STUDY PEACE AND SECURITY CHINA’S GLOBAL HEALTH DIPLOMACY Revisiting Beijing’s Pre- and Post-COVID-19 Outreach Efforts Moritz Rudolf October 2022 Unless Beijing’s Zero-COVID-19 policy pushes the global economy into chaos, the narrative of‘China, the first responder’ will persist in developing states. COVID-19 revealed China’s ability to act globally and to promote a streamlined narrative via digital channels. The pandemic served as a catalyst for China’s health outreach efforts. It fast-tracked the formation of Beijing’s envisioned global(China-centered) health cooperation network. Given China’s ambitious aims to garner support from third states, Europe should be more strategic in its health diplomacy, which is essential for the future of the international order.

PEACE AND SECURITY CHINA’S GLOBAL HEALTH DIPLOMACY Revisiting Beijing’s Pre- and Post-COVID-19 Outreach Efforts

 Content FOREWORD 2 INTRODUCTION 3  HEALTH DIPLOMACY BEFORE THE LAUNCH OF THE HEALTH SILK ROAD 5 2 THE BELT AND ROAD INITIATIVE(BRI) AND HEALTH DIPLOMACY(2015–2019) 8 A) Plan for Belt and Road Health Exchange and Cooperation 8 aa) Strategic 8 bb) Cooperation 9 cc) Cooperation Areas and Pilot 9 dd) Key 10 B) Health Cooperation in Practice 11 aa) Bilateral 11 bb) Regional Cooperation 11 cc) Multilateral dd) 3 CHINA’S HEALTH DIPLOMACY DURING THE COVID-19 PANDEMIC 17 A) Mask 17 B) Vaccine aa) Bilateral bb) Regional Cooperation   21 cc) Multilateral  24 C) Evaluating China’s Covid-19  25 4 RECOMMENDATIONS 27

FRIEDRICH-EBERT-STIFTUNG – CHINA’S GLOBAL HEALTH DIPLOMACY FOREWORD The People’s Republic of China(PRC) has abandoned its previous restraint and is now actively shaping the global order of the 21st century. For years, party and state leaders followed“part one” of Deng Xiaoping’s counsel for the field of foreign policy:“Hide your strength, bide your time”. Under Xi Jinping’s leadership, it would appear that the time has now come. China has shifted the logic underlying its foreign and security policy with a view to its increased political and economic power, thereby reprioritizing a variety of strategic interests. In the past, China’s foreign policy moved mainly within the institutional bounds of the post-war order laid down by the U.S. American leadership. This order was not questioned often, in part because it was not in China’s own interest to do so. Now, instead of selectively adjusting to international norms and rules, the PRC aims to incrementally bring the world into line with Chinese ideas. The intent is not to completely supplant previous structures upon which the international order is founded. Nevertheless, the Chinese Communist Party(CCP) is willing to shape world politics in China’s image. Its interests are being articulated increasingly clearly and sustainably, lending momentum in recent years to the discourse surrounding an intensifying competition between systems, with the Chinese model of authoritarian state capitalism squaring off against the Western model of a democratic constitutional state and social market economy. Beijing’s health diplomacy is a crucial piece of the strategy to reform the international order and build international coalitions. Accordingly, this analysis provides a comprehensive overview of China’s health cooperation efforts, illustrating how the Chinese leadership has utilized health diplomacy to generate soft power. Beijing’s stated goals are addressed as well as the country’s strategic interests in engaging in health cooperation. In particular, this analysis places China’s recent international COVID-19 relief assistance in the broader context of the Belt and Road Initiative(BRI) and the Health Silk Road(HSR). The author, Dr. Moritz Rudolf, shows that Beijing’s health diplomacy did not develop overnight. By sending medical teams to specific regions, Chinese provinces have cultivated close relationships with individual countries for decades. China also utilized health cooperation when it generated support among former colonies for its UN admission in 1971. Dr. Rudolf shows how Beijing stepped up its international health cooperation efforts after the 2002 SARS-CoV-1 outbreak, which challenged China’s economic and political stability. Moreover, he goes on to demonstrate how the 2015 launch of the HSR marked the beginning of a strategic, centralized, and streamlined health diplomacy campaign. The COVID-19 pandemic served as a catalyst and accelerator for Beijing’s efforts to extend regional health cooperation. A majority of third states welcomed China’s health cooperation and, in many cases, endorsed key policy positions of China in regional and multilateral settings(e.g., regarding Xinjiang and Hong Kong). Not only for this reason, and despite Beijing’s quixotic Zero-COVID-19 policy, Dr. Rudolf concludes that decision-makers in Brussels and Berlin should be aware of the long-term effects of Chinese aid to developing countries. This analysis closes with a series of proposals for how Europe can better counter China in the field of global health policy. These recommendations address setting priorities vis-a-vis third countries so as to be perceived a reliable partner on health issues. The analysis is part of a series of publications put out by the Friedrich-Ebert-Stiftung(FES) that explore Chinese strategies in a range of different global policy fields. The overarching question revolves around the future of multilateralism in the face of China’s ascendance and increasing competition over the establishment of values and norms: What approaches could facilitate chances to initiate a constructive process of political negotiation between Europe and China on the framework conditions for international governance? In which areas is more coordination and cooperation with China possible? Where is push-back by Europe warranted? And where does Europe have homework of its own to do? Through this publication series, the FES would like to contribute to an informed approach to China. The aim and intent is to help European actors gain a more profound understanding of key Chinese notions, Chinese thinking, and concepts as well as their real-world manifestations and implementations. This will help readers derive informed strategies and be(more) self-assured in and well-prepared for dialogue with Chinese partners. Stefan Pantekoek China Desk, Friedrich-Ebert-Stiftung, Berlin 2

INTRODUCTION INTRODUCTION On March 22, 2020, Serbian President Aleksandar Vu č i ć greeted the arrival of a Chinese medical team at Belgrade airport by kissing the Chinese flag. While the contribution of the Chinese doctors remains somewhat of a mystery, the images went viral. China’s aid to Serbia has become part of the public’s consciousness. According to a 2021 poll by the Serbian Institute of European Affairs, almost two-thirds of Serbian respondents viewed the People’s Republic of China (PRC) as Serbia’s biggest supporter during the pandemic, while only 17 percent named the EU despite substantial European support in the fight against COVID-19(Institut za evropske poslove: 2021). PRC officials and Chinese state media have communicated to developing states that the pandemic revealed the true face of the West and China. While European States were hoarding masks, the PRC selflessly helped the world. In so doing, they have regularly referenced Madagascar, which ranks among the poorest countries in the world. On March 25, only 120 hours after the African island state had declared a national health emergency, China’s Jack Ma Foundation and the Alibaba Foundation delivered the first batch of much-needed masks and test kits. Meanwhile, Germany, France, and other European states enforced export controls of coronavirus-related health equipment. Responses to COVID-19 have been politicized across the world. In Europe, there has been in-depth reporting about defective mask deliveries from China, the motives behind Beijing’s COVID-19 aid, and the absurdity of its Zero-COVID-19 policy. Yet, there is a lack of somber assessment of the PRC’s health diplomacy. 1 In the context of increasing tensions between the PRC and Western states, there appear to be two parallel assessments of the PRC’s health cooperation efforts: One exceedingly positive and the other overwhelmingly negative. The reality lies somewhere in the middle. Therefore, this study aims to provide a comprehensive overview of China’s health cooperation efforts, illustrating how the Chinese leadership has utilized them to generate soft power. This paper outlines the PRC’s declared goals and analyzes Beijing’s strategic interest in engaging in health cooperation. In addition, this study maps the main stakeholders and institutions involved in and affected by China’s outreach, illuminating the contours of China’s health diplomacy. Moreover, this analysis puts Beijing’s international COVID-19 relief assistance into the broader context of the Belt and Road Initiative(BRI) and the Health Silk Road(HSR). This paper differentiates between three stages of China’s health diplomacy: – Decentralized efforts before the launch of the HSR (1949–2015). – Streamlined efforts under the umbrella of the HSR (2015–2019). – Global outreach efforts since the pandemic(2020–2022). Furthermore, the author differentiates between the bilateral, regional, and multilateral dimensions of the PRC’s health diplomacy. On the bilateral level, the author interviewed government and non-government representatives from several states, including Serbia, the Philippines, Chile, the Democratic Republic of the Congo(DRC), and Iraq. On the regional level, the study delves into‘China+x mechanisms’, wherein health has become an essential agenda item. Finally, the author interviewed diplomats, experts, and World Health Organization(WHO) representatives about the PRC’s multilateral health diplomacy. Beijing’s health cooperation mirrors its actions in other foreign policy fields within the BRI framework. Since 2015, the PRC’s health-related development efforts have expanded significantly. These efforts are viewed positively among the general population in the Middle East and Africa and critically by people in Europe and(parts of) Southeast Asia. Apart from‘Western democracies’, the political elites from third states have overwhelmingly welcomed Beijing’s health aid, in many cases endorsing key policy positions of the PRC within regional and multilateral settings(e.g., regarding Xinjiang and Hong Kong). 1 This study defines health diplomacy as a form of soft power in which healthcare aid is used to improve political, economic, and/or cultural ties between donor and recipient countries, thereby catering to the foreign policy goals of the donor state. Soft power is the use of positive attraction and persuasion to achieve foreign policy objectives. Health diplomacy could be a‘high-return, low-risk’ endeavor for the EU and its member states. Europe should consider increasing and improving its strategic engagement, visibility, and digital messaging to market its generosity more effectively. Even though Beijing’s health diplomacy contains 3

FRIEDRICH-EBERT-STIFTUNG – CHINA’S GLOBAL HEALTH DIPLOMACY serious flaws, decision-makers should not underestimate the PRC’s ability to learn from mistakes and improve its outreach efforts. For Europe, generous and concrete material incentives are required to preserve third states as partners, as many recipient states appear pragmatic and unwilling to commit to a Chinese or a Western‘camp’. The ability to satisfy material interests appears to be as important as shared values when building the international coalitions necessary to preserve and reform international norms and institutions. Health cooperation could play an essential role in this endeavor. 4

China’s Health Diplomacy Before the Launch of the Health Silk Road 1 CHINA’S HEALTH DIPLOMACY BEFORE THE LAUNCH OF THE HEALTH SILK ROAD The PRC has been engaging in health diplomacy for several decades. During the Mao era, Beijing’s health-related international cooperation prioritized socialist countries. When Chinese-Soviet relations deteriorated in the early 1960s, Beijing primarily focused on developing countries in Africa and Asia. With the launch of the Cultural Revolution in 1966, the PRC ended its exchange program with Western countries. Instead, Beijing focused on utilizing foreign(medical) aid to expand its political influence in newly independent states to‘export revolution’. Sending medical teams abroad has traditionally been the most visible part of the PRC’s health diplomacy. In 2006, then Chinese Communist Party(CCP) General Secretary Hu Jintao underlined that, of all cooperation projects with countries in Africa, sending medical personnel“has the longest history, involves the largest number of countries, and is the most successful”(Huang: 2010). The PRC sent its first medical team to the newly independent Algeria in April 1963. By 2021, the PRC had sent 23,000 medical team members to Africa, who had treated 230 million patients (State Council Information Office: 2021a). Those teams usually included 10 to 15 physicians, laboratory technicians, and assistants and were sent to rural areas to support under-served communities. In addition to providing service to the general population, Chinese medical teams also treated the political elite(such as providing medical care for the former Presidents of Zambia and Sierra Leone)(Huang: 2010). Chinese provinces established close relations with individual countries. While the central government is responsible for negotiating health cooperation agreements, individual Chinese provinces are tasked with implementation(e.g., Yunnan sent medical personnel to Uganda, and Henan sent its medical teams to Zambia, Ethiopia, and Eritrea)(Shen/ Fan: 2014). This practice is ongoing, and long-lasting ties have been formed. This approach further aims to utilize the comparative cultural advantages of certain provinces and regions. For instance, the predominantly Muslim Ningxia Hui Autonomous Region serves as a bridge to the Arab world, and the southern Guangdong Province and Guangxi Region connect China with Southeast Asia. Health diplomacy helped generate support among former European colonies for the PRC’s admission to the UN in 1971. Beijing was able to establish good relations with the Global South, which had a majority within the UN General Assembly. The PRC’s health diplomacy has also been linked to international support for other desired foreign policy objectives, including China’s position on human rights, support for the 2008 Beijing Olympics bid, and its WTO application(Huang: 2010). When the PRC obtained WHO membership in 1972, its engagement at the multilateral level remained limited in scope. China’s engagement within the UN framework has traditionally been limited, and the international health regime is no exception. Beijing acted primarily bilaterally, utilizing health cooperation as a convenient, high-return, low risk tool for achieving its declared foreign policy goals. Between 1982 and 2002, health diplomacy lost relevance within the PRC’s foreign policy agenda. Beijing’s foreign aid policy shifted to focus on fostering its economic interest as internal priorities shifted away from revolution and towards development. The PRC reduced funding for medical missions, and the quality of the aid deteriorated. 2001 marked a low point in Chinese health diplomacy; 15 Chinese medical staff were arrested in Brussels on suspicion of smuggling ivory from Mali(Huang: 2010). The roots of treating health as a more prominent aspect of Beijing’s foreign policy can be traced back to 2002. China began to acknowledge‘non-traditional security threats’(including health risks) in its national security concept at the beginning of the century. Moreover, the SARS-CoV-1 (henceforth SARS) outbreak in 2002 revealed that infectious diseases threatened China’s economic development and political stability(Huang: 2010). Between 2002 and 2004, the SARS virus infected over 8000 people from 30 countries and territories, killing at least 774 people(including 349 in Mainland China and 299 in Hong Kong)(Pasley: 2020). In the aftermath of the SARS outbreak, the PRC fundamentally changed its approach toward international health cooperation. Domestically, the 2003 Regulation on Public Health Emergencies(Art. 7), the 2004 revised Law on Infectious Disease Prevention and Control(Art. 8), and the 2007 Emergency Response Law(Art. 17) all authorized government support for international cooperation on disease surveillance and response. The PRC also declassified veterinary epidemics, no longer treating them as state secrets. 5

