China-UK partnership for global health:practices and implications of the GlobalHealth Support Programme 2012–2019Xiaohua Wang1* , Peilong Liu2, Tongwu Xu3, Yan Chen4, Yang Yu1, Xun Chen1, Jingyi Chen1 andZhaoyang Zhang1
Abstract
Background: Over the past few decades, a series of major challenges to global health have successively emerged,which call for China’s deeper engagement in global health governance. In this context, the China-UK Global HealthSupport Programme (GHSP) was launched in 2012 with about 12 million pounds funded by the United Kingdom.
Objectives: The GHSP was expected to explore a new type of China-UK partnership to strengthen the cooperationin global health, and enhance China’s capacity to engage in global health governance and provide effectivedevelopment assistance in health (DAH), in order to jointly improve global health outcomes.
Programme design and implementation: The GHSP was programmed to support capacity building activities inChinese experience distillation, DAH, global health governance and pilot partnership at national and institutionallevels between October 2012 and March 2019. These activities were assigned to different project implementingagencies (PIAs) and their project cooperative agencies (PCAs) or pilot areas, and were then implemented under theguidance and management by the strategic oversight committee and the project management office of GHSPrespectively.
Main achievements: At the national level, the GHSP held five rounds of China-UK high-level dialogues, conductedstudies on China Global Health Strategies to provide robust evidence for developing and issuing relevant nationalpolicies, and supported the establishment of the China Global Health Network. At the institutional level, the GHSPfunded a series of activities in research, training, international exchange and pilots etc., produced a large number ofhigh-quality research outputs and policy briefings, cultivated a group of PIAs and individual researchers, facilitatedthe partnership building between the PIAs and PCAs, enhanced the practical ability of Chinese institutions toconduct overseas DAH, and improved the health service delivery and outcomes in pilot areas of three Asian andAfrican countries.
Policy implications: In the GHSP, China and UK have established a good model for North-South Cooperation andthe programme facilitated the 2030 Agenda for Sustainable Development by building a new type of bilateralpartnership and carrying out triangular cooperation practices. This model has demonstrated huge potential forcooperation through partnership and can also be referred to by other countries to develop bilateral partnerships.
Keywords: Global health policy, Global health governance, Partnership, China, UK, Health project management
* Correspondence: [email protected] article has been translated into Chinese and the Chinese version isaccessible from Additional file 1 attached.1Center for Project Supervision and Management, National HealthCommission of the People’s Republic of China, Beijing 100044, ChinaFull list of author information is available at the end of the article
Global HealthResearch and Policy
Wang et al. Global Health Research and Policy (2020) 5:13 https://doi.org/10.1186/s41256-020-00134-7
BackgroundThe importance and urgency of health-related issues inglobal governance have never been so evident as whatthey are now [1]. Globalization, together with the deteri-oration in the environment and climate change, have ledto a series of major challenges to global health develop-ment and global health security [2, 3].In the Millennium Development Goals (MDGs), some
key health indicators have yet to achieve the expectedgoals in 2011–2015 [4]. Inequity in global health develop-ment has become a common issue, especially in sub-Saharan Africa [5]. Non-communicable diseases (NCDs)have gradually become the main risks to human health[6]. Major public health events, especially epidemic-pronediseases with cross-border impacts, have increasingly oc-curred [7–11]. Other public health issues, such as anti-microbial resistance (AMR), chemical and biological ter-rorism, possible terrorist attacks by radiological and nu-clear means, and extreme climate events, have also posedincreasingly serious threats to global health security andtriggered global health crises [12–14].In addition, global development assistance for health
(DAH) is in transition. In order to meet the currentneeds of recipient countries and improve the effective-ness, efficiency, transparency and sustainability of aid,the international aid system formed after the WorldWar Two urgently needs reforming [15]. These globalchallenges cannot be addressed by one individual coun-try. They demand joint attention, collaboration and con-tribution from all the stakeholders in the internationalcommunity, where China is a key player.China is a beneficiary of global health development co-
operation. Since the establishment of the People’s Repub-lic of China in 1949, it has made great efforts to improveits people’s health with only limited financial, material andmedical resources [16, 17]. With the reform and openingup implemented since 1978, China has received a largeamount of financial and technical assistance from inter-national organizations and developed countries. Thosesupports, combined with China’s own constant dedication,have dramatically boosted the health development inChina. When the China-UK Global Health SupportProgramme (GHSP) was set up in 2011, China had alreadysuccessfully achieved Goals 4 and 5 of the MDGs, and wasworking hard to achieve Goal 6.China has been a contributor to global health develop-
ment cooperation. China’s population accounts for approxi-mately one-fifth of the whole world, thus the healthimprovement of Chinese people is in itself a significant con-tribution to global health. In the past few decades, Chinahas faithfully executed the global development agenda, vig-orously supporting the work of international organizationssuch as the World Health Organization (WHO), and ac-tively carrying out aid and “South-South cooperation” to
