China's Global Health Activities in Africa: Historical Perspectives and Case Studies

Short abstract

The authors examine the People's Republic of China's global health activities and policies in Africa since the 1960s and provide case studies of two nations—Sierra Leone and Kenya—that have received health aid from China. They analyze China's use of global health support in Africa as a soft-power tool for political and economic purposes and its advantages and weaknesses and offer policy recommendations for the United States and African countries.

Abstract

In this study, the authors describe the evolution of the People's Republic of China's global health activities and related policies in Africa from the 1960s through the present and provide field case studies of two African nations—Sierra Leone and Kenya—that have received health aid from China. They then analyze China's use of global health support in Africa as a tool of soft power.

The need to understand China's global health activities has intensified, given that Western, particularly U.S., foreign health aid policies are changing, prompting questions about whether China will shift its policies to strengthen its soft power in Africa and away from the decade-old Belt and Road Initiative's overarching Sino-centric trade focus.

This analysis of China's health aid history, its current role in African health aid, and its recent reform called for by President Xi Jinping's Global Development Initiative is intended to help U.S. policymakers understand China's decisionmaking and implementation strategy for foreign aid. The analysis of the advantages and weaknesses of China's approaches can offer lessons to both donor countries and African countries that receive global health aid from China. The authors offer policy recommendations for the United States and for African countries.

China has delivered substantial health aid to Africa: It has conducted more than 2,000 health-related projects across 54 African countries in the past two decades. However, understanding how these programs work is challenging because China operates outside traditional donor coordination mechanisms, does not routinely disclose aid statistics, and often blurs the line between aid and investment. Additionally, Chinese policy literature is often hard to interpret without a deep understanding of the Chinese Communist Party's rhetorical styles and governing structure; public health experts, development economists, and national security analysts often analyze foreign health aid in their disciplinary silos, and, critically, health aid impact analysis underrepresents African perspectives—despite African nations being the primary stakeholders affected by these programs.

The United States' America First Global Health Strategy, introduced in September 2025, explicitly recognizes China as a global health competitor and frames health assistance as a strategic tool for the United States to counter Chinese influence in Africa. The strategy emphasizes Africa's critical importance: The continent will hold 25 percent of the world's population by 2050 and possesses essential raw materials for advanced technologies. Given this emphasis, U.S. strategy would be enhanced by closing the knowledge gap on the goals, processes, and evolution of China's global health support to Africa and by better understanding how African stakeholders perceive this aid.

In this study, we analyze China's changing health aid activities in Africa, including a historical review of health aid's motivation and implementation process, a quantitative description of the Chinese government's health aid in the past two decades, and African field studies with African stakeholders' feedback on China's aid. U.S. global health policymakers and the African countries' governments and public will benefit from learning the advantages and weaknesses of China's health aid.

Key Findings

What motivates China's health assistance to Africa, and how has this motivation evolved? The motivation for China's health assistance has evolved through three distinct phases. Initially, in phase I (1949–1978), aid was driven by Maoist revolutionary ideology, promoting anti-imperialism solidarity and building support among newly independent nations. During phase II (1979–2021), motivations shifted to supporting China's economic development, with health aid being retooled as economic engagement under the Go Global policy and the Belt and Road Initiative, often blurring the lines between aid and investment. In phase III (2021 to present), following the 2021 introduction of the Global Development Initiative (GDI), China's approach has transitioned toward soft power in great-power competition, emphasizing great-power responsibility and global governance while moving from a Sino-centric economic focus toward providing public goods and strengthening multilateral frameworks.

How is Chinese health aid governed and delivered? Chinese health aid in Africa has increased dramatically in both quantity and variety over the past two decades, growing approximately fivefold from 2000 to 2019, and surged further during the coronavirus disease 2019 (COVID-19) pandemic. What began as China dispatching clinical professional teams (China medical teams) to the recipient country to support local health care delivery and providing medical training in the 1960s has expanded to multilayered health aid, including anti-malaria projects, humanitarian aid during pandemics, regional public health surveillance labs, and multilateral collaborations. The aid implementation has shifted across agencies following China's evolving political priorities. Implementation initially was led by the Ministry of Foreign Affairs in collaboration with provincial governments (1949–1978), then management was transferred to the Ministry of Health during China's internal economic reforms in the 1980s and subsequently to the Ministry of Commerce in 2003, whose primary aim was to promote trade. Since the GDI triggered foreign aid reform in 2021, the newly established China International Development Cooperation Agency has been the lead agency in drafting new foreign aid legislation and policies.

How do African stakeholders perceive Chinese health aid? African stakeholders have expressed mixed views of Chinese health aid. They acknowledge valuable infrastructure contributions: hospitals, medical equipment, mobile clinics, pandemic supplies, laboratories, and training programs that strengthen health systems. However, significant concerns persist. Language and cultural barriers isolate Chinese teams from local coordination. Stakeholders question commercial motivations behind loan-based projects that increase the country's debt. Lack of transparency in government negotiations raises suspicions of corruption. Top-down delivery often bypasses local consultation, sometimes failing to meet actual needs—exemplified by poorly coordinated COVID-19 vaccine deliveries that resulted in waste. Sustainability remains problematic: Equipment breaks without spare parts, facilities deteriorate without sustainable funding, and aid programs create a technological dependency on China. Many of the weaknesses can be traced to trade-focused health aid mentality: China's commercial focus erodes local trust, and its lack of global health expertise contributes to lack of involvement with local communities and health outcome evaluations.

What are the implications for the United States and African countries? China's experience reveals three pitfalls undermining health aid effectiveness: Subordinating aid to commercial interests eroded trust and soft power; opaque bilateral negotiations enabled corruption; and treating aid as an economic tool caused chronic sidelining of public health and underinvestment in global health workforce development. Successful health diplomacy requires donor countries' sustained commitment to health outcomes, transparent governance, and systematic capacity-building. Developing countries should assert greater agency in donor relationships by demanding transparency, meaningful local participation in project design, and genuine capacity-building over dependency. They should also leverage regional platforms, such as the African Union, to collectively negotiate equitable partnerships and standardize evaluation criteria.

Policy Recommendations

Our analysis of the advantages and weaknesses of China's approaches can offer lessons to both donor countries and African countries that receive global health aid from China. We provide the following policy recommendations for the United States and for African countries:

• The United States should improve its understanding of China's global health activities in Africa, which include aid and investment elements. It should adopt an analytical approach to assessing China's health assistance programs, recognizing both their strengths and their systematic limitations when mixing aid and investment, without exaggerating the competitive threat or underestimating their appeal to recipient countries.

• The United States should maintain a focus on health and resist overcommercialization. A commerce-first approach not only compromises health outcomes but also creates the very economic-dependency relationships and trust deficits that effective health diplomacy should avoid.

• The United States should preserve multidisciplinary global health workforce development. It should recognize the strategic value of its established multidisciplinary global health workforce as a critical comparative advantage that directly enables the America First strategy's ambitious implementation goals.

• African countries should leverage China's foreign aid reforms through regional and multilateral platforms. African countries should strategically capitalize on China's ongoing foreign aid reforms under the GDI by strengthening regional coordination mechanisms and multilateral partnerships to enhance China's health aid accountability and alignment with African priorities.

The research described in this study was funded by the Cyrus and Michael Tang Foundation and conducted by RAND Global and Emerging Risks.