FRIEDRICH-EBERT-STIFTUNG – CHINA’S GLOBAL HEALTH DIPLOMACY On the bilateral level, the PRC increased its international disaster relief efforts. Beijing dispatched medical aid teams to Algeria and Iran after the 2003 earthquakes and Southeast Asia after the 2005 earthquake and subsequent tsunami. The Peace Ark Hospital Ship, operated by the People’s Liberation Navy, has embarked on regular journeys to treat citizens from friendly nations since 2008(Bainbridge: 2018; Zhuo: 2022). The hospital ship is equipped with 300 beds and eight operating rooms. Additionally, it offers a range of traditional Chinese medicine treatments (CGTN: 2019a). Beijing launched its most comprehensive health aid initiative in December 2013 in response to the Ebola virus disease outbreak in Western Africa. The PRC provided five rounds of humanitarian aid, which included material, personal, and financial aid, as well as post-epidemic economic recovery packages. Beijing sent over 1200 medical personnel to Guinea, Liberia, Guinea-Bissau, and Sierra Leone. Also, the PRC delivered a mobile biosafety level 3 laboratory to Sierra Leone and established a 100-bed treatment center in Liberia(complete with a 163-member medical team)(Wang: 2018). In August 2015, Foreign Minister Wang Yi visited the affected region, promising Chinese investments for economic recovery. Beijing also cooperated with the WHO and traditional donor countries. For example, it signed its first memorandum of understanding(MOU) on development cooperation with the US in September 2015(Wang: 2018). During the Ebola outbreak, unlike most European workers, Chinese workers did not leave the region. This was noted by African media and constituted the most crucial narrative of China’s Ebola diplomacy(Cabestan: 2020). Health has been on the Chinese-African relationship agenda ever since the Forum of Chinese African Cooperation(FOCAC) was launched. When high-level representatives from China and 45 African States met in Beijing in October 2000, the Chinese side pledged to increase its health aid contributions. Both sides adopted the Plan of Action for the Cooperation of Traditional Medicine between China and African Countries. The 2003 FOCAC Addis Ababa Action Plan(2004–2006) identified cooperation in preventing and treating communicable and infectious diseases as a priority cooperation area(FOCAC: 2003). China’s first Africa Policy Paper(2006) outlined the scope of Chinese African health cooperation as follows:(1) medical personnel and information exchanges,(2) sending medical teams and providing medicines and medical materials to African countries, and(3) helping to establish and improve medical facilities and training medical personnel(Xinhua 2006). The first FOCAC Health Forum took place in August 2013 and produced the Beijing Declaration, which further expanded the FOCAC health agenda. 2 2 Accordingly, health cooperation includes:(1) Exchanges of medical institutions;(2) scholarships to China;(3) cooperation between medical schools and research institutions;(4) trainings;(5) support of African public health systems;(6) support for the prevention and control of communicable and non-communicable diseases;(7) pilot projects to fight against schistosomiasis and malaria;(8) access to reproductive health care and universal access to HIV and TB prevention, care, FOCAC health cooperation focused primarily on Beijing delivering aid to Africa. In 2006, the PRC pledged to build 10 hospitals and 30 anti-malaria clinics and to provide USD 37.5 million for the purchase of anti-malarial drugs. In addition to supplying the anti-malarial Artemisinin, the PRC conducted grassroots projects to fight malaria in over 34 African countries. It also launched malaria control and treatment programs within the FOCAC framework(FOCAC: 2006). In 2009, the PRC pledged to provide an additional RMB 500 million worth of medical and malaria-fighting equipment to 30 hospitals and 30 malaria prevention and treatment centers(FOCAC: 2009). It also pledged to train 3,000 doctors, nurses, and administrative personnel. In 2012, Beijing announced it would provide free treatment to cataract patients in Africa(FOCAC: 2012). The SARS outbreak triggered an institutionalization of China’s health cooperation with ASEAN. In 2003, the PRC participated in a Special ASEAN+3(China, Korea, and Japan) Health Ministers Meeting on SARS, which led to the ASEAN+3 Emerging Infectious Diseases Program and the Field Epidemiology Training Network. Between 2003 and 2022, the ASEAN+3 Health Ministers held nine forums. Areas of collaboration included(1) health promotion;(2) capacity building for health professionals;(3) human resource development;(4) infectious diseases;(5) traditional, complementary, and alternative medicine;(6) policy coherence for health and social welfare development; and(7) universal health coverage(ASEAN+3: 2008). Public health gradually became a priority area for ASEAN-China cooperation. Eight rounds of the ASEAN-China Health Ministers Meeting have taken place since 2005. The parties launched the China ASEAN Public Health Fund to finance health-related activities and projects. In 2012, the parties concluded an MOU on health cooperation, which outlines the following areas:(1) prevention and control of communicable diseases;(2) public health emergency response mechanism and capacity for mitigating health impacts of natural disasters;(3) prevention and control of non-communicable diseases;(4) food safety and rapid alert system;(5) human resources development for health;(6) traditional medicine development;(6) pharmaceutical development(ASEAN-China: 2012). SARS fundamentally changed the PRC’s relationship with the WHO. When the WHO learned about the true extent of the outbreak in China, it publicly chastised Beijing for misleading the global community(Huang: 2010). After initially barring WHO experts from entering Guangdong, the PRC changed its approach and followed the WHO’s demands in the anti-SARS campaign. Subsequently, the PRC gradually expanded its engagement within the WHO after becoming party to the 2005 International Health Regulations. treatment, and support;(9) cooperation in standard setting and inspection of medical products through capacity building; and(10) health technology transfer to increase the affordability of pharmaceuticals, diagnostics, vaccines, and equipment(China Daily: 2013). 6

China’s Health Diplomacy Before the Launch of the Health Silk Road Beijing draws a red line in its cooperation with the WHO, perceiving Taiwan’s participation in the WHO as a threat to China’s sovereignty and territorial integrity. Between 2009 and 2016, the PRC allowed Taiwan to participate in the World Health Assembly as an observer under the name Chinese Taipei. This step was possible due to improved Cross-Strait relations during that period. After the election of Tsai Ing-wen in 2016, Cross-Strait relations chilled. Between the election and the time of writing, Beijing has been blocking Taipei’s participation in the World Health Assembly(Chin: 2022). The 2006 election of Margret Chan as Director General of the WHO marked the first time a Chinese national(from Hong Kong) had headed a UN agency. The election of Chan revealed Beijing’s ability to gather majorities within the UN system. During the 2006 Ministerial Meeting of the FOCAC, Chinese leaders actively canvassed African votes for Chan. Then President Hu Jintao promised to double development assistance to Africa for the next three years and to provide preferential credit to African states worth five billion USD by 2009(FOCAC: 2006). It is, therefore, unsurprising that the PRC chose the health regime as the test case to get one of its nationals elected to a leadership position within the UN system. Chan was an experienced candidate, the PRC had already gathered significant experience in international public health affairs, and Beijing was able to set the right incentives for UN member states to elect her. 7

FRIEDRICH-EBERT-STIFTUNG – CHINA’S GLOBAL HEALTH DIPLOMACY 2 THE BELT AND ROAD INITIATIVE(BRI) AND HEALTH DIPLOMACY(2015–2019) The BRI is President Xi Jinping’s key foreign policy agenda item. Since its launch in 2013, the BRI has emerged as the strategic umbrella of the PRC’s foreign policy. The initiative contains five main areas of cooperation, namely:(1) intergovernmental policy coordination;(2) removal of trade barriers;(3) infrastructure connectivity;(4) financial cooperation; and(5) people-to-people exchanges. Each area contains several sub-categories, which have gained and lost significance over the past nine years(Rudolf: 2021a). In 2015, the first official framework document of the BRI outlined health cooperation as a sub-category of‘people-to-people exchanges’(State Council Information Office: 2015). Though it received very little attention before the ­COVID-19 pandemic, health cooperation has been a relevant BRI agenda item since the initiative’s inception. The March 2015 framework document Vision and Actions on Jointly Building Silk Road Economic Belt and 21st-Century Maritime Silk Road states that the PRC aims to“strengthen cooperation[…] on epidemic information sharing, the exchange of prevention and treatment technologies and the training of medical professionals, and improve[…] capability to jointly address public health emergencies[… China] will provide medical assistance and emergency medical aid to relevant countries, and carry out practical cooperation in maternal and child health, disability rehabilitation, and major infectious diseases including AIDS, tuberculosis, and malaria[… China] will also expand cooperation on traditional medicine”(State Council Information Office: 2015). The BRI framework documents from 2017 and 2019 also mention health cooperation(Office of the Leading Group for Promoting the BRI: 2017, 2019). Moreover, the BRI Standardization Action Plans(2015–2017) and(2018– 2020) mention Chinese efforts to set uniform standards for traditional Chinese medicine(TCM) and definitions of medical terms. The BRI Development Plans for Promoting TCM(2016– 2020) and(2020–2025) underline Beijing’s ambitions to promote TCM internationally through the BRI(State Administration of Traditional Chinese Medicine: 2022). A) PLAN FOR BELT AND ROAD HEALTH EXCHANGE AND COOPERATION(2015–2017) The October 2015 Three-year Plan for Promoting BRI Health Exchanges and Cooperation is the most relevant document for understanding the role of health cooperation within the BRI framework. It provides the foundation for the PRC’s health diplomacy under the BRI. In the document, the National Health Commission introduced the term Health Silk Road(HSR), laying out(1) strategic objectives,(2) principles,(3) areas of health cooperation, and (4) relevant actors in the planning and implementation of the HSR(NHFPC: 2015b). The presentation of details on health exchanges and cooperation mirrors how other areas of BRI cooperation are framed, planned, and implemented. For example, the structure and wording in the document are very similar to the BRI plan on agriculture cooperation and the BRI plan on green development cooperation(Rudolf: 2021a). AA) STRATEGIC OBJECTIVES The implementation plan refers to health cooperation as an important factor for strengthening public opinion,“effectively enhance[ing] China’s soft power and influence in the field of regional and global health governance,” and“enhance[ing] China’s status as a major country”(NHFPC: 2015b). Health cooperation is expected to lay the ground for the BRI to succeed in third countries. It is further viewed as part of‘neighbor diplomacy’— which includes the following(rather abstract) core values: peaceful cooperation, openness and inclusiveness, mutual learning, mutual benefit, and win-win cooperation. Domestically, the HSR shall promote the development and transformation of the Chinese health industry(e.g., China’s pharmaceutical and medical device industries, health food, medical tourism, health informatization, as well as technological innovation in health service models and medical products). The document identifies the HSR’s key regions, countries, and mechanisms. Central and Eastern Europe and Central Asia are identified as the key regions for the Silk Road Economic Belt. Furthermore, the Czech Republic, Russia, Mongolia, and the Central Asian countries are also identified as key countries. The China and Central and Eastern European Countries(CEEC) Health Ministers Forum and the Shanghai Cooperation Organization are named the main cooperation mechanism. Regarding the‘21st Century Maritime Silk Road’, South Asia and Southeast Asia are listed as the key regions. ASEAN states, India, Pakistan, Australia, and Fiji are listed as the key countries. China-ASEAN, Great8

The Belt and Road Initiative(BRI) and Health Diplomacy(2015–2019) er Mekong Subregion Economic Cooperation, APEC, the China-Pakistan Economic Corridor, and the Bangladesh-China-India-Myanmar Economic Corridor are the main cooperation mechanisms. The document differentiates between short-term, medium-term, and long-term goals. In the short-term (1–3 years), the PRC aims to consolidate the foundation of cooperation. In the medium term(3–5 years), a health cooperation network based on neighboring countries and key countries shall be initially formed, and the cooperation mechanism shall be further stabilized. In the long-term(5– 10 years), cooperation projects in key areas should achieve “remarkable results”, and a new round of cooperation projects shall be cultivated and formed. BB) COOPERATION PRINCIPLES CC) OOPERATION AREAS AND PILOT PROJECTS The HSR implementation plan lists eight cooperation areas and 38 pilot projects. While some projects are new initiatives, others merely relabel ongoing cooperation projects. Therefore, the plan appears not to be very ambitious, and most of the goals were achieved very early. (1) Establishing Health Cooperation Mechanisms: As a step towards forming a multi-level health cooperation network, the document calls on the PRC to sign health cooperation agreements and host regional and multilateral health cooperation forums. 3 (2) Prevention and Control of Infectious Diseases: Beijing is encouraged to strengthen cross-border cooperation in the fight against infectious diseases. 4 The implementation plan lists five cooperation principles, which reflect the vocabulary of other BRI documents and cooperation areas. The explicit goal is to lay the foundation of a comprehensive BRI health network. (1) Domestic Multi-Level Approach: The central government acts as a coordinator and pursues its own HSR projects. On the local level, provinces, autonomous regions, and municipalities are called to develop and carry out their health cooperation projects with neighboring countries(e.g., the Xinjiang Autonomous Region with Central Asian states or Guangdong Province with Vietnam). A cooperation network that includes central and local governments is anticipated to form incrementally. (2) Focus on Pilot Projects: Following the PRC’s domestic approach to policy making, the HSR relies on pilot projects. According to the plan, the primary focus should be on‘pivot countries’ with whom the PRC has already established sound health cooperation. While utilizing existing bilateral and multilateral cooperation mechanisms, pilot projects aim to create a“radiation effect”, attracting more countries to join the BRI/HSR. (3) Multi-Level Outreach Efforts: The HSR shall be promoted via existing multilateral cooperation mechanisms while simultaneously strengthening bilateral cooperation. (4) Multi-Actor Approach: The government acts as a macro-coordinator. The private sector(enterprises and civil society) is also encouraged to participate in the HSR(e.g., by carrying out academic exchanges or providing charitable assistance). (5) Combination of Assistance and Cooperation: The PRC aims to simultaneously provide aid(e.g., by dispatching ad-hoc emergency medical rescue teams) and enable the partner state to improve its health systems (e.g., via training programs). (3) Capacity Building and Talent Training: The PRC aims to facilitate training for health professionals from BRI states. Provinces and Autonomous Regions conduct the training sessions(provinces involved include Yunnan and Heilongjiang, while autonomous regions engaged in the project include Xinjiang, Guangxi, and Inner Mongolia). 5 (4) Health Emergency and Emergency Medical Assistance: Relief efforts for public health emergencies include dispatching short-term medical, health, and epi3(1) Silk Road Health Cooperation Forum,(2) China-ASEAN Health Cooperation Forum,(3) China-Central and Eastern European Countries Health Ministers Forum, and(4) China-Arab Health Cooperation Forum. 4 The proposed pilot projects are as follows:(1) Establishing a cross-border infectious disease epidemic notification system and a health emergency response coordination mechanism in Central Asia;(2) promoting the Greater Mekong Subregion Infectious Disease Surveillance, Prevention, and Control Project by the local governments of Guangxi and Yunnan;(3) expanding cooperation with Laos, Myanmar, and Vietnam in the fight against AIDS, malaria, and dengue fever in the areas bordering Guangxi and Yunnan;(4) implementing the 2030 Malaria Elimination Plan via the Mekong River Basin Artemisinin-like Malaria Drug Resistance Prevention Project;(5) implementing the Collaborative Project on Schistosomiasis Elimination and Control in the Mekong River Basin(with Laos, Cambodia, Thailand, Myanmar, the Philippines, and Indonesia); and(6) establishing a joint research and training center for the elimination of schistosomiasis in the Mekong River Basin. 5 The proposed pilot projects are as follows:(1) Following the China-­ ASEAN Health Hundred Talents Program, 100 public health technicians and administrators shall be trained. The local government of Guanxi shall carry out the China-ASEAN Nursing Personnel Training Cooperation Project and the China-ASEAN Health Care Personnel Training Project;(2) 100 Public health experts and professional technicians from Indonesia shall be trained through the China-Indonesia Public Health Talents Cooperation Training Program(2015–2017); ­ (3) the China-Central and Eastern European Public Hospitals Cooperation Network, which focuses on personnel exchanges and cooperation in the fields of medical resource planning and allocation, medical quality management, public-private partnerships, medical tourism, medical research, and education, shall be promoted;(4) medical exchanges shall be facilitated via the Sino-Russian Medical University Alliance. Also, a Sino-Russian medical research center and a special fund for exchange students shall be set up;(5) the China-Laos Medical Service Community Project, which fosters cooperation and exchanges with hospitals from the five northern provinces of Laos shall be promoted; and(6) the 5th Global Congress for Consensus in Pediatrics and Child Health shall be hosted. 9