help other developing countries to improve their localhealth status as much as possible [18–21].China has a large potential to make greater contribu-
tions to global health. The rich experience accumulatedduring China’s improvement of its own health outcomesover the past 70 years has made it possible for China toprovide effective public goods for global development. Inrecent times, the rapid growth of China’s overall nationalstrength have made it possible for the country to turn itseyes more to the rest of the world. The Chinese govern-ment has also made commitments to global health onmany major diplomatic occasions. Therefore, both theinternational community and China’s own healthworkers are expecting China to contribute further toglobal health.However, compared with developed countries, there is
still a substantial gap between China’s “strong willingness”and its actual “qualified capacity” to engage in global health.China is not good at distilling and disseminating Chineseexperience and lessons in health with a view to external ap-plicability. There is a lack of understanding of the best prac-tices of international DAH, and an inadequate ability toengage in global health governance and policy making andfor cross-border public health interventions and joint ac-tion. These insufficiencies have limited China’s contribu-tions to global health, and also make it difficult to meet thehigh expectations of the international community.It is widely recognized that the UK has been one of the
leading countries to promote global health. The UK hashelped set up guidelines for global health governance, pro-viding intellectual products relating to global health, ren-dering DAH, and maintaining national and global healthsecurity, all of which China can learn from [22–26], espe-cially its far-sighted and fruitful health diplomacy, such asthe establishment of the Department for International De-velopment (DFID) in 1997 and the publication of its firstnational Global Health Strategy in 2008 [27–29]. Since2011, the UK has been transforming its relationship withemerging countries, including China, from an aid-baseddevelopment relationship into a meaningful and mutualpartnership for global development [30].Under this circumstance, the governments of China
and the UK signed a memorandum of understanding(MoU) in 2011 to promote international developmentcooperation, identifying global health as a new field forfurther strategic cooperation between the two countries.On September 17, 2012, the Ministry of Commerce ofP.R.C. and the DFID of the UK formally signed the MoUon the Global Health Support Programme (GHSP).
Programme design and implementationProgramme design frameworkThe GHSP was implemented between October 2012 toMarch 2019 with about 12 million pounds financed by
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the UK. Its aims were to explore a new type of China-UK partnership, to strengthen their cooperation in glo-bal health, enhance China’s capacity to engage in globalhealth governance, and provide effective DAH, in orderto jointly improve global health outcomes.The GHSP was programmed to support capacity
building activities in four components, so as to achievethe following four outputs: (1) Increased ability to distil,disseminate and apply the Chinese experience in im-proving health outcomes and strengthening health sys-tems; (2) Improved understanding amongst the Chineseofficials and researchers of best practice in internationalhealth development cooperation (including bilateral andmultilateral); (3) Enhanced ability of Chinese officialsand researchers to contribute to global health policy andgovernance; (4) Pilot partnerships to apply China’s ex-perience and international best practice in developmentcooperation in low income countries. The activities ofthe programme were carried out at national and institu-tional levels. In addition, the outputs of the activities in“Component 1” and “Component 2” provided significantsupport for the design and implementation of the activ-ities in “Component 4”. The logic diagram of the GHSPis shown in Fig. 1.
Design of programme activitiesAt the national level, the programme emphasized the con-cept of “Strategy First” and focused on building platformsand setting up mechanisms. At the institutional level, theGHSP was expected to engage in “Learning by Doing” tobuild capacity, emphasizing the “Multi-disciplinary, Cross-sectoral and Trans-regional” concept of global health, with
the focus on building bridges between research anddecision-making. The programme activities were designedto improve five dimensions of capacity: research and ana-lysis, dissemination and training, policy consultation,overseas practice, and pilot partnerships. The main typesof activities are shown in Table 1.
Organizational StructureFigure 2 shows the GHSP’s organizational structure. Thestrategic oversight committee (SOC) of the GHSP wascomposed of delegates from the China’s National HealthCommission (NHC), China’s Ministry of Commerce(MOFCOM) and the UK’s DFID. The SOC was respon-sible for setting programme priorities, approving annualwork plans and budget, reviewing progress reports andassessing ongoing performance, as well as overseeing themonitoring and evaluation. The project management of-fice (PMO) was located in the Center for Project Super-vision and Management (CPSM) of NHC and wasresponsible for its daily operation and management.GHSP’s technical advisory group (TAG) was composedof independent individual consultants and the WHOChina Office, which is responsible for providing theSOC and the PMO with technical advice and support.The technical activities were organized and implementedby different project implementing agencies (PIAs) andtheir project cooperative agencies (PCAs) or pilot areas.
