Twenty-five years ago, a "global health strategy" didn't exist. The US-led millennium surge of global development assistance for health gave the phrase meaning and popularity. The funding boom lasted a decade, plateaued around 2013, and collapsed in 2025. Now, both the US and China have revised their global health strategies amid new domestic policies and geopolitical realities.
wenty-five years ago, a "global health strategy" didn't exist. The US-led millennium surge of global development assistance for health gave the phrase meaning and popularity. The funding boom lasted a decade, plateaued around 2013, and collapsed in 2025. Now, both the US and China have revised their global health strategies amid new domestic policies and geopolitical realities.
As Washington unveiled its America First Global Health Strategy in September 2025—four years after President Xi Jinping announced the Global Development Initiative (GDI) in 2021—a striking paradox emerged: The US and China appear to be moving in opposite rhetorical directions while their proposed implementation models converge in ways that undermine the foundations of conventional Western global health models.
Rooted in self-perception as a developing country and historical experiences with Western powers before 1949, China has consistently rejected traditional international development terminology such as "donor-recipient relations" or "official development assistance" (ODA) as defined by the Organization for Economic Cooperation and Development (OECD) Development Assistance Committee. Instead, Chinese official discourse, policy documents, and academic analyses frame global health development funding activities as "foreign aid," emphasizing mutual benefit and South-South cooperation.
Nevertheless, China has emerged as a major global donor and creditor. According to a November 2025 report from AidData at William & Mary, China committed nearly $2.2 trillion in grants and loans worldwide between 2000 and 2023, making Beijing the world's largest official creditor. Yet, the most significant evolution lies not in the sheer volume of financing but in the shifting instruments and strategic orientation of China's international development engagement—most clearly embodied in the GDI.
We argue that this strategic convergence—the US retreating toward bilateralism and conditionality while China advances multilateral soft-power positioning—paradoxically undermines US health diplomacy at the very moment China's global health structural limitations remain most exposed. The US should recommit to improving the multilateral, partnership-based, and accountability-driven approach that has long set US global health leadership apart.
China's foreign aid regime has shifted through distinct phases. In the Maoist era (1949–78), Beijing's aid was driven by revolutionary ideology and anti-imperialist solidarity, with the first Chinese medical team arriving in newly independent Algeria in 1963. Aid reached 6.9 percent of fiscal spending in 1973, delivered mostly as grants with few strings.
The post-Mao era brought pragmatism: Deng Xiaoping subordinated aid to China's economic development agenda, slashing volumes and emphasizing mutual benefit. By the mid-1990s, under the "Go Global" policy, aid had evolved into economic engagement, blending grants with concessional "soft loans" that both supported recipient economies and helped Chinese firms enter international markets. In 2003, China's foreign aid governance moved to the Ministry of Commerce (MOFCOM), which prioritizes global trade.
While Western donor countries focused their development aid on health, education, and governance development, China's Belt and Road Initiative (BRI) —a global infrastructure and investment initiative launched in 2013—transformed development cooperation into a platform for infrastructure-led growth. The Health Silk Road, a BRI branch announced in 2016, functioned as a strategic platform linking partner countries to Chinese medical products.
As China leveraged vaccine diplomacy and personal protective equipment exports to court global influence, the COVID-19 pandemic revealed how health aid could serve as a powerful vehicle for soft-power projection. At the same time, the crisis exposed the fragility of global health supply chains and ODA's limitations in reducing health inequities—vulnerabilities that made a more altruistic framing of China's engagement all the more strategically appealing. These dynamics converged with reputational costs associated with growing international scrutiny of BRI debt terms, sharply reduced economic returns on BRI projects, and mounting domestic fiscal strains. In 2021, Xi announced the Global Development Initiative at the United Nations—a rebranding that offered a more palatable, people-centered face for China's global ambitions. By 2023, mentions of the BRI by China's top leaders had declined noticeably.
The GDI marked a clear shift away from the BRI's Chinese energy and trade-centric, infrastructure-heavy model. Where the BRI emphasized ports, railways, and power plants financed through bilateral loans, the GDI promotes grants and multilateral "small and beautiful" projects and prioritizes technology-intensive activities with a public-good orientation—poverty reduction, agricultural modernization, the digital economy, green development, and health. In October 2025, the Fourth Plenary Session of the 20th Chinese Communist Party Central Committee explicated that China would "support the Global South in pursuing strength through unity, increase foreign assistance, and provide more global public goods." Yet, the GDI deliberately sidesteps traditional Western emphases on democracy, human rights, and accountability in its engagement with the Global South.