FRIEDRICH-EBERT-STIFTUNG – CHINA’S GLOBAL HEALTH DIPLOMACY demic prevention teams to provide emergency medical assistance to BRI countries. This includes the provision of protective equipment and treatment materials. 6 (5) Traditional Chinese Medicine(TCM): Beijing encourages TCM enterprises to‘go global’, promote international standards, and enhance the competitiveness of TCM. 7 (6) Health System and Health Policy: Beijing aims to establish cooperation mechanisms on health policies among BRI countries, specifically focusing on universal health coverage, health care reform, health promotion, and family planning. 8 (7) Health Development Assistance: China aims to assist developing countries by dispatching medical teams and public health experts. Beijing aims to donate medical supplies and materials, as well as conduct training programs. The PRC plans to provide free cataract surgery through the Brightness Action Program. 9 (8) Development of the Health Industry: Beijing aims to support domestic medical companies to‘go global’ (e.g., by setting up production sites in BRI countries). Also, medical tourism in China shall be developed. The Chinese leadership strives to reduce bilateral trade and investment barriers to support its domestic health industry. 10 6 The implementation plan lists two pilot projects, namely:(1) The Sino-Russian disaster medical cooperation project, which aims to attract Central Asian countries to participate in emergency medical relief exchanges and cooperation efforts with China and(2) The Guangxi Shipwreck Emergency Medical Rescue Center. 7 The following pilot projects will be pursued:(1) Promoting TCM in ASEAN countries, via public exhibitions, expert consultation activities, academic exchanges between partner countries and the Chinese Academy of Chinese Medical Sciences, special lectures at universities, and academic exchanges;(2) promoting the China-ASEAN Traditional Medicine Exchange and Cooperation Center;(3) hosting the 16th World Congress of Traditional Medicine(May 2016) in Yulin City, Guangxi Autonomous Region;(4) hosting the 2015 China-ASEAN International Forum on Traditional Medicine and Health Tourism;(5) hosting the 3rd China(Ningxia) Ethnic Medicine Expo(to increase publicity of TCM in Arab countries);(6) promoting the China-Czech Traditional Chinese Medicine Center;(7) hosting the China Quanzhou-Southeast Asian Traditional Chinese Medicine Symposium;(8) establishing a Confucius Institute for TCM in Oman(the agreement dates to 2013 between Ningxia Medical University and Qaboos University);(9) launching an exchange program between the Hubei Provincial Hospital of TCM and the Czech Jihlava Hospital TCM Center; and(10) building a TCM diagnosis and treatment center an the Pilsen State Hospital, Czechia. 8 The document lists the following pilot projects:(1) Fostering the APEC Universal Health Coverage Progress Monitoring and Research Network and(2) working towards integrating health into economic development strategies. 9 Namely, in the Maldives, Tanzania, Eritrea, Sudan, Myanmar, and Ghana. 10 The document lists the following goals:(1) Develop Xinjiang into an important medical tourism center for Central Asian countries;(2) provide aid for the construction of the Masanqi Hospital in Kazakhstan; (3) promote the Chinese medical industry in Central Asia;(4) provide free access to traditional Mongolian medicine for Mongolian citizens and ethnic Mongols in China;(5) construct the UAE-China-Arab Friendship Hospital; and(6) construct the China-ASEAN Healthcare Cooperation Center. DD) KEY ACTORS The National Health and Family Planning Commission leads the implementation of the HSR. In addition to the Central National Health and Family Planning Commission, several local Health and Family Planning Commissions(e.g., those in Shanghai, Heilongjiang, Fujian, Guangxi, Xinjiang, Shaanxi, Hubei, Zhejiang, Yunnan, Inner Mongolia) implement specific HSR pilot projects. Besides, local commissions are tasked with strengthening coordination and cooperation with relevant ministries, international organizations, Chinese embassies, and foreign embassies or consulates in China. They are also tasked to carry out progress assessments of pilot projects and formulate annual work summaries. The Governments of the Autonomous Regions of Xinjiang and Guangxi play pivotal roles in reaching out to bordering states. The Chinese leadership envisions Xinjiang developing into a BRI hub in Central Asia. The Guangxi Zhuang Autonomous Region shall reach out to the Southeast Asian States. Moreover, the Ningxia Hui Autonomous Region shall serve as a bridge to Arab countries. The State Administration of Traditional Chinese Medicine coordinates the promotion of TCM within the HSR. Moreover, several hospitals and universities support those efforts. 11 The Chinese Center for Disease Control and Prevention implements pilot projects focused on combatting the spread of infectious diseases. Several hospitals and research facilities are involved in exchanges and capacity-building measures, training, and promoting medical tourism. 12 The implementation plan further identifies several business entities that will promote the HSR. 13 Other involved actors include the National Tourism Administration, the Expo, and the Guangxi Region’s Tourism Bureaus. 11 These include the Chinese Association of Traditional Chinese Medicine, the Shanghai University of TCM, the Xinjiang Autonomous Region TCM Hospital, the Hubei Provincial Hospital of TCM, the Ningxia District TCM Hospital, the Guangxi Zhuang Autonomous Region TCM Administration, the Fujian Association of TCM, and the Quanzhou Association of TCM. 12 These are the China Hospital Association, Peking University People’s Hospital, Shanghai Oriental Hospital, Beihai People’s Hospital, Xi’an First Hospital, The First People’s Hospital of Yunnan Province, Xinjiang Uygur Autonomous Region People’s Hospital, First Affiliated Hospital of Xinjiang Medical University, Xinjiang Autonomous Region Cancer Hospital, Autonomous Region Uygur Medical Hospital, Inner Mongolia International Mongolian Medical Hospital, Ningxia People’s Hospital, Ningxia Medical University General Hospital, The First Affiliated Hospital of Guangxi Medical University, and the Xishuangbanna Prefecture People’s Hospital of Yunnan Province. Moreover, the following academic institutions are relevant actors in the promotion of the HSR: the National Academy of Chinese Medical Sciences, China Health Education Center, Harbin Medical University, Peking University, Tsinghua University, and Ningxia Medical University. 13 Relevant business entities include the China Medical Equipment Association, the China Medical Device Industry Association, and Reed Sinopharm(China’s leading healthcare and pharmaceutical exhibition and conference organizer). 10

The Belt and Road Initiative(BRI) and Health Diplomacy(2015–2019) B) COOPERATION IN PRACTICE (2015–2019) Following the principle of‘multi-level outreach’, the PRC has been pursuing health cooperation via bilateral, regional, and multilateral platforms. AA) BILATERAL LEVEL By April 2019, Beijing had concluded 56 bilateral health cooperation agreements(Office of the Leading Group for Promoting the BRI: 2019). The PRC’s practice deviated, to some extent, from the three-year plan, failing to achieve some of its self-set goals(such as reaching out to India) while overdelivering in other areas(for example, by providing more cost-free eye and heart surgeries to more countries than planned). The Brightness Action Program developed into a flagship HSR project. Since its launch in 2014, China has dispatched over one-hundred ophthalmology teams to perform cataract surgeries in other countries. Beijing also donated advanced eye surgical instruments to Asian and African countries; recipient countries included Namibia, the Philippines, Cambodia, Myanmar, Laos, Chad, Pakistan, and Sri Lanka(Global Times: 2021). When Beijing proposed extending the HSR to new geographic areas(e.g., Latin America, the South Pacific, or the Middle East), it singled the Brightness Action Program as exemplary of bilateral health cooperation under the BRI framework. The PRC offered emergency medical assistance to Fiji, Tonga, Vanuatu, and Nepal. Furthermore, in 2017, the Pease Ark Hospital Ship embarked on a journey once around the African continent, offering free treatment to BRI countries. In 2018, it embarked on another journey from Papua New Guinea through the Pacific Ocean to the Caribbean. Compared to previous missions, Beijing labeled its 2017 and 2018 tours as part of the BRI narrative(Global Times: 2021). The most effective bilateral HSR efforts have been the promotion of TCM centers. In 2018, Beijing had already reached its target to build 30 TCM centers in 2020(National Administration of Traditional Chinese Medicine: 2017). By 2019 Beijing had established 43 international TCM cooperation bases and TCM centers in 35 BRI countries(Office of the Leading Group on Promoting the Implementation of BRI: 2019). Demand was particularly high in Eastern Europe (e.g., the Czech Republic and Serbia) and Southeast Asia (e.g., Cambodia, Vietnam, Malaysia, and Myanmar). Some bilateral health cooperation targets set in the HSR implementation plan were not achieved. For instance, health cooperation with Central Asian states remained limited. Xinjiang did not develop into a medical tourism hub for Central Asian countries. Also, Russian-Chinese health cooperation did not play the anticipated“radiation effect.” Besides, India, Fiji, and Australia did not emerge as key partners in promoting the HSR. Relations with Australia have been deteriorating since 2018. Moreover, the BRI did not help improving Beijing’s complicated relationship with India. BB) REGIONAL COOPERATION MECHANISMS Regional cooperation mechanisms played an essential role in the promotion of the HSR. China+x mechanisms are cooperation formats between the PRC and a specific group of states, for instance, the Association of Southeast Asian Nations(ASEAN), African countries(FOCAC), Central and Eastern European States(16+1), or of the Arab League. Between 2015 and 2019, the 16+1 and the China Arab Cooperation Forum added health cooperation to their agenda, while the ASEAN and FOCAC expanded the scope of health cooperation within the format. While health cooperation within these mechanisms differs from region to region, by 2019, the formats had embraced the HSR narrative, serving explicitly as BRI sub-forums. (1) ASEAN The Chinese Red Cross Foundation(CRCF) played an extraordinary role in serving the BRI. In February 2017, the CRCF established the Belt and Road Fraternity Fund (BRFF), which has subsequently financed several bilateral HSR projects(CRCF: 2017). For instance, between 2017 and 2019, over 100 Afghan children received free heart surgery in Xinjiang as part of the‘Angels Tour’. The BRFF also financed similar projects in Mongolia. By 2018, it had launched nine overseas projects in 23 countries, including, but not limited to, Pakistan, Mongolia, Kenya, Uganda, Ethiopia, Syria, and Iraq(LYU: 2020). The China-Pakistan Life Rescue Corridor, which aims to provide emergency care along the China-Pakistan Economic Corridor, is another project financed by the BRFF. As part of the project, in May 2017, the China-Pakistan Fraternity Emergency Care Center opened at the strategically important Gwadar Port. By August 2019, the medical center had treated 3,087 Pakistani and 1,193 Chinese patients(LYU: 2020). While the PRC has been using the BRI label domestically to describe China-ASEAN health cooperation, joint statements do not mention the HSR. This is because China’s regional health cooperation efforts with ASEAN are the most institutionalized, and they had developed outside the scope of the BRI. The introduction of the HSR was primarily a relabeling effort of ongoing cooperation projects. A shift occurred in October 2016 when China-ASEAN Health Cooperation Forum participants adopted the Nanning Declaration. Compared to previous Joint Statements, the document reads very similarly to an official BRI document. For instance, it references the BRI term China-ASEAN‘community of shared destiny’(ASEAN-China: 2016). 14 14 Regarding the scope of health cooperation, the document lists the following areas:(1) prevention and control of non-communicable diseases,(2) promoting healthy and active aging,(3) address11

FRIEDRICH-EBERT-STIFTUNG – CHINA’S GLOBAL HEALTH DIPLOMACY (2) FOCAC Chinese-African health cooperation also evolved outside of the BRI framework. The HSR implementation plan hardly cites cooperation projects in Africa, despite the PRC’s long engagement in the region. In October 2015, when South Africa hosted the 2nd Ministerial Forum of China-Africa Health Development, the participants issued the Cape Town Declaration, which does not mention the BRI(FOCAC: 2015b). 15 The December 2015 Johannesburg Action Plan(2016–2018) was the first official FOCAC document to reference the BRI(FOCAC: 2015b). 16 When the African continent became more relevant within the BRI context, the PRC also stepped up its health cooperation efforts in the region. In 2018, Chinese-African health cooperation incorporated the BRI narrative, and the HSR gradually expanded to the FOCAC. The 2018 Beijing Action Plan(2019–2021) and the 2018 Beijing Declaration-Toward an Even Stronger China-Africa Community with a Shared Future are full of BRI references. In the Beijing Action Plan(2019–2021), the PRC expressed its willingness to expand health cooperation projects in Africa(FOCAC: 2018a). In August 2018, Beijing hosted the China-Africa Traditional Medicine Cooperation Forum (FOCAC: 2018b), which included a symposium on women’s and children’s health(FOCAC: 2018c). The Meeting produced the 2018 China-Africa Health Cooperation Initiative. Adjacent to the summit, the CCP’s Central Propaganda Commission held a symposium about a four-part documentary titled Medicine Without Boundaries, featuring 50 years of Chinese medical aid to Africa(FOCAC: 2018d). The Chinese side framed Chinese-African health cooperation as evidence of the success of the BRI. The African side also adopted the BRI and HSR narrative. Moreover, the PRC expanded its health cooperation efforts in the region(e.g., by building the African Center for Disease Control and Prevention and investing heavily in China-Africa Friendship Hospitals). Finally, the PRC increased its commitment to medical training, free surgeries, and exchange programs. ing communicable diseases with a specific focus on tuberculosis, ­malaria, HIV and AIDS, and schistosomiasis,(4) collaboration to control the spread of communicable diseases in border regions, ­ (5) strengthening the quality of traditional and complementary medicine. 15 The parties committed to the following:(1) Improving the health system of African countries in the post-Ebola era;(2) reinforcing the surveillance and epidemiological systems on the national and regional level;(3) assisting with human resources development in Africa;(4) improving health infrastructure through the construction and renovation of medical facilities;(5) reinforcing laboratory capacity and diagnostic systems;(6) contributing to the improvement of health information systems;(7) improving health care accessibility; (8) improving the accessibility of quality medicines, vaccine, diagnostics, and health commodities. 16 This action plan states:“The African side welcomes the Chinese side’s championing‘the 21st Century Maritime Silk Road’, which includes the African continent, and the two sides will promote mutually beneficial cooperation in the blue economy”(FOCAC: 2015b). (3) and Eastern European Countries(CEEC) Cooperation(16+1) In December 2014, health emerged as a new cooperation area within the 16+1 format. 17 Between 2015 and 2019, health cooperation rose in prominence within the format. According to the Medium-Term Agenda for Cooperation between China and Central and Eastern European Countries, the China-CEEC Health Ministers’ Forum is tasked with establishing a China-CEEC Association on the Promotion of Health Cooperation. Moreover, health cooperation includes:(1) Joint research on healthcare systems;(2) exchanges of health professionals and workers;(3) the launch of a China-CEEC cooperation network for public hospitals and a China-CEEC alliance for cooperation among public health institutes; and(4) TCM cooperation(China-CEEC: 2015a). Early on, the Chinese and the European side utilized the 16+1 Health Cooperation forum as a BRI sub-initiative. The scope of 16+1 health cooperation overlaps in large part with the 2015 HSR implementation plan, as outlined in several joint declarations and guidelines. 18 The connection between health cooperation and the BRI was first mentioned in the 2017 Budapest Guidelines, which refer to health cooperation as a“catalyst for the promotion of the BRI”(China-CEEC: 2017). Between 2015 and 2019, 16+1 relations developed considerably, and health cooperation exceeded stakeholders’ expectations. By 2019, the parties had hosted four Health Ministers’ Meetings, and the scope of cooperation had expanded significantly. The first meeting was held 17 The Belgrade Guidelines were issued during the 3rd China-CEEC Heads of Government meeting in December 2014. In the document, the parties identified TCM as a cooperation area and announced the first China-CEEC Health Minister’s Forum(China-CEEC: 2014). 18 The 2015 Suzhou Guidelines stated that CEEC health professionals would be invited to visit China in 2016 for seminars on global health diplomacy, healthcare system reforms, and health promotion. CEEC medical and health business resprentatives were also invited to China for exhibitions on health services and medical devices to promote cooperation in the medical industry(China-CEEC: 2015b). The 2016 Riga Guidelines praised efforts by the Czech Republic, Hungary, Macedonia, Montenegro, and Lithuania for their efforts to explore traditional Chinese medicine. China offered to provide technical assistance in this arena. Also, cooperation in the field of the health industry was listed, and direct cooperation of medical and health enterprises from both sides was encouraged(China-CEEC: 2016a). The 2017 Budapest Guidelines also featured a paragraph on health cooperation. In addition to the affirmation of existing projects, the guidelines acknowledge the new Central and Eastern European Medical Education and Research Center for Traditional Chinese Medicine in Hungary. The parties also declared their support for more cooperation in Chinese herbal medicine cultivation and production, including establishing herbal medicine cultivation bases within CEECs(China-CEEC: 2017a). The 2018 Sofia Guidelines encouraged the Academy of Chinese Medical Sciences and local TCM universities to conduct direct cooperation with medical universities in Eastern and Central Europe and support exploring building herbal medicine cultivation bases(China-CEEC: 2018). In the 2019 Dubrovnik Guidelines, the parties reiterated their willingness to further strengthen their cooperation in public health and medical service industries through contacts between government departments, academic and talent exchanges, and inter-agency cooperation. The signatories welcome additional venues of cooperation in the field of TCM(China-CEEC: 2019a). 12