Programme implementationProgramme management rulesAll programme management rules were detailed in theProgramme Management Manual (PMM), which is one
Fig. 1 The logic diagram of the GHSP
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Table 1 The design of GHSP activities
Fig. 2 Organizational structure of the GHSP
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of most important documents of the GHSP. It wasdrafted by the PMO at the beginning of the GHSP, ap-proved by the SOC, and adhered to by all programmestakeholders, irrespective of the institution or individual,throughout the whole implementation cycle. The PMMwas developed in accordance with the relevant Chinaand UK laws and regulations, the donor’s (the DFID)special requirements, all programme legal documents, aswell as the international project management norms. Ithas clearly defined the organizational structure and re-sponsibilities of each component, detailed rules and reg-ulations for daily management, financial management,procurement management, monitoring and evaluation.
Programme decision-making mechanismThe SOC meeting involved decision making and washeld twice a year. The main topics included: reviewingand approving the annual work plan, reviewing the pro-gress, discussing important issues and possible solutions.During its intersessional period, if there were any im-portant issues that needed the collective decision-making of SOC, the PMO could propose an ad hoc SOCmeeting or communicate with SOC members by email,depending on the complexity of the issue.
Selection and determination of the institutions andindividuals involved in GHSPThe SOC member units were jointly nominated byChina and the UK during the project preparation period.Other related institutions and individuals participatingin the GHSP were selected as follows:
(1) The PMO was selected by the SOC throughbidding, after which the DFID China office and thePMO signed the GHSP Project ManagementAgreement;
(2) The TAG members were selected by the SOC’scollective discussions based on the list ofinternational and domestic candidates, which werenominated by SOC members separately accordingto the requirements of the Terms of Reference(TOR) approved by all SOC members. The TAGmembers’ contracts were first signed and managedby the DFID China office, and later the job wastaken over by the PMO.
(3) PIAs. A PIA for each task was selected throughbidding or direct selection. Bidding was frequentlyadopted in the early stage of the programme. Thedirect selection had been mainly used in the laterstages of GHSP for seeking a qualified PIA, whichwas first nominated by the SOC under any of thefollowing three circumstances: (a) The task wasawarded a small amount of money; (b) The taskwas a natural extension of the previous one; (c) A
task that only one institution could be qualified tocarry out.The TOR of each individual task was jointly draftedby the PMO and the TAG members based on theprogramme design documents and the approvedannual work plan. This was then finalized after theSOC’s approval. The PMO was responsible for boththe bidding process and managing the consultingservice contracts with each PIA.
(4) PCAs. The GHSP was committed to promotingcross-border communication and collaboration,attracting as many institutions as possible. Forlarge-scale tasks, PIAs were thus encouraged to in-vite domestic or international partners for jointbids. After winning the bid, the joint bidding agen-cies became the PCAs on this task, and the PIAswould start the work with their PCAs by signingcontracts or agreements with them.
Programme quality controlThe quality control of the GHSP included five mainaspects:
(1) Logical framework approach. A logical frameworkwith expression of the GHSP’s result chain wasformulated by the design team prior to the officiallaunch of the GHSP. It was fundamental tomonitoring the progress and evaluating the resultsof the programme. In accordance with the GHSP’srequirements, the PMO updated data of the logicalframework indicators every year to indicate whetheror not the programme was going as planned.
(2) Annual work plan approval. At the beginning ofeach year, the PMO and PIAs formulated theirannual work plans according to the programmedesign documents, the logical framework andindividual task proposals. Annual work plans weretaken as the basis for activities and payments, whichhad to be reviewed and approved by the SOC inadvance.
(3) Process review. The reviews mainly consisted ofpayment reviews conducted by the PMO, semi-annual progress reviews and on-site supervisions onpilot areas by the SOC, annual audits by the ChinaNational Audit Office, and annual reviews by thespecial experts designated by the DFID. The processreview paid special attention to the following di-mensions: implementation progress, logical frame-work indicators, the quality and quantity of theintermediate outputs, and the compliance with fi-nancial and procurement requirements.
