO?

• How have major outbreaks influenced China’s approach to working with multilateral health organizations?

• Since 2020, have you noticed changes in China’s narratives, priorities, or style within multilateral forums?

Influence & Mechanisms

• In practice, what tends to shape influence at the WHO (for example, funding, procedures, staffing, coalitions, technical expertise)?

• How does China’s funding approach affect its ability to shape priorities?

• How do people and relationships (appointments, secondments, informal networks) matter alongside contributions?

Tactics & Perceptions

• How does China typically advance its positions in multilateral settings?

• How do bilateral relationships interact with multilateral work at the WHO, and has that balance shifted recently?

• How do other countries perceive China’s growing role—both traditional donors and recipient countries?

Friction & Learning

• Share a case where China’s approach faced resistance. What happened and what was learned?

• Where are the best opportunities for practical collaboration that avoid political flashpoints?

• What delivery models work well (for example, expert deployments, joint training or labs, supply chain and quality systems, digital infrastructure)?

Governance & Sovereignty

• Where might governance or coordination challenges arise as China’s role grows?

• How do sovereignty concerns and questions of representation shape engagement at the WHO?

• What realistic changes over the next few years could most alter China’s leverage or role at the WHO?

Transparency & Limits

• What have recent health emergencies taught about transparency, data sharing, and trust?

• Are there practical limits on any country’s ability to steer the WHO? How do those limits show up day to day?

U.S. Withdrawal

• What is your reaction to the announcement of U.S. withdrawal from WHO?

• Do you anticipate a cascade of withdrawals or reduced engagement by other governments?

• How do you believe China’s role within WHO will evolve?

• Could China mitigate some effects of a U.S. retreat, and if so, how?

Wrap-Up

• What topics about China’s role in global health deserve more attention?

• What practical steps could improve collaboration with China through the WHO?

• Anything important we didn’t cover that you would add?

• Thank you

Author contributions

The paper was jointly designed and written by both authors. ZS conducted the data collection and analysis under the supervision of YH. ZS drafted the manuscript under the supervision and guidance of YH. Both authors reviewed and revised the manuscript.

Funding

None.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from Tsinghua University.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.