The Belt and Road Initiative(BRI) and Health Diplomacy(2015–2019) in the Czech Republic, the fulcrum country for the HSR in Europe. In Prague, the participating parties announced the Prague Declaration on Health Cooperation and Development. This document outlines 16+1 health cooperation (NHC: 2015a). 19 The Second Health Ministers Meeting took place in Suzhou in June 2016. According to the Suzhou Joint Communique, health cooperation aims to(1) promote TCM in Europe,(2) establish programs for exchange and cooperation among hospitals, the health industry, and universities, (3) foster market access for the pharmaceutical industry, and (4) cooperate on combating infectious diseases like MERS and SARS(China-CEEC: 2016b). In 2017, Hungary hosted the Third Health Cooperation Forum. During the event, the China-CEEC Human Resources for Health Cooperation Network, the China-CEEC Health Policy Research Network, and the China-CEEC Public Health Cooperation Network were established. The forum issued the Budapest Declaration, which proposes strengthening the connection between traditional and Western medicine and shifting from a“disease-centered” approach to a“prevention-focused” strategy. The parties further agreed to promote international research and development(R&D) cooperation, health tourism, and international cooperation on research, innovation, and medical professional training(China-CEEC: 2017b). In November 2019, the Bulgarian Government and China’s National Health Commission hosted the 4th Health Ministers Meeting. The forum featured exhibitions to praise 16+1 health cooperation, the HSR, and the BRI(China-CEEC: 2019b). While some decision-makers in Brussels had criticized 16+1 cooperation as an attempt to‘divide and conquer’ Europe, the health cooperation forum was largely ignored. Dialogue does not equal cooperation. While the frequency of meetings and the proposed visions of the parties has been impressive, the real substance of health cooperation has been difficult to measure. For instance, the China-CEEC Hospital Alliance launched a website in 2016, but the concrete significance of this alliance remained questionable, even six years after its launch. In addition, the success of China-CEEC health cooperation cannot be properly assessed independently from the“BRI love affair” between the PRC and the CEEC, which stretched from around 2014 to 2019. The success of the HSR appears to have been a function of the CEEC’s hunger for Chinese BRI investment. The most sustainable area of health cooperation has been the(demand-driven) field of TCM due to its genuine popularity among the CEEC. 19 The declaration includes the following proposals:(1) Medical institutes should increase direct communications and a public hospital cooperation network shall be established;(2) both sides shall increase exchanges on infectious disease monitoring, prevention, control and response, as well as on chronic non-communicable disease prevention, and build a public health institute alliance;(3) support should be provided for joint health system studies and regular seminars for joint exploration of health systems;(4) an increase in health professional and technical personnel exchanges, and the provision of scholarships for Europeans to study medicine in China; and(5) to increase communication and coordination with the WHO and other international organizations to help them play a greater role in global health governance. (4) China-Arab States Cooperation Forum Compared to other regional health cooperation mechanisms, health cooperation with Arab states stresses opportunities for the health industry and high-tech cooperation. Health cooperation focuses on opening the medical and pharmaceutical market, promoting interaction and cooperation in the Chinese-Arab medical industry, and allowing Chinese companies to introduce their pharmaceutical products to Arab states. 20 The Ningxia Hui Autonomous Region has been designated to serve as a‘bridgehead’ for China to explore opportunities arising from the medical market of Arab countries. Ningxia has been hosting Chinese-Arab Cooperation forums since 2010 due to its cultural ties as a Muslim region(People’s Daily: 2015). Not surprisingly, it assumed the same role in regional health cooperation. On September 11, 2015, the First China-Arab Health Cooperation Forum took place in Yinchuan(Ningxia). The forum featured(1) meetings on infectious and non-infectious disease prevention and control,(2) academic exchanges about traditional medicine,(3) an international ophthalmology summit, and(4) a Sino-Arab health industry exhibition(Feng: 2015). The parties issued the Yinchuan Declaration, which includes a comprehensive list of cooperation targets. 21 Furthermore, on September 12, 2015, nearly 20 Chinese and Arab medical institutions signed the Joint Statement on the Preparation of the China-Arab Medical and Health Cooperation and Development Alliance to strengthen the exchanges, cooperation, and development of medical and health science research. 20 On September 10, 2015, the Ningxia Health and Family Planning ­Commission, Dubai Nashley E-commerce Service Platform, Ningxia Pharmaceutical Industry Association, and Ningxia Medical Device Industry Association signed a framework cooperation agreement at the China-Arab Health Industry Forum to jointly build a China-Arab medical and health industry e-commerce platform(China Business News: 2015). 21 The targets listed are:(1) Jointly implement the relevant contents of the 2014–2016 Health Cooperation Action Plan signed by the National Health and Family Planning Commission of the PRC and the Secretariat of the League of Arab States;(2) strengthen direct cooperation between medical and health institutions and establish a China-Arab Medical and Health Cooperation and Development Alliance to carry out medical education interaction, medical service personnel exchanges, and medical technology cooperation;(3) strengthen personnel exchanges and trainings through exchanges of health and medical experts, and health vocational technical training courses and seminars; (4) carry out exchanges and cooperation in traditional medicine and support scientific research institutions to establish a regular exchange and cooperation mechanisms in the fields of traditional medicine and modern medicine;(5) support the cooperation between Chinese and Arab medical institutions and encourage the transfer of medical technology;(6) strengthen the exchange of information on medical policies and regulations between governments;(7) strengthen the cooperation between China and Arab countries in pharmaceutical product standards, supervision, and other aspects to ensure the quality, safety, and effectiveness of pharmaceutical products;(8) strengthen work on the prevention and control of infectious diseases and non-communicable chronic diseases;(9) strengthen coordination and mutual support in global health affairs and strengthen foreign policy coordination in the field of health;(10) strengthen cooperation in the field of environmental sanitation, including water safety, food safety, public health, sewage treatment, etc., as well as the elimination of environmental pollution(NHFPC: 2015a). 13

FRIEDRICH-EBERT-STIFTUNG – CHINA’S GLOBAL HEALTH DIPLOMACY In August 2019, the participants of the 2nd China-Arab States Health Cooperation Forum declared their willingness to construct an Arab-Chinese HSR(Kuwait Times: 2019). The parties issued the Beijing Initiative, which advocates for cooperation on health policies, major disease control, and traditional medicine. The parties also called for training and exchange programs, as well as better information sharing on the health of women, children, and the elderly(China-Arab States: 2019b). Moreover, they expressed their willingness to build a hospital cooperation network. The parties further pledged to establish a joint center for applied research that utilizes both TCM and modern medicine. The UAE, Iraq, Egypt, Saudi-Arabia, and Tunisia stand out as key HSR cooperation partners. The Beijing Communiqué is more ambitious and concrete than the 2015 HSR implementation plan. It lists more cooperation areas and proposes an array of new cooperation platforms. 22 For instance, women’s and children’s health emerged as an independent cooperation area, which appears to be an attempt to align the HSR more closely with the 2030 UN Sustainable Development Goals. The deviations from the 2015 plan are not surprising. The BRI is inherently flexible, and the content of other BRI cooperation areas has also changed significantly over time. This adaptability appears to be a feature rather than a bug of the HSR and BRI. (2) WHO (5) Evaluation While the PRC was able to host the anticipated health forums with the ASEAN, CEEC, and the Arab States, and even extended the HSR to the FOCAC, it failed to put health cooperation on the agenda of the Shanghai Cooperation Organization(SCO). In addition, the Bangladesh-China-India-Myanmar Economic Corridor played no role within the HSR. CC) MULTILATERAL LEVEL In January 2017, the PRC and the WHO signed an MOU on Health Sector Cooperation under the BRI framework. Accordingly, cooperation between the PRC and WTO under the BRI framework focuses on(1) control of malaria and schistosomiasis,(2) health workforce training,(3) local production of medicines, and(4) health systems development to support universal health coverage(WHO: 2022b). During the August 2017 BRI Health Cooperation summit, the WHO Director General, Dr. Tedros Adhanom Ghebreyesus, praised the BRI and proposed a strategic partnership with China to target vulnerable countries in Africa(WHO: 2017). Beijing promoted the HSR primarily bilaterally and through regional China+x mechanisms. At the multilateral level, the PRC’s health diplomacy mostly focused on paying lip service to the central role of the WHO in the international health regime. Also, the PRC signed BRI cooperation agreements with UN Agencies, including the WHO and the United Nations Development Programme(UNDP), to explore synergies between the UN’s agenda and the HSR. Beijing strove to promote the narrative that the BRI(and the HSR) could deliver goals explicitly shared by the international community(e.g., aims related to economic and social development). On a more abstract level, Beijing used health diplomacy to advocate for its view that collective human rights(including the‘right to health’) are more relevant than individual human rights. (1) elt and Road High-Level Meeting for Health Cooperation In August 2017, Beijing hosted the Belt and Road High-Level Meeting for Health Cooperation(BRI Health Forum: 2017). High-level officials from several countries, international organizations, and NGOs signed the Beijing Communiqué on BRI Health Cooperation and the HSR(henceforth Beijing Communiqué). An important adaptation to the 2015 HSR implementation plan has been the strong emphasis on linking health to(economic) development. While development has been a core narrative of the BRI, in 2017, the PRC started to frame the HSR as a path to economic development(National Health Commission: 2017). Beijing has been demonstrating its influence within the WHO through its ability to build coalitions among UN member states. Since the launch of the BRI, the PRC has become more strategic and assertive in getting its preferred candidates elected to high-level UN positions. 23 When Margaret Chan stepped down as WHO Director-General in 2017, the PRC advocated for the election of Tedros Ghebreyesus. In a competitive campaign, Beijing built a stronger coalition than the Western states(who supported David Nabarro from the UK). 22 The document lists the following cooperation measures:(1) Establish the Belt and Road Health Policy Research Network and achieve the health-related 2030 Sustainable Development Goals(SDGs);(2) establish the Belt and Road Public Health Cooperation Network to increase capacity for fighting major infectious diseases and responding to public health emergencies;(3) improve the health level of women and children in BRI countries;(4) conduct trainings and exchanges for health and medical experts in BRI countries;(5) promote TCM in BRI countries;(6) facilitate cooperation between medical research institutions(e.g., via the Belt and Road Hospital Alliance);(7) form the Belt and Road Health Industry Sustainable Development Alliance and explore cooperation on mutual recognition of drug and device access standards;(8) dispatch medical teams and carry out free cataract and cleft-palate surgeries;(9) strengthen communications within international organizations(e.g., WHO), and promote global heal governance reforms. 23 Some preferred candidates include: Qu Dongyu, Director General of the FAO; Fang Liu Secretary General of ICAO; Houlin Zhao, Secretary-General of the ITU; Pingfan Hong, Director of the Development Policy and Analysis Division in the Department of Economic and Social Affairs(UN/DESA); Haoliang Xu, Assistant Administrator and Director of the Regional Bureau for Asia and the Pacific of the UNDP; Liu Zhenmin UN Under-Secretary-General for Economic and Social Affairs(Rudolf: 2021a). 14

The Belt and Road Initiative(BRI) and Health Diplomacy(2015–2019) While the PRC’s share of the WHO budget has risen, Beijing’s voluntary contributions remained small, especially compared to the United States. 24 In the biannual budget from 2016-2017, when combining assessed and voluntary contributions, the PRC ranked 24th among the WHO members(0.19 percent of the total budget)(WHO Budget 2016–2017: 2017). In 2018, it ranked 22nd(0.2 percent of the total budget)(WHO Budget 2018–2019: 2019). The WHO has viewed the PRC’s approach to public health as a model for developing countries for decades. To illustrate, the 1978 Declaration of Alma-Ata advocates for China’s model for healthcare integration to achieve ‘health for all’(WTO: 1978). The Chinese approach includes the development of the primary level of rural healthcare via so-called‘barefoot doctors’, the training of community health workers, and the integration of local healthcare practices and practitioners into the biomedical healthcare system. Admiration for the PRC’s ability to develop a decent public health system has been expressed by developing states and the WHO. The BRI seems to build on the spirit of Alma-Ata. In the words of a high-level WHO official:“For most of the developing world, China is a fellow traveler that faced and overcame similar development challenges not so long ago. This shared experience creates a rapport not always enjoyed by wealthy development partners”(WHO: 2016). The WHO and the PRC have forged a symbiotic relationship. The WHO’s interests and the objectives of the BRI align. From the WHO’s perspective, the BRI may help to facilitate the WHO’s goals, even if the PRC acts(for the most part) bilaterally and utilizes the WHO for cosmetic purposes (e.g., to promote the image of responsible great power that upholds the UN-based system). By the same token, the PRC’s close ties with developing countries may enable it to set the agenda within the WHO and utilize it as a vessel to promote the BRI agenda. (3) 030 UN Sustainable Development Goals and the‘Right to Health’ The PRC has described health as a precondition for and accelerator of development. When the 2030 SDGs were formulated in 2015, the PRC quickly tied them rhetorically to the BRI agenda. In September 2016, then-administrator of the UNDP Helen Clark signed a bilateral MOU for the Implementation of the BRI and the 2030 Agenda for Sustainable Development. It was the first BRI MOU between the PRC and an international organization(People’s Daily: 2016). The PRC launched joint projects with the UNDP and the WHO to explore synergies between the BRI and 24 The budget of the WHO is comprised of assessments(which depend on the country’s population and economic development) and voluntary contributions. Voluntary contributions are donations from governments as well as partners such as charities and trusts, and the funding is usually earmarked for projects. The WHO has increasingly become reliant on voluntary contributions, which amount to over 75 percent of its budget. the 2030 SDGs, including the health-related SDGs. For instance, since 2017, the PRC has been promoting the HSR as a catalyst for improving maternal and child health and universal health coverage, which are all at the heart of the health-related SDGs. While Beijing has been able to insert references to the ‘BRI’ and the‘community of shared future of mankind’ into numerous resolutions of the United Nations Human Rights Council(UNHRC), 25 the term HSR does not appear. Most resolutions citing the‘right to health’ are uncontroversial and have been adopted without a vote. 26 Resolutions that aim to promote collective human rights over individual human rights regularly reference the‘right to health’. These resolutions were typically passed by a majority of about 30 developing states(including the PRC), while a minority of western countries(around 15 states) have either abstained or voted against them. 27 The PRC also belongs to a majority of states that criticize‘inherent biases’ in the international order. The‘right to health’ is usually mentioned in related critical resolutions as well. 28 The HSR served as a tool for the PRC to gain discourse power within the international human rights regime. Beijing has promoted the HSR as a mechanism to achieve economic and social development and, thus, as crucial to improving human rights. Within the international human rights regime, Beijing primarily aims to advance social and economic human rights, which include the‘right to health’. Civil and political human rights are not a priority for the Chinese Communist Party. Notably, many developing states share Beijing’s assessment when it comes to prioritizing collective over individual human rights. The BRI and the HSR aim to support this narrative. 25 See for instance the UN Human Rights Council resolutions on The right to food,(34/L.21 on 21 March 2017 and 37/10 on 8 April 2018); Question of the realization in all countries of economic, social and cultural rights(34/L.4/Rev.1 on 21 March 2017 and 37/13 on 9 April 2018); The contribution of development to the enjoyment of all human rights(35/21 on 7 July 2017); Promoting Mutually Beneficial cooperation in the field of human rights(37/23 on 6 April 2018.)(See: Rudolf: 2021a) 26 Some examples of resolutions adopted unanimously include the Human Rights Council resolutions on The right of everyone to the enjoyment of the highest attainable standard of physical and mental health in the implementation of the 2030 Agenda for Sustainable Development; 42/16 of 26 September 2019, 15/22 of 27 September 2010, 24/6 of 8 October 2013, and 33/9 of 29 September 2016. 27 Examples include the following resolutions: Protection of the family: role of the family in supporting the protection and promotion of human rights of persons with disabilities(32/23 on 1 July 2016 and 35/13 on 22 June 2017); Effects of terrorism on the enjoyment of all human rights(34/8 on 23 March 2017); The contribution of development to the enjoyment of all human rights(41/19 on 12 July 2019). 28 Examples include the following resolutions: Unilateral coercive measures(27/21 of 26 September 2015, 36/10 of 28 September 2017, 37/21 of 23 March 2018, and 40/3 of 21 March 2019); Promotion of a democratic and equitable international order(33/3 on 29 September 2016 and 42/8 on 26 September 2019); The effects of foreign debt and other related international financial obligations of States on the full enjoyment of all human rights, particularly economic, social, and cultural rights(34/11 of 23 March 2017, 37/11 of 22 March 2018, and 40/8 of 21 March 2019); and Enhancement of international cooperation in the field of human rights(38/3 on 5 July 2018 and 41/3 on 11 July 2019). 15