(4) Completion acceptance of each task. The PMOcarried out the completion acceptance for each taskbefore the last payment, which was used to confirm
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the expected outputs, the compliance with thefinancial and procurement requirements, as well asthe total final accounts. In order to achieve the“Money for Value” proposed by the DFID, thePMO opted to manage this programme with themethod of “linking payments with the quality andquantity of the outputs”, which ensured that eachPIA would be able to submit qualified outputs asplanned.
(5) Independent evaluation. GHSP adopted a third-party evaluation to comprehensively assess its im-plementation progress and final outputs andachievements. This was composed of a baseline sur-vey, and mid-term and final evaluations. The inde-pendent evaluation team was selected by the DFIDthrough international competitive bidding at theinitial stage of the GHSP. Evaluation reports writtenby the independent evaluation team of each stageprovided evidence for the SOC to determine thework priorities at the next stage, as well as evidencefor the Chinese and British governments to explorefuture cooperation.
Main achievements of the GHSPIn its nearly 7 years of implementation, the GHSPachieved its original goal, i.e. it helped build up a sus-tainable development partnership between China andthe UK, which has great potential to facilitate continu-ous exchanges and cooperation between the two coun-tries, and to contribute to improved health policy andoutcomes globally. It is delighted that the outputs wereeven better than expected (Table 2).
National LevelChina-UK Global Health dialogueThe GHSP has supported five rounds of China-UK globalhealth dialogues since 2013. This is the first dialogue onglobal health between China and a major Western coun-try. The China-UK global health dialogues were held be-tween director-general level officials of the relevantdepartments of both sides. The establishment of thismechanism enabled two global health powers to comple-ment each other and form synergies, thus more effectivelycontributing to global health governance, ultimately im-proving global health outcomes and promoting theachievement of sustainable development goals (SDGs).Depending on the status of the domestic and internationalhealth development and the concerns of both sides, thefocus of each of the dialogues varied. The topics discussedin each dialogue are presented in Table 3.
Studies conducted on China Global Health StrategyThe GHSP promoted a comprehensive set of studies onglobal health strategies, producing a total of 12 research
reports and a draft of China’s global health strategy,which provides data, facts and constructive policy rec-ommendations for the central government of China todevelop its national global health strategy document.The topics of these studies are shown in Fig. 3.The research recommendations on China’s global
health strategy are consistent with the Healthy China2030 Plan and 13th Five-year Health Plan, released bythe central government of China in 2016. Health China2030 Plan includes assertions such as “China’s globalhealth strategy will be implemented”, “By establishinghigh-level strategic dialogues between countries, Chinawill encourage putting health on the diplomatic agendaof major countries”, “China will actively participate inglobal health governance, gain international influenceand a strong voice in building institutional health”, andso forth [31]. The 13th Five-year Health Plan includesassertions such as “develop China’s global health strat-egy”, “improve China’s influence and strengthen China’sleading voice in global health diplomacy”, “continue tostrengthen health assistance to foreign countries”, and“promote global health personnel training and teambuilding” [32]. These statements highlight how the rele-vant research work of GHSP has gained positive affirm-ation from the China’s NHC and also the top decision-makers of the central government of China.
The establishment and operation of the CGHNWith the support of GHSP, the China Global HealthNetwork (CGHN), a non-profit, membership alliancewas founded in Beijing on 6 December 2015. The Schoolof Public Health, Peking University was elected as thefirst round of leading organization of the CGHN, andwas responsible for the CGHN secretariat. The CGHNadheres to the principle of openness and inclusiveness,as well as welcoming various actors to join in the net-work and participate in relative activities. As of March2019, organizations that joined the CGHN increasedfrom 46 at the beginning of its establishment to 77. Theyare universities, academic institutes, think tanks, govern-mental units, public health institutions, as well as enter-prises and civil society organizations in more than 20provinces and municipals (Fig. 4). The CGHN plays akey role in expanding and consolidating the influence ofGHSP and promoting China’s global health cause.Since its establishment, the CGHN has not only func-
tioned a global health communication platform for net-work members, but it also became an exchange channelbetween China’s global health community and the exter-nal world. This is done through co-convening inter-national conferences, carrying out studies commissionedby health departments on global health cooperation, de-veloping capacity-building training activities, and estab-lishing partnerships with overseas institutions.
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Table 2 GHSP logic framework indicators achievementsOutput Indicators Target Actual
Indicator 1.1Number of Chinese individuals andinstitutions supported by GHSP withstrengthened capacity to distill Chineseexperience in improving health outcomesand strengthening health systems.
Indicator 1.2Number of publications supported byGHSP disseminating Chinese experiencein improving health outcomes andstrengthening national health systemsin a way that is relevant to LMICs.