The GDI was preceded by China's foreign aid reform, which began in 2018 with the transfer of policy leadership from the MOFCOM to the newly established China International Development Cooperation Agency (CIDCA). The CIDCA has since drafted comprehensive foreign aid legislation—including the Foreign Aid Evaluation Measurement System (2021), Foreign Aid Governance Methods (2021), Foreign Relations Law (2023), and Manual for the Foreign Aid Project Database (2023)—aimed at standardizing aid categories, governance, financing, and evaluation.
In health-related development assistance, China is increasingly positioning itself as a global health knowledge producer rather than merely an aid provider. Tsinghua University's BRIGHT program, launched in 2022, funds early-career researchers in developing countries to collaborate with Chinese scientists, building networks similar to the National Institutes of Health's Fogarty model. In September 2025, China launched its first research, development, and translation institution dedicated to global health equity—the Global Health Innovation Institute in Shanghai—leveraging China's low-cost manufacturing and rapid clinical trial capabilities to develop affordable treatments for tuberculosis, malaria, neglected tropical diseases, and maternal-child health.
Against the backdrop of the US pause from global health and development assistance, China is positioning itself as a "stabilizing force." In March 2025, Cambodia announced a partnership with China and UNICEF for children's education, health, nutrition, and sanitation—channeling Chinese resources toward goals that USAID had abandoned. Two months later, Beijing pledged an additional $500 million to the World Health Organization (WHO) over five years, potentially making China the agency's largest state donor. In late 2025, China fully paid its assessed dues to the United Nations' (UN's) regular budget, contributing more than $685 million (about 20 percent of the total).
Simultaneously, Beijing is mobilizing its private sector for overseas development—addressing domestic overcapacity while advancing strategic influence and setting international standards favorable to Chinese products. A prominent example is the 2025 Memorandum of Understanding between Nigeria's National Biotechnology Research and Development Agency and Shanghai Haiqi Industrial Company to establish Africa's first local insulin production facility in Nigeria, presented as sustainable technology transfer and capacity building rather than mere aid.
While still unfolding, China's evolving approach to international development is generating a multifaceted array of effects—spanning economic, geopolitical, normative, and developmental dimensions. In the health sector, China has strategically sustained signature initiatives that exemplify its long-term commitment to South-South cooperation. These include Chinese medical teams and friendship hospitals operating across dozens of developing countries; major infrastructure investments, such as the Africa Centers for Disease Control and Prevention (CDC) headquarters and central laboratory (completed in 2023 with Chinese funding), specialized tropical disease surveillance laboratories in West Africa, and high-level biosafety facilities for outbreak response in formerly Ebola-affected countries; and decades-long medical training programs that have equipped African health professionals—many now in key governance positions across the Global South.
Previously dwarfed by large-scale US global programs such as PEPFAR and the President's Malaria Initiative, China's international health assistance is poised to gain considerably greater significance as the US canceled its disease-specific strategy. China has actively showcased its price-competitive medical equipment and digital health solutions—including artificial intelligence–powered diagnostic tools and telemedicine systems. This positioning has the potential to reshape global health technology markets, influence technical standards, and challenge long-standing Western dominance in the sector.
Can China translate these changes into meaningful soft-power gains and reshape global health norms? Evidence from RAND Corporation field research in Africa suggests significant structural constraints remain. China's foreign aid budget—a combined $2.85 billion from the MOFCOM and the CIDCA in 2024, compared to USAID's $42.8 billion—limits scale, while overlapping mandates between the CIDCA and the MOFCOM keep commercial imperatives dominant over health outcomes. Most fundamentally, decades of prioritizing trade and geopolitical returns over health impact have left China with a chronic shortage of global health professionals skilled in cross-cultural communication, implementation science, and health systems strengthening. These constraints are not incidental—they are structural, and they offer the US a durable competitive opening.
While China pivots its international development agenda toward a softer, more multilateral posture, the US is moving in the opposite direction. Last September, the US government unveiled its America First Global Health Strategy. Critiquing past-US health aid for sidelining local governments in recipient countries and channeling disproportionate funds to US agencies and personnel, the strategy signals a dramatic shift: from disease-specific global strategies to country-specific bilateral Memoranda of Understanding (MOUs), from funding multilateral organizations and non-governmental organizations (NGOs) implementation to direct government-to-government treasury transfers, and explicitly conditioning aid on US economic and political interests. The process, ironically, mirrors the very mechanisms Washington has long criticized in Chinese development assistance.