FRIEDRICH-EBERT-STIFTUNG – CHINA’S GLOBAL HEALTH DIPLOMACY DD) EVALUATION Health cooperation evolved from a niche topic within the BRI into a key area. While political decision makers and researchers in Europe have primarily focused on analyzing the BRI as a global infrastructure development project, the PRC has promoted its ambitions to create China-centered health cooperation networks. The PRC’s health diplomacy efforts have become more streamlined and strategic under the BRI. According to the HSR implementation plan, the PRC aims to utilize health diplomacy to gain soft power and to‘enhance China’s status as a major country’(NHFPC: 2015b). Compared to the previous goals of‘exporting revolution’ or improving conditions for Chinese development, the HSR represents a more ambitious, strategic, and sophisticated type of health diplomacy. Moreover, China’s health diplomacy under the HSR is more centralized. This streamlining of Beijing’s foreign policy may be witnessed across other BRI cooperation areas as well. Between 2015 and 2019, the HSR exceeded the cooperation goals identified in the 2015 implementation plan. On the bilateral level, Beijing was most effective in promoting TCM, cost-free medical procedures, and investments in health infrastructure. In addition, the PRC institutionalized its health diplomacy in China+x mechanisms in regions of crucial geopolitical significance for the BRI(Africa, the Middle East, Southeast Asia, and Europe). At the multilateral level, the PRC benefited from aligned interests with UN Agencies and the US withdrawal from the UN system during the Trump years. While the extent of the HSR cooperation efforts is impressive on paper, its true significance was not tested until the COVID-19 pandemic. 16

China’s Health Diplomacy During the COVID-19 Pandemic 3 CHINA’S HEALTH DIPLOMACY DURING THE COVID-19 PANDEMIC The COVID-19 pandemic represented an external shock for the BRI. Beijing’s response underscored the flexible nature of the initiative. It also illustrated a new level of sophistication and assertiveness of Beijing’s health diplomacy. For instance, the PRC provided the whole world with medical aid while Chinese state media(and officials) engaged in concerted efforts to propagate a narrative of Western decline in developing countries via social media. Surging COVID-19 cases since the beginning of 2022 and the inability of the Chinese leadership to move beyond the pandemic may put Beijing’s health diplomacy into jeopardy. tonomous Region. In Southeast Asia(Laos, Cambodia, and Myanmar), soldiers from the People’s Liberation Army delivered medical aid supplies. In countries where Chinese stateowned companies run infrastructure projects, donors included banks, construction companies, and raw material companies. Huawei preferentially gave support to countries in which it was pursuing strategic interests in the 5G expansion. 29 Business foundations(especially the Jack Ma Foundation and the Alibaba Foundation) delivered masks, respirators, and testing apparatus to over 150 countries. Trade associations, overseas Chinese, and NGOs were also involved(Rudolf: 2021b). A) MASK DIPLOMACY Once the coronavirus outbreak in Wuhan became public knowledge in late December 2019, the PRC appealed to the international community and received material and financial aid from over 58 countries (some donor countries included Australia, Djibouti, Germany, Pakistan, Bahrain, and Suriname). Even smaller contributions(for instance, a 100 Euro donation from Comoros) were used by Beijing for propaganda as a sign of solidarity and evidence of the HSR spirit and an‘international community of health’(Rudolf: 2021b). In late February 2020, when the authorities had mitigated the outbreak in China(by enforcing strict lockdown measures in Wuhan), Beijing quickly took on the role of aid provider. Given that most of the world’s mask factories are located in China and because many industrialized nations had delivered relief aid to Wuhan, the Chinese leadership was in an almost monopolistic position to supply the world with masks(Rudolf: 2021b). Countries facing medical equipment scarcity promptly received donations of much-needed aid supplies(masks, test kits, and respirators). The PRC acted mostly bilaterally in this endeavor. Most states in the world received support from China in an incredibly short period of time. China offered aid supplies to states that have not (yet) established diplomatic relations with Beijing, especially in Latin America. In Paraguay, the parliamentary opposition demanded cutting diplomatic relations with Taipei to receive aid from Beijing. Belize received donations from Chinese‘non-governmental’ organizations. A remarkable PR coup for Beijing involved a photo session with Belize City councilors in front of PRC flags. Belize is one of the remaining 13 states that maintains full diplomatic relations with Taiwan(Rudolf: 2021b). 30 China’s propaganda machine quickly streamlined its public response to the pandemic. Chinese diplomats published articles in their host countries’ local daily newspapers describing the nation as a responsible, international great power. The articles espoused the PRC’s aid as proof of an emerging‘community of shared future of mankind’. While the scale of outreach efforts has been much larger during COVID-19, the articles are reminiscent of the PRC’s communications strategy in the early days of the BRI when newspaper op-eds were used to promote the BRI. These were written primarily by members of the leadership, not diplomats. Xi Jinping’s wife, the singer and WHO special envoy Peng Liyuan, also played a role in China’s health diplomacy by leading online handover ceremonies to mark Chinese assistance. Peng also donated protective masks to African countries(Rudolf: 2021b). Aid supplies came from a variety of actors, often considering China’s(or their own) strategic(economic and political) interests vis-à-vis the recipients. Provinces and cities supplied their partner municipalities and regions. Majority Muslim countries(such as Afghanistan, Egypt, Iran, Iraq, Lebanon, and Jordan) received masks from the Xinjiang Au29 In Europe these included the Czech Republic, Ireland, Italy, Lithuania, the Netherlands, Poland, Romania, Serbia, and Spain. 30 The other states maintaining full diplomatic relations with Taiwan are Eswatini, Guatemala, Haiti, Honduras, the Marshall Islands, Nauru, Palau, Paraguay, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, and Tuvalu. 17

FRIEDRICH-EBERT-STIFTUNG – CHINA’S ROLE IN MULTILATERAL ARMS CONTROL English language channels of the Chinese state media reported extensively on Western states hoarding medical supplies juxtaposed with the PRC helping the world. The target audiences for these broadcasts were in BRI countries. According to the narrative, COVID-19 revealed the true faces of the West(selfish and unreliable) and China (a reliable friend of developing states). In addition, Chinese state media pushed the narrative of Western decline, pointing to their inability to curb the spread of the virus and prevent high death tolls. Beijing’s handling was promoted as illustrative of China’s rise as a responsible global power. A new development has been the PRC’s efforts to shape the international narrative about the pandemic on‘Western’ social media platforms such as Twitter and Facebook(Xiao et al.: 2020). Several Chinese embassies and consulates set up Twitter and Facebook profiles after the pandemic began. Social network channels run by Chinese diplomatic missions disseminated daily updates about China’s contributions to combating COVID-19. The scope of the output by far exceeded previous activities. In many cases, tweets revolved around high-level politicians from BRI countries welcoming planes carrying Chinese aid. Social media was also utilized to criticize and ridicule the Western states’ COVID-19 response. For instance, in October 2021, Xinhua News shared a music video via Twitter titled“World’s No. 1 power: USA World’s No. 1#COVID cases& Deaths”(China Xinhua News: 2021). The song is performed in English by Xinhua presenter Dier Wang. In the song, the personalized versions of the US and the PRC engage in a back-and-forth rap battle about their country’s handling of COVID-19. When the US performs, lightning strikes and bats fly in the background, like in a horror movie. The US calls the virus harmless(like the flu) and underlines that the US is only about the“slogan” freedom instead of saving lives. Also,“freedom of AMERICA” is“turning countries into dust”(referencing Vietnam and Afghanistan). When the PRC raps, the singer is dressed as a nurse and acts as the voice of reason. She defends Beijing’s Zero-COVID-19 policy and calls out the US for wanting to blame China for the virus(China Xinhua News: 2021). In another animated mock video titled‘once upon a virus’, the PRC(LEGO doctors) and the US(LEGO version of the statue of liberty) engage in a discussion about COVID-19. The US behaves very childishly and contradicts itself in assessing the threat of the virus. The LEGO statue of liberty claims,“we are correct, even though we contradict ourselves.” The Chinese side replies:“That’s what I love best about you Americans— your consistency”(New China TV: 2020). While the PRC’s mask diplomacy has been criticized in Europe, for many countries, especially those in the global south, China was a reliable partner in a time when traditional aid donors were absent. The activation of a wide range of Chinese actors and uniform external communication efforts by the Chinese government are remarkable achievements, despite many examples of flawed medical equipment. For the first time, Beijing was able to add substance to its BRI rhetoric. In the following months, Beijing benefited from its first-mover advantage. Other states(including those in Europe) increased their aid deliveries to developing countries by the second half of 2020. Nevertheless, those donations failed to generate the same popular recognition as the Chinese deliveries. 31 B) VACCINE DIPLOMACY Chinese vaccines have played a significant role in immunizing the world against the SARS-CoV-2 virus, despite their relatively low efficacy rates. 32 As of August 2022, Chinese manufacturers have sold 1.9 billion doses of COVID-19 vaccines to 68 countries(Bridge: 2022). 33 Sinovac’s‘CoronaVac’ has been the most successful Chinese COVID-19 vaccine, selling over one billion doses to 30 countries. 34 During the same period, Sinopharm sold 468 million doses to 48 countries. 35 CanSino Biologics sold 147 million to eight countries, while Anhui Zhifei Longcom Biopharmaceutical sold 20.5 million doses to Uzbekistan and an undisclosed amount to Malaysia(UNICEF: 2022). 31 According a 2021 survey report by the Yusof Isak Institute, which conducts polling in Southeast Asia, 44.2 percent of the respondents said that the PRC provided the most help to the region during the pandemic. 10.3 percent mentioned the EU(Seah et al.: 2021). Local news agencies of the following countries have reported positively about Chinese medical aid during the beginning of the pandemic: Algeria(Benali: 2020), Argentina(La Nacion: 2020), Bolivia(Luna: 2020), Colombia(Radio Nacional: 2020), DRC(Politico Magazine: 2020). Gabon(Eock: 2020), Jamaica(Williams: 2020), Kenya(The Standard 2020), Malawi(Chikoti: 2020), Nigeria(Nuhu: 2020), Papua-New-Guinea(Post Courier: 2020), Peru(Andina: 2020), Solomon Islands(Sasako: 2020), Seychelles(Karapetyan: 2020), Tunisia(Business News: 2020). The same phenomena may be witnessed with regards to the PRC’s vaccine diplomacy. 32 In 2021, Sinovac produced the most vaccine doses(2.39 B doses), slightly ahead of AstraZeneca(2.3 B). Sinopharm ranked fourth(1.17 B) just behind Moderna(1.46 B)( Duke: 2022). 33 CanSino Bio(4 States): Chile(04/2021), Ecuador(06/2021), Mexico(02/2021), and Pakistan(02/2021). Sinopharm(26 states plus COVAX on 7 May 2021): Argentina(02/2021), Bahrain(12/2020), Bangladesh(04/2021), Bolivia(02/2021), Cambodia(02/2021), Egypt (01/2021), Hungary(01/2021), Indonesia(04/2021), Iran(02/2021), Iraq(01/2021), Jordan(01/2021), Lebanon(03/2021), Malaysia (07/2021), Morocco(01/2021), Nepal(02/2021), Pakistan(01/2021), Peru(01/2021), PRC(12/2020), Senegal(02/2021), Serbia(01/2021), South Africa(02/2022), Sri Lanka,(03/2021), Thailand(03/2021), UAE (12/2020), and Vietnam(03/2021). Sinovac(18 states plus COVAX on 1 June 2021): Azerbaijan(01/2021), Brazil(01/2021), Cambodia (02/2021), Chile(01/2021), Colombia(02/2021), Ecuador(02/2021), Egypt(04/2021), Hong Kong(02/2021), Indonesia(01/2021), Malaysia(02/2021), Mexico(02/2021), Pakistan(04/2021), Philippines (02/2021), Singapore(06/2021), Thailand(02/2021), Turkey(01/2021), Ukraine(03/2021), Uruguay(02/2021), and Zimbabwe(03/2021). Anhui Zhifei Longcom Bio was approved in the PRC(03/2021) and Uzbekistan(03/2021)(Duke: 2022). 34 Albania, Algeria, Azerbaijan, Benin, Botswana, Brazil, Cambodia, Chile, Colombia, Djibouti, Dominican Republic, Ecuador, Egypt, El Salvador, Georgia, Hong Kong, Indonesia, Kazakhstan, Malaysia, Mauritius, Mexico, Moldova, Myanmar, Oman, Pakistan, Peru, Philippines, Singapore, Thailand, Turkey, Ukraine, Uruguay, and Zimbabwe. 35 Angola, Argentina, Armenia, Bahrain, Bangladesh, Belarus, Bolivia, Bosnia, Egypt, Equatorial Guinea, Georgia, Guyana, Hungary, Indonesia, Iran, Iraq, Jordan, Kyrgyzstan, Libya, Malaysia, Mauritius, Mexico, Mongolia, Montenegro, Morocco, Myanmar, Namibia, Nepal, North Macedonia, Pakistan, Paraguay, Peru, Senegal, Serbia, Somalia, South Africa, Sri Lanka, Thailand, Trinidad and Tobago, Turkmenistan, Uganda, UAE, Vietnam, and Zimbabwe(UNICEF: 2022). 18

China’s Health Diplomacy During the COVID-19 Pandemic Table 1 Overview of Vaccines Sold by Chinese Manufacturers Sinovac Doses sold Sinopharm Indonesia 125 million Bangladesh Turkey 100 million COVAX Brazil 100 million Peru Chile 60 million Morocco COVAX 50 million Myanmar Thailand 40.2 million Argentina Egypt 40 million Vietnam The Philippines 35 million Sri Lanka Malaysia 20.4 million Egypt Mexico 20 million Uganda Source: UNICEF(2022) Doses sold 75 million 60 million 49 million 41 million 36 million 34 million 25 million 22 million 20 million 18 million CanSino Bio Brazil Mexico Pakistan Indonesia Ecuador Argentina Malaysia Chile – – Doses sold 60 million 35 million 20.3 million 15 million 6 million 5.4 million 3.5 million 1.8 million – – Notably, millions of doses were sold by private business actors primarily driven by economic considerations rather than an intrinsic desire to further the PRC’s health diplomacy. While very few high-income countries purchased Chinese vaccines, upper-middle-income countries relied extensively on Sinovac’s‘CoronaVac’. Sinopharm has been primarily sold to lower-middle-income countries and, to a lesser degree, low-income countries. In comparison, Biontech’s and Moderna’s vaccines have been primarily sold to high-income countries. Lower-middle-income countries have received the most doses from AstraZeneca(Duke: 2022). Chinese vaccines are not cheap. In an international comparison, Chinese vaccines are generally more expensive than AstraZeneca, the Indian Bharat Biotech BBV152 COVAXIN vaccine, and the Russian Sputnik V. Conversely, they are cheaper than Moderna, the Janssen COVID-19 vaccine, and the Pfizer-BioNTech COVID-19 mRNA vaccine. In Hungary, Sinopharm was sold for 36 USD per dose, among the highest prices for any COVID-19 vaccine. Similarly, the Sinopharm vaccine in Kazakhstan costs over 31 USD. Moreover, the Serum Institute of India’s vaccine was sold at much lower prices to African countries(around 3 USD) than Chinese vaccines(Sinopharm was sold for 5.50 USD per dose). In Bangladesh, the Indian vaccine costs 4 USD; meanwhile, Sinopharm costs 10 USD(UNICEF: 2022). The wide price range may be explained by the fact that many entrepreneurs from the private sector were involved in selling Chinese vaccines abroad. In addition, the delivery of the vaccines was usually not part of the vaccine contracts. According to most contracts, the vaccines had to be picked up in China, causing logistical and financial challenges for several developing countries. Chinese vaccine manufacturers closed manufacturing deals with an array of BRI states. 36 The PRC has framed these contracts as examples of the BRI delivering on its promised technology transfer. As an additional incentive, countries where Chinese vaccine manufacturers conducted Phase III trials received preferential access to the vaccines. AA) BILATERAL LEVEL The PRC has been the second largest donor of COVID-­­ 19 vaccines worldwide, reaching 96 countries. During the first half of 2021, the PRC was the unchallenged champion of vaccine donations. In June 2021, the Biden administration stepped up its commitment(White House: 2021). By August 2022, the PRC had pledged 270 million doses and shipped 144 million, compared to 1.2 billion doses pledged and 600 million shipped by the US(Duke: 2022). Geostrategic considerations guided China’s vaccine donation policy. The main recipients have been neighboring South and Southeast Asian countries, close African partners, and other BRI countries. 36 Anhui Zhifei Longcom Bio entered into a manufacturing agreement with Uzbekistan’s Jurabek Laboratories. CanSino Bio entered into a bulk manufacturing and fill and finish agreement with Pakistan(AJ Pharma), and fill and finish agreements with Russia(NPO Petrovax), Malaysia(Solution Biologics Sdn Bhd), and Mexico(Drugmex). Sinopharm engaged in bulk manufacturing and fill and finish agreements with Hungary and the UAE(Group 42). It engaged in a fill and finish agreement with Bangladesh(Incepta Vaccins Ltd). Meanwhile, the specific nature of manufacturing agreements with Argentina(Sinergium Biotech), Belarus, Egypt(VACSERA), Morocco(Sothema) and Serbia(Group 42) has not been disclosed. Sinovac signed a bulk manufacturing and fill and finish agreement with Indonesia(Bio Farma). It also signed fill and finish agreements with Brazil(Butantan), Egypt (VACSERA), Malaysia(Pharmaniaga), and Ukraine(Lekhim). The exact role of Algeria’s Saidal, who has also entered into a manufacturing arrangement with Sinovac, has not been disclosed(Duke: 2022). 19

