During the Covid pandemic China donated more vaccines to Africa than any other country.

But five years before the first whispers of a virus had even left Wuhan, Beijing was already hard at work enacting a plan to increase its soft power and influence in global health through a project known as the Health Silk Road.

A special report published in the National Bureau of Asian Research (NBR) lifts the curtain on this strategically significant branch of the country’s Belt and Road Initiative (BRI) and brings into focus China’s growing healthcare investments in African nations at a time when Western countries and the multinational pharmaceutical giants are retreating.

Its author Nadège Rolland, a Distinguished Fellow of China Studies at the NBR, argues that the Health Silk Road is a “useful illustration of the extensively systematic organisation of the BRI’s deployment, at the service of greater geopolitical ambitions”.

China has long been a major contributor to healthcare in Africa with a relationship that goes back to the 1960s. But as the West gets out it is only accelerating its move into healthcare on the continent.

At the 2024 Forum on China Africa Cooperation, Beijing announced it would start encouraging Chinese businesses to invest in the production of medicines and vaccines in Africa in its 2025-2027 action plan.

“Most people see China in Africa either through the lens of a glass half full or half empty. Not everything China does in Africa is bad, and you have to be careful not to throw the baby out with the bathwater,” said Andrew Mitchell, former Deputy Foreign Secretary and Shadow Foreign secretary.

“But what you want from China is transparency. If I said to you that Britain in Malawi is going to build a hospital, train their doctors and help them make their drugs, you’d say that was fantastic.”

“Africa has no illusions about China, but they are there when others are not,” said Labour Peer Lord Paul Boateng. “What we have lacked is the focus and will to take on a new set of competitors on the continent, amongst whom China is omnipresent.”

The West retreats and China moves in

Western multinationals are retreating from the same African countries they were once optimistic about.

In 2023, GSK and Sanofi ceased commercial operations in Nigeria. The pharmaceutical giants produced critical vaccines, antibiotics and antiretrovirals but there was “no end in sight for their losses,” according to a financial analyst from Nigeria’s TLCom Capital. In Kenya, Bayer followed suit, and Moderna put plans for a $200m vaccine facility on hold citing similar concerns.

But China is only diving deeper into the continent to grow its influence in healthcare.

“China’s experience navigating complex cultural and logistical landscapes within its own diverse population gives it an edge in adapting solutions to local African contexts,” said Dr Ruby Wang, Managing Director at LINTRIS Health and previously Head of Health for the UK Government’s Foreign Office in Beijing.

At the same time, Africa is increasingly looking to China to build local healthcare capacity.

In September, Nigerian pharmaceutical company Fidson partnered with Jiangsu Aidea Pharma, Nanjing PharmaBlock, and the China Africa Development Fund to build a drug manufacturing facility within a Chinese-backed free trade zone in Lagos.

“What the Chinese are doing is taking their experience in producing drugs, often out-of-patent medications, at a scale and price that make it affordable for African consumers to buy and for these firms to generate a profit. Albeit a much smaller one than what Western firms would tolerate,” said Eric Olander, Editor-in-Chief of The China Global South Project.

But African leaders are concerned about the exit of big pharma and the medical needs of the continent are only growing, said Dr Lenias Hwenda, the CEO of Medicines for Africa.

“When companies leave, like we have seen with big pharma, it erodes an already small manufacturing base and accentuates African vulnerability by worsening poor access to treatment. That concerns me,” she said.

“Chinese companies are stepping in to fill some of the gaps in the African market. Only time will tell how well.”

Penetration

Pharmaceutical investments appear to be a high priority for Beijing in its quest to grow soft power.

Linda Calabrese, Senior Research Fellow at OCDI said: “In this area there is certainly a lot of interest, and a lot of MoUs are being signed by Chinese companies and African governments. but in terms of actual implementation on the ground, I have not seen much yet – these investments take years to materialise.”

But it isn’t only pharmaceutical companies who have been encouraged to expand into Africa by Beijing.

Under the Health Silk Road, Beijing has embedded itself as a critical partner across Africa’s entire healthcare ecosystem, financing infrastructure that serves both humanitarian and economic goals.

“What was striking to me working on the report was the degree of penetration of the different layers of health ecosystems that China has started to dig into very deeply,” Ms Rolland said of her research.

As well as plans by private companies to invest in manufacturing plants like the one Fosun Pharma is building in Cote d’Ivoire, Beijing has funded what it calls “Friendship Hospitals” across the continent and in other BRI countries in the Global South.

It has also built the Africa Centre for Disease Control headquarters in Ethiopia, which was completed in January last year. That project was at the centre of a geopolitical spat under the Trump administration, who accused China of attempting to use the building to steal Africa’s genomic data.

‘A Chinese-made vaccine or nothing’

Yet many experts say China’s focus on critical public healthcare infrastructure need not be a cause for concern.

“Rather than criticise investment from China, Western countries should consider how they can support the African pharmaceutical sector, since they are world leaders and have knowledge and expertise to share with African partners,” said Ms Calabrese. “I think these investments will be beneficial for African countries.”

Mr Olander said the needs of African countries are so acute that there is no alternative but to cosy up to Beijing.

“At this point, the need is so acute in most African countries for local production of pharmaceuticals, new healthcare infrastructure and greater access to medical technology, that I don’t see much in the way of concern about dependencies on Chinese suppliers,” he said. “It’s either a Chinese made vaccine or nothing.”

But Africa needs investment and seeks partners for home-grown self-sufficiency, not continued dependency, said Lord Boateng.

“It wants to be recognised as a fast-growing market opportunity with a youth demographic and a growing middle class that offers huge opportunities for growth. Not a basket case in need of philanthropy and lectures on good governance.”

Dr Wang said China’s ability to scale up health infrastructure cannot be matched by the West.

“China’s transformation from a developing to a middle-income country means it holds recent and highly relevant experience in delivering healthcare across vast landmasses and remote populations, insights that resonate strongly with Africa’s needs,” she said. “And partnerships feel less intrusive, less paternalistic compared to traditional Western aid programmes.”

Experts agree that China has major economic and strategic incentives for its involvement in healthcare on the continent.

“It’s a win-win. Investing in Africa’s health sector grants China access to a rapidly expanding market for medical products, enhanced soft power, and a global leadership reputation in health,” Dr Wang said.

A new world order for global health?

Beijing wants the world to buy into the idea that China’s healthcare investments, loans, and aid donations under the Health Silk Road is simply a natural extension of its longstanding solidarity with the Global South.

But should we believe it?

By leveraging health cooperation as a geopolitical tool, China seeks not only economic and soft power gains but also to position itself as the architect of a new order for global health governance.

Ms Rolland argues that the Health Silk Road is far from a simple act of altruism, but a highly organised branch of the Belt and Road Initiative.

It is the backbone of a new world order that China, under Xi Jinping, is trying to establish, but only time will tell if this grand vision can be realised.