The irony is striking. Just as Beijing's structural constraints—limited global health capacity, modest grant budgets, bilateral bias, and implementation shortcomings—remain most evident, the US is stepping back from the very strengths that have historically given US health diplomacy its credibility and legitimacy: deep multilateral partnerships, multidisciplinary global health workforce, NGO-mediated accountability, and long-term investment in local community capacity.
China's decades of health assistance in Africa also offer concrete lessons that should directly inform US strategy. We recommend that Washington would be unwise to replicate China's methods and should instead double down on the differentiators that have long set US health diplomacy apart. We make the following recommendations for priorities in the US-led global health development approach moving forward.
First, separate the impact of China's foreign direct investment from that of its global health activities. When BRI financed railroads and power plants in the Global South in exchange for trade advantages, the US invested in health, education, and civil society engagement to build political alignment and soft power. US health initiatives have consistently overshadowed China's transactional health aids in funding, technical support, and measurable impact. If Washington sacrifices this advantage, it risks ceding ground to Beijing in both infrastructure and soft-power competition simultaneously.
Second, resist the temptation to prioritize short-term commercial gain over the quality of health aid. When the MOFCOM dominated Chinese health-aid decisions after 2003, programs were evaluated based on trade outcomes rather than health impacts. Government-to-government transactional aid deals fueled corruption, poor strategic planning generated waste, and these problems ultimately eroded the very soft power the aid was meant to build. The America First Global Health Strategy's explicit framing of health aid as a vehicle for promoting US health products and securing commercial returns risks importing exactly these weaknesses. Congress and the State Department should ensure that program evaluation criteria remain anchored to disease burden, service coverage, and health-system strengthening—not procurement volumes or export metrics. PEPFAR's 20-year track record demonstrates that sustained focus on measurable health outcomes yields durable diplomatic returns. Beyond aid quality, the US should also recognize that China is increasingly responding to African demands for health sovereignty—local manufacturing capacity, reduced import dependence—through private-sector mobilization, as illustrated by the 2025 Nigeria insulin facility MOU. Washington should leverage its unparalleled pharmaceutical industry expertise and deploy Development Finance Corporation financing to support African-led health production initiatives, framing this as a response to African priorities rather than US commercial interest—a distinction that would meaningfully differentiate the US approach from China's.
Third, preserve the multidisciplinary global health workforce. Chinese scholars have long documented that Beijing's global health ambitions have been hamstrung by a shortage of professionals trained at the intersection of public health, diplomacy, and implementation science. Field interviews in Africa consistently identify this workforce gap as a root cause of communication failures, cultural isolation, and poor integration with local health systems. The US has spent decades building precisely the ecosystem China lacks: university-based global health programs; Fulbright and Peace Corps pipelines; Fogarty-funded international research collaborations; and career pathways linking academia, the CDC, USAID, and multilateral agencies. Washington should protect and expand funding for experienced global health professionals and for training programs that embed young US professionals in low- and middle-income country health systems early in their careers.
Fourth, leverage rather than abandon multilateral and NGO channels. One revealing finding from recent field research in Africa is that the most effective Chinese health initiatives of the past five years have been the China-UN-Africa projects—cases in which Chinese funding flowed through UNICEF and the UN Population Fund country teams that provided the local expertise, language capacity, and community relationships that Beijing's own agencies lacked. In effect, China is quietly learning that multilateral channels function as operational force multipliers and the UN procurement platform offers an efficient and transparent market. The US has far more mature versions of exactly those collaborations: Gavi, the Global Fund, WHO country offices, and a deep bench of US and local NGOs with decades of embedded relationships. Treating these as dispensable in favor of bilateral treasury transfers would not only cede a structural advantage to China, but it would also dismantle the accountability and community-engagement mechanisms that have long distinguished US assistance from Chinese trade-oriented aid.
By abandoning its legacy in global health, the US risks not only ceding ground to China but also undermining the capacity workforce pipelines, multilateral partnerships, and community-rooted accountability mechanisms—that no other country is currently positioned to replicate. The real competitive advantage lies not in convergence with Beijing's approach but in principled differentiation—demonstrating that sustainable progress depends on trust, transparency, and authentic partnership, not merely on transactional exchange. If the US cannot clearly articulate and consistently embody that distinction, it will have surrendered not just its strategic position but the very model of global health that has saved the most lives, built the most durable partnerships, and proven most worthy of global trust.
Posted on rand.org Jun 26, 2026Published in: Health Affairs (2026). DOI: 10.1377/forefront.20260520.802945
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