FRIEDRICH-EBERT-STIFTUNG – CHINA’S GLOBAL HEALTH DIPLOMACY Map 1 China’s COVID-19 Vaccine Manufacturing Agreements Anhui Zhifei Longcom Bio CanSino Bio Sinopharm Sinovac Hungary Group 42(bulk manufacturing+ fill& finish agreements) Belarus VACSERA (unspecified manufacturing agreement) Russia NPO Petrovax (fill& finish agreement) Uzbekistan Jurabek Laboratories (unspecified manufacturing agreement) Mexico Drugmex (fill& finish agreement) Argentinia Sinergium Biotech (unspecified manufacturing agreement) Source: Duke 2022 Serbia Group 42 (unspecified manufacturing agreement) Morocco Sothema (unspecified manufacturing agreement) Brazil Butantan (fill& finish agreement) Algeria Saidal (unspecified manufacturing agreement) UAE Group 42(bulk manufacturing+ fill& finish agreement) Ukraine Lekhim(fill& finish agreement) Egypt VACSERA (unspecified manufacturing agreement with Sinopharm+ fill& finish agreement with Sinovac) Bangladesh Incepta Vaccins Ltd (fill+ finish agreement) Malaysia Solution Biologics Sdn Bhd Pharmaniaga (fill& finish agreements) Indonesia Bio Farma (bulk manufacturing+ fill& finish agreement) Map 2 Top 20 recipients of Chinese COVID-19 Vaccine Donations Europe Belarus(3.0 Mio.) South America Bolivia(3.5 Mio.) Ecuador(3.2 Mio.) Source: UNICEF 2022 Africa Ethiopia(13.9 Mio.) Uganda(6.0 Mio.) Tanzania(4.5 Mio.) Tunisia(2.6 Mio.) Egypt(2.3 Mio.) Zimbabwe(2.0 Mio) 20 Asia Myanmar(19.2 Mio.) Cambodia(13.4 Mio.) Laos(7.7 Mio.) Bangladesh(7.6 Mio.) Nepal(7.4 Mio.) Vietnam(5.3 Mio.) Philippines(5.0 Mio.) Pakistan(3.2 Mio.) Indonesia(3.2 Mio) Sri Lanka(3.0 Mio.) Afghanistan(2.7 Mio.)

China’s Health Diplomacy During the COVID-19 Pandemic China’s vaccine donations correspond with the‘lighthouse approach’ outlined in the HSR implementation plan. Accordingly, close BRI partners received large vaccine donations to serve as shining examples of BRI cooperation. With the anticipated‘radiation effect’, the PRC aims to convince neighboring states to join the BRI as well. In early 2021 when vaccines were still scarce, strategically relevant BRI states such as Serbia, Hungary, Cambodia, and Zimbabwe had the highest vaccination rates in their respective region due to Chinese supplies(DUKE: 2021). Nicaragua received 1 million doses just after it severed diplomatic ties with Taiwan(BBC: 2021). El Salvador, which had also just cut its diplomatic relations with Taiwan, had the highest vaccination rate in Central America during the first half of 2021 (DUKE: 2021). Bolivia, which borders Paraguay, also received an extraordinary 3.5 million doses as a donation(UNICEF: 2022). In other cases, such as Chile, government officials were very quick and efficient in reaching out to the Chinese government and negotiating vaccine contracts. In this context, the interest-driven behavior of the recipient state rather than China’s health diplomacy led to high vaccination rates. Handover ceremonies featuring the Ministers of Health or Foreign Affairs from the recipient country created an exaggerated image of Beijing’s generosity. Chinese officials usually use the verb“to provide” when referencing Chinese vaccines sold, donated, or pledged(Xinhua: 2021a). While vaccine contracts are often accompanied by donations, they amount to about 10 percent of the sold quantity. By August 2022, 90 percent of the vaccines‘provided’ by China were sold(Bridge: 2022). From a Chinese health diplomacy perspective, whether the vaccines were donated or sold is irrelevant. In the case of Serbia, the EU paid for a significant share of Chinese vaccines bound to Belgrade. Nevertheless, according to a 2021 poll by the Serbian Institute of European Affairs, 56.4 percent of the Serbian respondents viewed the PRC as the biggest supporter of Serbia during the pandemic, while only 17 percent named the EU(Institut za evropske poslove: 2021). In efforts to shape the international COVID-19 narrative, Chinese state media also joined efforts to discredit Western vaccines by spreading fake news about their alleged side effects. For instance, Chinese media spread fake news about the side effects of the BioNTech/ Pfizer vaccine when it became evident that the Chinese vaccines had a comparatively low efficacy rate(Emmott: 2021). BB) REGIONAL COOPERATION MECHANISMS While the PRC focused on bilateral aid during the first months of the pandemic, starting in mid-2020, Beijing shifted towards using regional China+x formats, linking vaccine promises with the prospect of post-pandemic economic support. In return, recipient regions declared their support for China’s key policy positions(such as on Hong Kong, Xinjiang, and Taiwan). (1) FOCAC The June 2020‘Extraordinary China-Africa Summit on Solidarity against COVID’ marks the starting point of China’s vaccine diplomacy within regional cooperation mechanisms(FOCAC: 2020a). The Chinese leadership promised preferential vaccine deliveries, debt cancellation, and economic investment after the pandemic(e.g., investments in the digital economy, boosting renewable energies, and expanding the 5-G network). In return, the African side expressed its support for China’s position on Taiwan and the controversial Hong Kong National Security Law(MOFA: 2020e). In November 2021, the PRC issued its second white paper on China-Africa cooperation titled‘China and Africa in the New Era: A Partnership of Equals’. Insinuating that Western states have not treated Africa as an equal, it stresses that the PRC has proven itself to be a reliable partner during the pandemic. The document outlines the future of health cooperation between China and Africa under the BRI umbrella. It puts a particular emphasis on capacity building in Africa, comprehensive aid programs, and setting incentives for Chinese pharmaceutical companies to invest in the African market(State Council Information Office: 2021a). 37 In November 2021, the participants of the 8th FOCAC Meeting reiterated the central role of the BRI in China-Africa cooperation as well as the importance of health cooperation in the fight against COVID-19. The participants adopted the Dakar Declaration, the Dakar Action Plan 2022–2024, the China-Africa Cooperation Vision 2035, 38 and the Declaration on China-Africa Cooperation on Combatting Climate Change. The Dakar Action Plan dedicates a comprehensive chapter to health cooperation that includes a pledge by the PRC to supply Africa with 1 billion COVID-19 37 According to the document, China will:(1) Strengthen communications with Africa on medical and health policies, and support Africa’s efforts to strengthen its public health and disease control and prevention system;(2) participate in the preparation for the establishment of an African Center for Disease Control and Prevention;(3) assist African countries in improving the level of laboratory technology and deliver training to medical personnel, with a focus on assisting in prevention and control of non-contagious chronic diseases, malaria and other insect-borne infectious diseases, cholera, Ebola, AIDS, and tuberculosis; (4) support the efforts of African countries to enhance their core capacity in border health quarantine, build infectious diseases monitoring stations, provide medical services to women and children;(5) support African countries in health infrastructure development;(6) send medical teams to African countries, launch cooperation between Chinese and African hospitals, and enhance exchanges and cooperation between modern and traditional medicine with a focus on improving local medical services;(7) promote the“Brightness Action” campaign in providing free cataract surgery and other short-term free medical services;(8) increase paired exchanges and cooperation between Chinese and African medical institutions and drug administration agencies; and(9) encourage Chinese pharmaceutical enterprises to invest in Africa in a bid to lower the cost of medicines in Africa and increase the affordability of medical and pharmaceutical products in Africa. 38 The China-Africa Cooperation Vision 2035 states that China“supports African health policies and helps it strengthen the prevention and control system of communicable diseases, improve medical research, vigorously develop traditional medicine, and improve medicine accessibility and affordability. It also supports Africa in reducing the prevalence of HIV/AIDS, tuberculosis, malaria, and other communicable diseases” (FOCAC: 2021a). 21

FRIEDRICH-EBERT-STIFTUNG – CHINA’S ROLE IN MULTILATERAL ARMS CONTROL vaccines(600 million doses as donations and 400 million doses through joint production by Chinese companies and relevant African countries). 39 The Dakar Declaration also refers extensively to health cooperation(MOFA: 2021c). Notably, technology transfer to Africa and health industry cooperation have a more prominent role in this document compared to previous declarations. In particular, the parties noted efforts by Chinese companies in conducting joint vaccine production in African countries and expressed their support for the waiver of intellectual property rights of COVID-19 vaccines. Also, the documents support China’s political positions on the origin of the virus, Taiwan, Hong Kong, and Xinjiang. 40 (2) ASEAN Most of the vaccines donated by the PRC went to ASEAN states, as Southeast Asia constitutes the priority region for the PRC’s health diplomacy. Regular health-related exchanges took place within the China+ASEAN and the ASEAN+3 setting. 41 The PRC also utilized regular ASEAN-­ China meetings, such as the annual ASEAN-China Expo, to promise vaccine donations to ASEAN states. During the pandemic, health cooperation became an essential part of China-ASEAN cooperation. For instance, Xi Jinping’s five proposals for the future of the relationship between China and ASEAN presented at the“Special Summit to Commemorate the 30th Anniversary of China-ASEAN Dialogue Relations” feature health cooperation more prominently than earlier comparable documents(ASEAN-China: 2021b). 42 Beijing explicitly linked Chinese-ASEAN health cooperation with post-pandemic economic recovery programs under the BRI framework. This is illustrated by the Joint Statement on Cooperation in Support of the ASEAN Recovery Framework from October 26, 2021(ASEAN-China: 2021c). (3) China-CEEC Forum 39 The document also refers to the following aspects of Chinese African health cooperation:(1) An expression of gratitude for Chinese aid during the pandemic;(2) an announcement about strengthening health exchanges(e.g., via the Ministerial Forum on China-Africa Health Cooperation);(3) a pledge by the PRC to scale up medical assistance to African countries(e.g., building national public health institutions);(4) text related to capacity building of local drug production, and that China will support the establishment of the African Medicines Agency; (5) a promise that China will complete  the construction of the Africa CDC headquarters and build more China-Africa Friendship Hospitals. China supports African countries in improving health services and hospital management;(6) China will continue to carry out anti-malaria projects in Africa and assist Africa in fighting communicable(HIV, TB, malaria, and schistosomiasis) and non-communicable(cancer and cardiovascular diseases) diseases. China will help Africa reduce maternal and infant mortality rates;(7) China will use the Belt and Road Demonstration and Training Platform on Health Cooperation to share its best practices and appropriate technologies in such areas as maternal and infant health, public health, hospital management, and screening exams through online and offline exchanges and training to support African countries to enhance the service capacity of their health systems, make basic health services more accessible, and promote the realization of full health coverage of the African people;(8) the two sides will enhance cooperation on drug supervision;(9) China encourages and supports Chinese enterprises’ medical and pharmaceutical cooperation with Africa and supports cooperation related to traditional medicine; (10) China will send 1,500 medical personnel and public health experts to Africa for the treatment of cataracts and heart disease and build a training platform for China-Africa health cooperation(MOFA: 2021b). 40“African members of FOCAC reaffirm their commitment to the oneChina principle,  their support for China’s reunification and China’s efforts in resolving territorial and maritime disputes peacefully through friendly consultation and negotiation. Hong Kong, Xinjiang, and Tibet related issues are China’s internal affairs, as observed in  the international law and the non-interference principle[…] We firmly oppose any attempt to politicize, label or stigmatize the virus”(MOFA: 2021c). The Dakar Action Plan(2022–2024) states:“The two sides firmly oppose politicizing origins-tracing or using the issue as a tool to stigmatize others.”(MOFA: 2021c) 41 On 3 February 2020(and again on 7 April 2020) a Special Video Conference of the ASEAN+3 Senior Officials Meeting on Health Development took place to discuss the spread of the SARS-CoV-2 and ways to cooperate in the fight against the virus. On 20 February 2020, a Special ASEAN-China Foreign Ministers’ Meeting on Coronavirus Disease took place in Vientiane, Laos(ASEAN+3: 2020a). On 14 April 2020, the Joint Statement of the Special ASEAN+3 Summit on Coronavirus Disease 2019(COVID-19) was issued, in which the parties expressed their willingness to keep markets open and to increase health cooperation(E.g., establishing an early warning system for epidemic diseases; The 17+1 forum 43 did not play a relevant role in China’s vaccine diplomacy. Since the start of the pandemic, the China-CEEC Forum has lost momentum due to political setting up reserves of essential medical supplies; strengthening scientific cooperation in epidemiological research; ensure adequate financing through the COVID-19 ASEAN Response Fund for public health emergencies)(ASEAN+3: 2020b). The“ASEAN-China Vaccine Friend Program” held regular exchanges(e.g., in October 2020, March 2021 and July 2021)(ASEAN-China: 2021a). On 15 May 2022, the 8th China-ASEAN Health Ministers Meeting took place. In a joint statement the parties proposed to focus health cooperation by(1) focusing on the One Health approach;(2) strengthening capacities and capabilities towards potential threats caused by the interface of humans, animals, and the environment;(3) optimizing the Program on Public Health Emergency Preparedness Capacity(PROMPT) and the ASEAN-China Health Forum;(4) implementing technical exchange and training programs on maternal and child health and medical services;(5) exploring health management cooperation;(6) enhancing the cooperation in the prevention and containment of non-communicable and communicable diseases;(7) exploring exchanges and cooperation in traditional medicine with regards to quality control, clinical diagnosis, treatment, and management of noncommunicable diseases such as diabetes;(8) strengthening China-ASEAN collaboration in building more robust and resilient regional health systems in ASEAN(ASEAN-China: 2022a). The Joint statement of the 9th ASEAN+ 3 Health Ministers Meeting, called for optimizing existing ASEAN+ 3 Health mechanisms(E.g., the ASEAN Plus Three Senior Officials Meeting for Health Development (APT SOMHD); ASEAN Emergency Operations Centre(ASEAN EOC) Network for public health emergencies; ASEAN Plus Three Field Epidemiology Training Network(ASEAN+3 FETN); ASEAN Plus Three Universal Health Coverage(UHC) Network ASEAN-China(2022b). 42 The five proposals are the following:(1) Building a peaceful home together.(2) Building a safe and secure home together, which includes the proposal of building a“health shield” for the region. China proposed to donate an additional 150 million doses of COVID-19 vaccines to ASEAN countries, contribute an additional 5 million U.S. dollars to the COVID-19 ASEAN Response Fund, step up joint vaccine production and technology transfer, and collaborate on research and development of essential medicines. China will also support ASEAN countries in strengthening primary-level public health systems.(3) Building a prosperous  home together. China is ready to  provide ASEAN with another 1.5 billion U.S. dollars of development assistance in  the next three years to support ASEAN countries’ fight against COVID-19 and economic recovery.(4) Building a beautiful  home together.(5) Building an amicable home together. 43 Greece became the 17th member in April 2019. 22

