Escaping the Kindleberger Trap: What Role for China in Reshaping Global Health for a Low-Cooperation World?

The United States, a country that has been central to the post-Cold War liberal global health and development agenda, has now withdrawn from the World Health Organization and shut down USAID. And it is not alone in cutting health and development spending. High-income countries are being asked to backfill the deficit in global health and development left by the US retreat, but the threat to the US-Atlantic alliance has meant a radical tilt to defence spending. The UK announced a cut in its official development assistance funding to 0.3 percent of GDP, a figure that may fall even further. France plans to reduce its public development aid by a huge 40 percent for 2025.

This retreat from multilateralism and the provision of global goods will have broad and deep impacts. Large, technologically sophisticated middle-income countries—principally China—will be vital to the new global health order. New partnerships are needed to manage complex risks in a low-cooperation world. The alternative is what Joseph Nye describes as the “Kindleberger Trap”—the gulf that emerges when no great power is able to function as a global stabiliser.

An inflection point for global health

Current developments in the United States and elsewhere will profoundly impact global health security, reshape scientific cooperation, and undermine the governance of emerging health technologies. They threaten lives at a time when the Sustainable Development Goals are already drastically off track, and undermine health and development programmes in low- and middle-income countries.

This creates an existential crisis for global health as we know it—at a time when global health and development replenishments are already facing a traffic jam, and when conflicts (in Sudan, Gaza, Eastern DRC, Ukraine, and elsewhere) and climate change are reducing countries’ fiscal headroom for health. There is little doubt that the global health and development architecture needs systemic reform, but this shock is not the right way to achieve change.

The field of global health—a set of ideas, institutions, and practices—has a short history. It is a product of the post-Cold War period, a field in which the United States and a small number of high-income countries have been central to the production of knowledge, governance of key institutions, and norms governing the field. To be sure, there has been resistance to this dominance—often framed as decolonising global health—but the US retrenchment brings us closer to a “geopolitical inflection point” at which the field itself is now in question.

The geography of global health is shifting—towards Asia

The US contribution to existing global health institutions and structures is irreplaceable. So, the question now is how this field will be reconstituted, and where the ideas, organisation, and human and financial resources will come from to support the new global health order. This will be a change in the geography of global health as large, technologically sophisticated middle-income countries exert increased influence over the agenda, norms, and approaches to global health.

This makes China systemically important to global health and development as never before. But its engagement stems from a different place, and different ideas and priorities, linked to the country's history, its global goals, and its domestic institutional and fiscal constraints.

China is now a leading provider of health assistance, though with a different profile than OECD Development Assistance Committee donors. In the 2010s, China issued Belt and Road and Health Silk Road health cooperation strategies and signed agreements with the World Health Organization (WHO), the Africa Centres for Disease Control and Prevention, and others on strengthening health cooperation, and included health in the Forum on China-Africa Cooperation.

The focus and modalities of China’s health cooperation are evolving rapidly, reflecting evolution in the country’s institutions and priorities and changing leadership thinking about China’s global role. But China is unlikely to fill major funding gaps left by the US withdrawal—it is a significant contributor to WHO, but through assessed contributions, rather than voluntary contributions. Its contributions to Gavi ($25 million over two funding rounds, plus $100 million to COVAX AMC) and the Global Fund ($99 million pledged since 2001-2005 funding round) are limited, as is its engagement with initiatives concerned with fundamental global priorities such as antimicrobial resistance and the search for new antibiotics.

However, China is increasingly important in the production of knowledge on health and development. The country’s rapid health reforms—including building the world’s largest health insurance system and progressing towards universal health coverage—provide very recent experience of health system strengthening in a middle-income country with huge regional disparities. It means the country has deep technical capacity on health challenges faced by both its high-income peers and many low-income countries. And that capacity is increasingly being mobilised internationally.

Similarly, China is now fundamental to global science, innovation, and value chains. Chinese pharmaceuticals and health consumables are essential to health systems the world over, and the country is a potential source of “appropriate” health technologies, including diagnostics and vaccines suited to low-income contexts. Equally, it is emerging as a global leader in some areas of biopharmaceuticals, such as immuno-oncology, next generation biological therapies, chimeric antigen receptor (CAR) T-cell therapies, and AI and virtual reality applied to cancer, all of which have relevance to developed and developing countries alike.

Stabilisers for a fragmenting, low-cooperation world

At the same time as the United States retreats as a provider of global public goods for health, China increasingly recognises the importance of stronger global systems to maintain health security and stability, as well as the soft power and commercial importance of global health. Foreign Minister Wang Yi’s recent comments on the US retreat from global responsibilities clearly position China as a responsible great power, seeking to uphold the international order.

But the world’s second superpower brings a seemingly different set of assumptions about global order, global governance, and global public goods. It seems likely that there will be increasing securitisation and fragmentation of global health governance and programming, not least linked to the US stipulation that countering Chinese influence will be a key criterion for any recipient of overseas funding.

How China’s global health engagement evolves matters. That includes how the country prioritises its spending, how it partners with low- and middle-income countries on issues including local production of pharmaceuticals and health commodities, and how it engages in the governance of transnational health threats.

The current conjuncture poses major questions for the global health field. As one superpower retreats, there is a need for balancing mechanisms to provide stability. China recognises the importance of global health, but the country is unlikely to simply replace the role of the US. Its health engagement is developing but doesn’t yet have the breadth or the depth of major traditional global health powers or the US. There remains insufficient policy coherence, as China seeks to transition from an earlier model of health assistance based on building infrastructure, sending clinicians, and providing training, to a model more based on technical support. The country does not have a history of supporting large scale public health programmes overseas.

Reshaping global health

Where does this leave us? We are now operating on increasingly politicised and securitised terrain. In this fractious and contested world, health threats have not receded, and building effective, inclusive health systems remains an urgent challenge. In a context of dramatically reduced spending for global health and development, and increasing military spending, there is a need to remake arguments about global health as fundamental to collective security, and to make every pound, euro—and yuan—count.

In this world without global leadership, the fundamental challenge is to create a new politics of global health, founded on shared interests and new solidarities. That must include China, despite differences in thinking and approaches. This implies the need for pragmatism and what UK Foreign Minister David Lammy has termed progressive realism—bringing a realist politics to tackling global challenges in the context of a fundamental shift in the global balance of power.

Record numbers of Chinese students are studying global health at high-income-country universities, and there are active debates in China about the country’s evolving role in health and development. High-income countries now need to step up and invest in developing the analysis, understanding, and capabilities necessary to build effective partnerships to manage complex risks in an uncertain, low-cooperation world.