China’s Health Diplomacy During the COVID-19 Pandemic tensions between the PRC and some Eastern European States. Lithuania left the forum in May 2021(Lau: 2021). In August 2022, Estonia and Latvia announced their withdrawal(Bermingham/ Delaney: 2022). The collapse of the Chinese-CEEC Forum is noteworthy since it had proven itself to be very successful until the emergence of China’s so-called ‘wolf-warrior diplomacy’. Wolf-warrior diplomacy describes an aggressive style of coercive diplomacy adopted by several Chinese diplomats. It is confrontational and combative, with its proponents loudly denouncing any perceived criticism of the Chinese government and its policies on social media. During the height of the pandemic, several Chinese diplomats in Europe engaged in this practice in France, Slovakia, Poland, the Czech Republic, and Latvia. The China-CEEC Health Ministers’ Forum lost momentum as well. In 2020, only two webinars were held at the vice-ministerial level, a downgrade from previous forums held at the ministerial level. The 2021 Cooperation between China and Central and Eastern European Countries Beijing List of Activities merely refers to a vague intention to conduct“Special China-CEEC Health Ministers’ and Health Experts’ Meetings”, depending on the development of the pandemic(MOFA: 2021a). (4) China-Arab States Cooperation Forum Sino-Arab health cooperation flourished during the pandemic. Similar to the FOCAC and China+ASEAN format, Beijing communicated that COVID-19 had brought the PRC and Arab states closer together within the‘Community of Shared Future of Mankind’. In July 2020, during the 9th Ministerial Conference of the China-Arab States Cooperation Forum, Chinese Foreign Minister Wang Yi proposed to provide Arab states with medical equipment, share experience, send expert teams, and cooperate on vaccine research and development. In addition, Wang conveyed the PRC’s appreciation that Arab states support Beijing’s position on “Hong Kong, Xinjiang, Taiwan, and other matters that are China’s internal affairs”(MOFA: 2020c). Notably, while the human rights situation in Xinjiang has become a hotly debated issue in Europe and the US, Arab states have constantly supported the PRC’s Xinjiang policy, for instance, within the UNHRC and the United Nations General Assembly(UNGA)(Putz: 2020). Sino-Arab health cooperation focused on vaccine cooperation and post-COVID-19 economic development. In September 2020, the PRC and the Arab League held a health experts video conference to discuss economic policies under COVID-19 conditions(MOFA: 2020d). In March 2021, Wang Yi congratulated the Arab states for their“pioneering spirit” since they were among the first to cooperate with China on COVID-19 vaccine development (MOFA: 2021a). 44 In August 2021, the China-Arab States 44 Sinopharm and the Abu Dhabi-based artificial intelligence company G42 had been conducting phase III trials in the Middle East in 2020. In 2021, the parties formed a joint venture, turning the UAE into the Expo was hosted in Yinchuan, focusing on post-COVID-19 economic recovery, Sino-Arab public health cooperation, and cooperation in vaccine production(China-Arab States: 2021b). (5) hina–Community of Latin American and Caribbean States(CELAC) Forum China-CELAC health cooperation represents a new development, echoing Beijing’s geopolitical focus on the region. Even before the pandemic, the PRC had been expanding the BRI to Latin America and the Caribbean. When the pandemic hit, the PRC accelerated those efforts, becoming a primary provider of masks and testing equipment in the‘backyard’ of the US. In July 2020, during a Special Video Conference of Foreign Ministers on COVID-19, Beijing offered Latin American and Caribbean countries a 1 billion USD loan to purchase COVID-19 vaccines. Wang Yi proposed to expand the HSR to the region, offering public health support to Latin American and Caribbean states and post-COVID-19 investment(MOFA: 2020a). 45 Health cooperation also featured prominently during the Third Ministers’ Meeting of the China-CELAC Forum on December 3rd, 2021. 46 Notably, while Latin America ranks third in terms of Chinese vaccine donations(after Asia and Africa), it is the region to which Beijing has sold the second most vaccines— more than three times the amount it has sold to Europe and twice the amount it has sold to Africa. 47 first country to produce Sinopharm overseas. The deal enabled the UAE to become the nation in the region to set up a coronavirus vaccine production facility(Westall/ Nair/ Elbahrawy: 2021). 45 In particular, he proposed a number of concrete measures, beginning with(1) deepening cooperation in the fight against COVID-19(e.g., sending more Chinese medical personnel to the region and intensifying cooperation on vaccine research and development). Wang underlined that the Special Loan Program for China-Latin America Infrastructure Project will be used to support public health projects. The subsequent measures are as follows:(2) Protecting economic growth (e.g., via Chinese investment and trade cooperation) while containing the virus;(3) advancing Belt and Road cooperation, in the areas of public health(China-LAC health silk road), digital economy, and infrastructure;(4) putting public health on the agenda of CELAC cooperation(in addition to cooperation in agriculture, food security, poverty, disaster reduction, digital economy, and clean energy); and finally,(5) enhancing coordination on global governance to safeguard the interests of developing countries. 46 According to the China-CELAC Joint Action Plan for Cooperation in Key Areas(2022–2024) the health cooperation is envisioned as follows:(1) More dialogue on public health policies;(2) cooperation in studying COVID-19 variants, joint vaccine production, research, and development. The Chinese side offers anti-epidemic assistance;(3) cooperation between medical centers(exchange of best practices and experience in clinical medicine, disease prevention and control, prevention and treatment of communicable diseases, response to health emergencies, biomedicine, and drug research, development, and regulation);(4) intensified exchanges and cooperation in traditional medicine(China-CELAC Forum on Traditional Medicine);(5) exchanges and training of administrative and professional health personnel;(6) Special China-LAC Anti-epidemic Loans to support the construction of public health infrastructure; and(7) free cataract surgery under the “Brightness Action” project(MOFA: 2020b). 47 By August 2022, the PRC had sold 938 million doses to Asia and the Pacific Islands region, 397 million doses to Latin America, 186 million doses to Africa, and 124 million doses to Europe(Bridge Beijing: 2022). 23

FRIEDRICH-EBERT-STIFTUNG – CHINA’S ROLE IN MULTILATERAL ARMS CONTROL (6) China-Pacific Island Forum CC) MULTILATERAL LEVEL Geopolitical interests also guided Beijing’s outreach efforts to the South Pacific. The PRC further institutionalized its engagement in the region within the framework of the China-Pacific Island Forum, focusing on Chinese deliveries of medical supplies, cash donations, and post-COVID-19 economic recovery perspectives. As early as March 10, 2020, the day before the WHO declared the COVID-19 pandemic, health experts from China and Pacific Island Countries held a video conference on COVID-19(MOFA: 2020d). During the event, the PRC expressed its willingness to join hands with Pacific Island countries to step up information sharing and deepen cooperation on epidemic prevention. In practice, the PRC provided South Pacific states primarily with medical supplies, in particular, vaccine donations to Vanuatu and the Solomon Islands, as well as cash donations to Fiji, Tonga, and the Solomon Islands. Public health cooperation remains of secondary importance within the China-Pacific Island Forum. In May 2022, the Second Foreign Ministers’ Meeting with Pacific Island Countries identified poverty reduction, climate change, disaster prevention, and agriculture as priority cooperation areas(MOFA: 2022a). Also, China’s Position Paper on Mutual Respect and Common Development with Pacific Island Countries does not list public health cooperation as a priority issue. Instead, it briefly references“cooperation between medical institutions” and China’s pledge to“provide anti-COVID-19 assistance to Pacific Island Countries” while paying more attention to the above-mentioned cooperation areas(MOFA: 2022b). (7) Evaluation The pandemic provided Beijing the opportunity to extend regional health cooperation mechanisms to Latin America, the Middle East, and the South Pacific. These regions had already been gaining importance within the BRI. The pandemic served as a catalyst and accelerator for Beijing’s outreach efforts. Within those forums, the PRC has been attempting to connect health cooperation with the BRI promises of development and prosperity. The PRC also utilized China+x cooperation platforms to receive endorsements of its political positions. The cooperation forums with African, Latin American, Caribbean, and Arab states produced joint statements supporting Beijing’s Hong Kong and Xinjiang policies, as well as China’s position regarding the origin of the SARS-CoV-2 virus and Beijing’s“Zero-COVID” approach. The PRC continued to promote the‘responsible major power’ narrative within multilateral institutions while conducting most of its COVID-19 diplomacy at the bilateral and regional levels. Beijing also used multilateral platforms to criticize the US government for acting unilaterally and trying to manipulate the WHO(especially during the Trump administration). China also attempted and failed to obtain discourse power over the origin of the virus debate. At the same time, Beijing repeatedly proved capable of mobilizing majorities within the UNGA to endorse the PRC’s policy positions. (1) WHO The PRC and the WHO have both been criticized for acting too slowly at the beginning of the COVID-19 outbreak. While the WHO publicly praised the PRC for its response, there is evidence that local officials ignored early warnings. In December 2019, Wuhan police“punished” eight people for“publishing or forwarding false information on the internet without verification”(BBC: 2019). Moreover, the WHO did not consider directly conveyed warnings from Taiwanese health officials about human-to-human transmission(Godement: 2020). 48 When the WHO declared a public health emergency on January 30, 2022, there were already 7,818 confirmed cases within China and 82 cases in 18 additional countries(Joseph: 2020). Praising Beijing’s COVID-19 response seems to have been a tactical error by the WHO Director. Public praise has reportedly been the condition for Beijing to approve the WHO’s first COVID-19 mission to China the week of February 16–24, 2020(Brown: 2020). WHO Director Ghebreyesus defended his applause of Beijing’s COVID-19 response by explaining the necessity of obtaining PRC cooperation. It is questionable whether the WHO received sufficient information and cooperation in return. On March 11, 2020, when the WHO declared the pandemic, 114 countries had already reported 118,000 cases and 4,291 deaths(Godement: 2020). When the PRC controlled the spread of the virus, Beijing started to use UN platforms to portray itself as a responsible great power. Meanwhile, the Trump administration withdrew from the multilateral level. On May 18, 2020, in a speech to the WHO in Geneva, President Xi called for solidarity among states and announced that China would be providing the world with an inexpensive vaccine as a“global public good”. Xi also promised the WHO USD 2 billion for the fight against the SARS-CoV-2 viChina-CEEC cooperation deteriorated and is now on the brink of collapse. Beijing was unable to build on the foundation it had paved between 2015 and 2019. The 16/7+1 health cooperation format exemplifies that dialogue platforms do not necessarily equal meaningful cooperation. 48 China informed the WHO about the new virus on December 31, 2019. A week later on January 7, Chinese scientists published the COVID-19 genome to help with case identification outside China(Bouey: 2021). While the WHO suspected by January 14 that human-to-human transmission was taking place, there was no confirmed evidence presented by China until January 23, 2022. 24

China’s Health Diplomacy During the COVID-19 Pandemic rus. Less than two weeks later, on May 29, President Trump declared that the US would terminate its relationship with the WHO(Chorev: 2020). regional China+x(health) forums endorse China’s political positions. Despite rising tensions between Western states and the PRC, Beijing does not appear to be isolated. Despite its outspoken support for the WHO, the PRC primarily acted bilaterally. In October 2020, Beijing joined the vaccine platform COVAX, which aims to ensure a fair distribution of vaccines. While the Chinese leadership publicly endorsed the“importance of the WHO in combatting the pandemic”, 49 the share of Chinese vaccines at COVAX remained low(around 5 percent). The PRC has pledged USD 100 million doses to Gavi COVAX AMC(GAVI: 2022). This comes to about one-fortieth of the US’s contributions. While Germany has donated 112.2 million doses to 43 countries through COVAX, the PRC primarily relied on bilateral channels for its donations(UNICEF: 2022). While the PRC has indeed gained influence within the UN system, the WHO should not be viewed as a puppet of the Chinese Communist Party. The‘origin of the virus’ debate, 50 which has been uncomfortable for the Chinese leadership, underlines that the WHO continues to pursue its interests. In January 2021, the second WHO mission to China concluded that the lab accident hypothesis was “extremely unlikely”(WHO: 2021, p. 119). In July 2021, the WHO announced a further investigation into the virus’ origin. In June 2022, the first report by the WHO’s Scientific Advisory Group for the Origins of Novel Pathogens suggested a further investigation into the COVID-19‘lab leak’ theory(WHO: 2022b). This report was criticized by Chinese government officials, who called it“political manipulation” (NBC: 2022). Also, in May 2022, the WHO Director called on the PRC to rethink its zero-COVID-19 policy given the more transmissible omicron variant. His comments were censored in China, and the Chinese Foreign Ministry criticized the remarks as“irresponsible”(Kuo: 2022). (2) International Discourse Power Since the pandemic started, the PRC has repeatedly proven capable of mobilizing majorities at the UN to endorse its position on controversial topics. For instance, in October 2020, Beijing gathered more states in the general debate of the 3rd UN Committee in support of its Hong Kong policy than Western states. Also, in October 2020, the UNGA reelected the PRC to the UNHRC, despite its Xinjiang policy(Rudolf: 2020). While it is not possible to determine the causality between medical aid and support for the PRC, it is remarkable that several joint statements of 49 For example, the November 2021 Dakar Declaration states:“We reaffirm our full support to the WHO for its leading and coordinating role in COVID-19 response and the wider global health agenda. We firmly oppose any attempt to politicize, label or stigmatize the virus”(MOFA: 2021c). The Joint Statement of the 2021 CELAC Meeting states:“The two sides need to support WHO’s due role in global COVID-19 response and firmly reject any politicization or stigmatization.”(CELAC: 2021). 50 The PRC has dismissed claims that SARS-CoV-2 originated in a Wuhan lab, while former US President Trump pushed for the lab theory. (3) Evaluation The PRC failed to take advantage of the US retreating from the WHO during the Trump years. For instance, it refrained from significantly increasing its voluntary WHO contributions to fill the vacuum left by the US at the beginning of the pandemic. According to the WHO’s 2022–2023 budget, the PRC ranks 22nd(behind Bangladesh and Guinea-Bissau); its contributions account for 0.35 percent of the WHO budget. The US contributed 15.05 percent, the European Commission 8.92 percent, and Germany 8.5 percent (WHO Budget 2022–2023: 2022). When Joe Biden assumed office as President of the US, he quickly reestablished relations with the WHO, rebuilding trust in the US(e.g., through its support for COVAX). Beijing might eventually step up its engagement within the WHO. While the PRC’s involvement remains overshadowed by its pro-WHO rhetoric, the Trump years highlighted that the US has become a less reliable partner at the multilateral level. It seems plausible that the US-American people elect another President who does not believe in multilateralism. If this scenario were to become a reality, Beijing would most likely be better prepared and determined to fill the vacuum within the WHO. C) VALUATING CHINA’S COVID-19 DIPLOMACY The BRI has been able to adapt to and accommodate the COVID-19 pandemic. The pandemic revealed the inherent flexibility of the initiative, as illustrated by the elevation of the HSR from a marginal aspect to a key subject of the BRI. With strong political will and a logistically advantageous starting position, China was able to activate BRI networks around the globe, even before the WHO had declared a pandemic. The necessary infrastructure was available from other BRI components. BRI rail links and the socalled Air Silk Road(with hubs in Luxembourg and Liège) were repurposed as supply lines for aid goods(Rudolf: 2021b). Beijing appears to lack much of this flexibility and ingenuity in its response to rising domestic case counts in 2022. Nevertheless, HSR outreach efforts continue despite the domestic struggle to contain the spread of the virus. In addition, the HSR narrative has shifted back to reports about foreigners volunteering in China to fight against the spread of COVID-19(Xinhua: 2022a). The analysis of the eight HSR cooperation areas in the context of the COVID-19 pandemic indicates that this crisis has served as an accelerator for Chinese health cooperation. The PRC has been most active in providing Health Emergency and Emergency Medical Assistance. At the beginning of the pandemic, the PRC acted as a‘first-re25

FRIEDRICH-EBERT-STIFTUNG – CHINA’S ROLE IN MULTILATERAL ARMS CONTROL sponder’, sending medical supplies all over the globe. As demonstrated above, the PRC has been very active in establishing and deepening regional Health Cooperation Mechanisms(expanding them to Latin America, the South Pacific, and the Middle East). It is important to point out that dialogue does not equal cooperation. The collapse of the 16/17+1 format underlines this. While the PRC was unable to prevent the spread of COVID-19, it has significantly increased its outreach efforts in the HSR cooperation area of Prevention and Control of Infectious Diseases. The PRC has also been very active in Health Development Assistance, sending medical teams to over 42 countries during the pandemic. COVID-19 has not stopped the promotion of TCM across the globe. Furthermore, the pandemic has catalyzed the PRC’s efforts to develop its health industry( Development of the Health Industry). Sinovac and Sinopharm have emerged as globally recognized pharmaceutical brands. Chinese vaccines were also approved by the WHO and distributed via COVAX. Besides, additional Chinese vaccines have recently been approved in third countries, including a Chinese HVP vaccine in Morocco(Huichen: 2022). While the PRC has not yet approved foreign COVID-19 vaccines, Beijing has entered into cooperation agreements with AstraZeneca and Pfizer, indicating a trend toward partial opening-up of its pharmaceutical market in return for technology transfers (Xinhua: 2022b). Regarding the HSR cooperation areas that are oriented toward the long-term(specifically, Capacity Building and Talent Training and Health System and Health Policy), it is too early to determine whether the PRC will be able to achieve its self-set goals. Whether or not the PRC will serve as a role model for other states really depends on how, when, and at what cost Beijing will exit from the COVID-19 modus. The Zero-COVID-19 strategy is not serving as a model to the world. Upholding the Zero-COVID-19 policy has even started to tarnish Beijing’s reputation as a forward-looking and rational crisis manager. It may cause significant economic damage and appears unsustainable. The success of the PRC’s COVID-19 diplomacy has been moderate. During the pandemic, the geopolitical environment has become more difficult for the PRC to maneuver in. The conflict of political systems with the US has increased significantly, and European states have become more critical of China. Polling data by the Pew Research Center indicate that Beijing’s health efforts have not resulted in a more positive attitude towards the PRC in Europe, North America, Australia, Japan, and South Korea(Silver/ Devlin/ Huang: 2020). According to a survey by the Singaporean Yusof Isak Institute, people from ASEAN states recognize the PRC as the largest source of aid in the fight against COVID-19. Nevertheless, Beijing’s influence in Southeast Asia continues to be viewed unfavorably(Seah et al.: 2021). Opinion polls conducted in the Middle East and Africa point in a different direction. The PRC is generally viewed positively, and favorability rates have increased moderately since the onset of the pandemic. 51 According to polls conducted in Latin America, 51 In the Middle East and North Africa(MENA region), the PRC is viewed more positively than the US, e.g., in Iraq, Tunisia, Sudan, and Mauritania(Robbins: 2022). Also, between 2020 and 2021, the PRC’s popular35 percent of the respondents had a positive opinion of the PRC, 28 percent were neutral, and 32 percent had a negative view(American University: 2022). In order to assess the impact of the PRC’s health diplomacy, it is important to differentiate between public opinion polls and actions taken by state representatives. The wording of joint statements and voting behavior in multilateral settings indicate that the PRC has been successful in gathering support among developing states in multilateral settings(notably, the PRC has gathered more support for its positions on Xinjiang, Hong Kong, and Taiwan), despite the strong favorability of the US or Europe among the general population. Beijing has maneuvered itself into a situation that might undermine the initial success of its health diplomacy. As the world reopens, the PRC remains caught in the COVID-19 chokehold. The narrative of‘western decline’ seems to prevent the PRC from approving a Western booster vaccine that could enable Beijing to terminate its Zero-­ COVID-19 policy. Western mRNA vaccine manufacturers appear also unwilling to share their technology to enter Chinese market(FT, 2022). Whether the PRC will find an attractive way out of the COVID-19 modus could be the Achilles heel of the PRC’s health diplomacy. Moreover, other Asian states have started to lift their strict COVID-19 measures. The pressure for the PRC to follow suit is likely to increase further, especially after the completion of the 20th National Congress of the Chinese Communist Party, which is scheduled for October 16, 2022. In the long term, Beijing may still benefit from its COVID-19 diplomacy. Unless the PRC’s“Zero-COVID” policy causes severe turmoil for its domestic economy, with global repercussions, the narrative of China as the‘first responder’ and‘responsible great power’ may remain alive in recipient states. China’s COVID-19 aid may become the connecting narrative with developing states in the future. From the perspective of those states, it might be irrelevant if the PRC took an additional six, 12, or 18 months to transition out of its COVID-19 modus, especially if Beijing succeeds in delivering on its post-COVID-19 economic relief promise. ity increased from 55 percent to 65 percent in Morocco(Arab Barometer – Morocco: 2021), from 54 percent to 59 percent in Tunisia(Arab Barometer – Tunisia: 2021), from 51% to 56% in Iraq(Arab Barometer – Iraq 2021), and from 60 percent to 65 percent in Algeria(Arab Barometer – Algeria: 2021). According to the AfroBarometer, 63 percent of Africans say the economic and political influence of China in their country is “somewhat positive” or“very positive,” while only about one in seven (14%) consider it negative(Sanny/Selormey: 2021). The data does not indicate a significant impact of the PRC’s health diplomacy. 26

Recommendations 4 RECOMMENDATIONS Since the launch of the BRI in 2013, the PRC has shifted to– Acknowledge that support from third states is cruwards a more assertive foreign policy approach. Beijing is re- cial in the pursuit to uphold and reform the intermarkably transparent about its aim to reform the interna- national rules-based order: The PRC targets third tional order. It views third states as its main allies in this procountries for this precise reason, offering itself as the cess and health diplomacy as an essential tool to build internatural partner of the developing world. Health diplomanational coalitions. cy plays an essential part in Beijing’s international coalition-building efforts. Based on the above analysis, political decision-makers in Berlin and Brussels are advised to take the following recom– Act strategic: The PRC views health cooperation in stramendations into consideration. These recommendations are tegic terms(‘to gain soft power’). Accordingly, deciparticularly relevant given that Germany is currently formusion-makers in Europe are advised to regard health cooplating its national security and China strategies, while the eration in strategic and geopolitical terms as well. European Commission is in the process of finalizing the EU Global Gateway Strategy. – Improve visibility and marketing: Over decades, Europe has been a reliable partner on public health mat– Draw analogies: The PRC’s health diplomacy illustrates ters for(developing) third states. Thus, health diplomathe functionality of the BRI and the PRC’s approach to cy could be a high-yield, low-risk endeavor for Berlin foreign policy. The design and implementation of the and Brussels. The EU and EU member states could imHSR have been very similar to other BRI cooperation areprove the visibility of their efforts. NGO and state repreas(common features include a degree of flexibility, a sentatives from Serbia, the Philippines, Chile, and Egypt multi-level approach, and reliance on pilot projects). It highlighted to the author that aid deliveries from China would be a miscalculation to write off the BRI. As long as(and the US) were professionally marketed. Meanwhile, the constitution of the Chinese Communist Party refer- there was little recollection of European aid. The arguences the initiative, it will remain the key foreign policy ment that the PRC has delivered fewer supplies than agenda item of the Chinese leadership. The BRI is here to Europe is insufficient. Most recipients are unaware and stay, not as a mere infrastructure investment scheme but uninterested in whether Europe has been donating via rather as a comprehensive vision for the establishment of multilateral mechanisms. What matters appears to be China-centered networks across a multitude of policy ar- good communication and marketing skills. This is exemeas, including health. plified in the example in Serbia, where medical supplies purchased by the EU but manufactured in China arrived – Recognize the significance of Chinese aid for recipin Belgrade, and the subsequent local headlines were ient countries: Beijing’s measures during the first not about the EU paying for the deliveries but about the months of the pandemic constitute a remarkable logistiPRC sending them. Therefore, significant resources cal achievement. No other state, including traditional doshould be put into social media outreach efforts in renor countries, was willing or able to offer similar support cipient countries to counter the PRC’s monopoly over to developing countries. While the PRC did not act out of the public narrative. The European Commission and altruistic motives, cynicism is misplaced when assessing embassies in the recipient countries could hire social Beijing’s COVID-19 diplomacy. media experts with knowledge of the domestic digital landscape to advertise and inform about European – Acknowledge the PRC’s willingness and capability health donations. Additionally, to raise more public to participate in the international race to win over awareness, ambassadors from EU member states(and the hearts and minds of third states: This is the esthe EU itself) could join forces by writing joint articles in sence of the HSR. It would also be unwise to underestilocal newspapers to highlight European health aid in mate the PRC’s ambition and ability to learn from its misthe recipient country. Finally, officials from recipient takes(e.g., its lack of cultural sensibility) and improve its states could be invited to attend handing-over ceremohealth diplomacy. nies for European donations. 27

FRIEDRICH-EBERT-STIFTUNG – CHINA’S ROLE IN MULTILATERAL ARMS CONTROL – Focus on a positive message: Berlin and Brussels are – Apply a multi-level approach: In addition to multilatadvised to promote their ability to exit the COVID-19 moeral health cooperation, it is worth considering exploring dus. A positive message of strength appears more prombilateral and regional channels. At the bilateral level, this ising than criticizing the PRC. While Beijing has been could include identifying fulcrum countries with whom pushing the narrative of Western decline, European decihealth cooperation has already developed fruitfully or sion-makers should promote the narrative of the West’s which are also of key strategic interest for Europe and ability to vaccinate themselves back to normality, extendwithin the framework of the BRI(some potential sites ing an open invitation to third countries. include Nigeria, Morocco, Egypt, Indonesia, or Serbia). EU+x formats with countries in strategically relevant re– Empathize with third states: Perceptions of and disgions(such as the Indo-Pacific or Africa) could also be a cussions about the PRC are different in Europe and(depotential course of action. At the multilateral level(e.g., veloping) third states. Despite the limitations of individual the WHO), it would be advisable to anticipate and match liberties, third(developing) states recognize the PRC’s China’s increasing level of engagement. achievement of overcoming rampant poverty and transitioning from aid recipient to aid provider. Since Western – Cooperate with like-minded states: The G7 might be democracies will not be received with open arms when a suitable platform for launching transatlantic health outclaiming moral superiority, they should apply a degree of reach efforts to third states. Bilateral health cooperation humility when engaging with aid recipients. In that recould also play a more relevant role in implementing Gergard, acknowledging the connection between economic many’s Indo-Pacific guidelines or within the EU’s neighdevelopment, health, and human rights does not mean borhood outreach efforts. abandoning the crucial importance of civil and political human rights. To be perceived as a force of good in the – Cooperate with the PRC at the bilateral and multiworld, European states might also consider supporting lateral level: Despite growing differences, upholding a patent waivers on COVID-19 vaccines. Moreover, surveys working relationship with the PRC is in the best interest in aid recipient states could be conducted to derive needs of Berlin and Brussels. The emergence of the next panand demands, which might serve as the foundation for demic is just a matter of time. The deterioration of tailor-made health cooperation measures. This botUS-Chinese health cooperation formats may present an tom-up approach could be an elegant and popular reopportunity for Europe to fill the vacuum and assume the sponse to the top-down approach of Beijing’s HSR. role of a strategic mediator between the US and China. This step would not be an illustration of weakening trans– Focus on interests: Interviews conducted for this study atlantic cooperation but rather an opportunity for Euhave shown that recipient states care about the concrete rope to gain a bargaining chip vis-à-vis the PRC. Health material aid they receive. You can grasp a bridge or a cooperation could serve as a high-yield, low-risk cooperpiece of infrastructure, but you cannot touch the rule of ation area at the multilateral level as well. China and Eulaw. Donor countries may enable recipient states to rope share a common goal: To achieve the health-related achieve their domestic goals, but this will not cause them SDGs. Despite different fundamental values, cooperation to commit to an ideological camp. Most states appear to on health should be pursued and expanded where possiprefer maintaining working relations with all sides. 52 As ble such as related to the health of women and children part of a more strategic approach to health diplomacy, or the fight against malaria. European decision-makers might consider mapping the interests of the recipient states and utilizing non-essential health aid as a political bargaining chip. – Offer post-pandemic economic aid: Europe should outline a post-COVID-19 vision of economic prosperity and offer closer political relations with third countries. The EU’s Global Gateway Initiative has the potential to play such a role. There could also be advantages to framing the initiative as a post-COVID-19 recovery measure instead of a‘response to the BRI’. When preparing emergency medical supply depots for a potential future pandemic, it would be advisable to include the anticipated needs of states unable to stockpile enough equipment themselves. 52 For instance, Serbia has been utilizing the PRC(and the EU) for its domestic interests. Belgrade used Chinese vaccines to immunize the Serbian population. Serbia also sent donations of BioNTech and Moderna from Europe to Africa as part of its vaccine diplomacy(and, additionally, to have enough states in the developing world who refuse to recognize Kosovo as an independent state). 28

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IMPRINT ABOUT THE AUTHORS IMPRINT Moritz Rudolf is a Research Scholar in Law and Fellow at Yale Law School’s Paul Tsai China Center, where he focuses on the implications of China’s rise for the international legal order. He was previously an Associate in the Asia Division of the German Institute for International and Security Affairs (SWP). Publisher: Friedrich-Ebert-Stiftung e. V. Godesberger Allee 149 53175 Bonn Germany Email: info@fes.de Issuing Department: Division for International Cooperation, Department for Asia and the Pacific Responsibility for content and editing: Stefan Pantekoek, Head of China Desk Dept. for Asia and the Pacific https://www.fes.de/referat-asien-und-pazifik Contact: Meike.Adam@fes.de Design: pertext, Berlin| www.pertext.de Cover design:© Dominik Ziller| DZGN Illustrationen:© istock| SurfUpVector The views expressed in this publication are not necessarily those of the Friedrich-Ebert-Stiftung. Commercial use of media published by the Friedrich-Ebert-Stiftung(FES) is not permitted without the written consent of the FES. Publications by the Friedrich-Ebert-Stiftung may not be used for electioneering purposes. ISBN 978-3-98628-209-7 © 2022 www.fes.de/bibliothek/fes-publikationen

CHINA’S GLOBAL HEALTH DIPLOMACY Revisiting Beijing’s Pre- and Post-COVID-19 Outreach Efforts Unless Beijing’s zero COVID-19 policy pushes the global economy into chaos, the‘China, the first responder’ narrative will persist in developing states. The pandemic revealed China’s global capabilities. Geostrategic considerations guided China’s donations, with key BRI countries receiving 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 which China is the responsible major power, and the West is in decline. China’s COVID-19 diplomacy failed in the West and Southeast Asia but succeeded in the Middle East and Africa. Political elites from third states welcomed Beijing’s health aid, often endorsing policy positions of the PRC at the UN level. COVID-19 served as a catalyst for Beijing’s health outreach efforts. Chinese provinces have been cultivating close relationships with individual countries for decades by sending medical teams. After SARSCoV-1(2002–2004), which challenged China’s economic and political stability, the PRC stepped up its international health cooperation efforts. The 2015 launch of the Health Silk Road marked the beginning of China’s more strategic and centralized health diplomacy. The pandemic fasttracked the formation of Beijing’s envisioned global(China-centered) health cooperation network. Despite the PRC’s quixotical Zero-COVID-­ 19 policy, decision-makers should recognize the long-term effects of Chinese aid. Taking China’s ambitions in the global competition over the support from third (developing) states into account, Europe should be more strategic in its health diplomacy. Health diplomacy is essential to the future of the international order. Decision-makers should invest in social media outreach efforts in recipient states, map their interests, and utilize(non-essential) health aid as a political bargaining chip. Europe should focus on countries with whom health cooperation has already developed, or which are of key strategic interest for both Europe and China. Regional EU+x formats should be built. At the multilateral level, Europe needs to anticipate and match China’s increasing level of engagement. Further information on the topic can be found here: https://www.fes.de/referat-asien-und-pazifik