200 275 (87 research reports + 126journal papers + 48 policy briefings+ 14 published books)
Indicator 1.3Number of research partnerships betweenChinese and LMIC institutions
10 26
Indicator 1.4Number of research dissemination eventswith low-to-middle income countries(LMIC) partners, to include researchers and public health officials
10 18
Indicator 1.5Chinese institutions develop capacity to useevidence on clinical effectiveness to makeproposals for policy and clinical guidelines toimprove allocative efficiency in the health sector.
2 4
Indicator 1.6Chinese institutions share experience ofimproving allocative efficiency with LMICs.
2 4
Indicator 2.1Number of policy or programmatic paperson development cooperation in health
15 67
Indicator 2.2Policy- and project- relevant research papersdeveloped reflecting international practice indevelopment cooperation in health (DCIH)
20 35
Indicator 2.3Core Chinese institutions developed withcapacity as think tank and training providerin development cooperation in health
4 6
Indicator 2.4Development of a cadre of Chinese consultantssupported by GHSP with capacity to supportDevelopment Cooperation in Health and activelyengaged in support to the Chinese government,global health institutions, LMICs governments and/oragencies (Consultants supported by the programmeproviding support for government)
50 135
Indicator 3.1Establishment and strengthening of China GlobalHealth Network, providing a forum for discussion,development and mutual learning among PIAsand other concerned institutions
Establishment and functioning of the Network The CGHN was established inDec. 2015 and is still operative
Indicator 3.2Policy-relevant research produced and proposalsdeveloped for a China’s global health strategy
Indicator 3.3Increased collaboration between China and UKthrough High Level Global Health Dialogue
Joint work on global health issues Five dialogues convened regularlyon key global health issues ofmutual concern; A joint visit toEthiopia on Africa CDC relatedissues in 2018
Indicator 4.1Number of pilot partnerships implemented
2 4
Indicator 4.2Pilots incorporate China experience andinternational practice in DCIH.
2 4
Indicator 4.3Pilot partnerships lead to improved Chineseengagement in global health cooperation
2 4
Data source: GHSP project completion report from PMO, Mar 2019
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Institutional levelA priority of GHSP is to improve the ability of Chineseinstitutions to participate in global health. During theseven-year period, 53 Chinese institutions, either as PIAsor PCAs, were involved in various project activities.GHSP has promoted a number of universities and re-search institutions to become the backbone for globalhealth research and practice in China, such as the sixCenters of Excellence of the GHSP, namely, Peking Uni-versity School of Public Health (PKUSPH), Fudan Uni-versity School of Public Health (FUSPH), FudanUniversity Global Health Institute (FUGHI), Center forGlobal Public Health of China CDC (China CDC), Na-tional Institute for Parasitic Diseases of China CDC(NIPD), and China National Health Development Re-search Center (CNHDRC).
Research and analysisPIAs carried out a series of policy studies on the distilla-tion of the Chinese experience, international health de-velopment cooperation, global health policy andgovernance, and pilot partnerships in other developingcountries, thereby improving their expertise in relation
Table 3 Topics discussed in China-UK Global Health Dialogues
Time Venue Topic discussed
First DialogueMar. 11, 2013
London, UK Universal health coverage (UHC),access to medicines in the contextof malaria and poliomyelitis control,international health policy andgovernance, and post- MDGs andhealth, etc.
SecondDialogueNov. 12, 2014
Shanghai,China
Access to essential drugs, Ebolaresponse, reproductive, maternaland child health (RMNCH), internationalhealth partnerships and governance,post MDGs and health, and Chinaglobal health strategy, etc.
Third DialogueSept. 14, 2015
London, UK Antimicrobial resistance and drugresistant malaria, post-Ebolacollaboration, health and SDGs, andWHO reform, etc.
FourthDialogueJul. 12, 2017
Beijing, China WHO reform agenda, policy update,health cooperation in Africa, secondphase of global health collaboration,etc.
Fifth DialogueJan. 22,2019
London, UK New global health programme designand development, WHO reform, UHC,collaboration on global health securityin Africa, etc.
Data source: GHSP project completion report from PMO, Mar 2019
Fig. 3 Series of studies on China global health strategy
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to global health research and analysis. The outputs gen-erated by these PIAs have been published in the form ofresearch reports, papers and monographs, etc. throughdomestic and international publishing houses and aca-demic journals. Figure 5 shows the number of differenttypes of GHSP academic outputs generated under thefour components. As of March, 2019, the programmehad produced 87 research reports, 126 journal papers(57 in English, 69 in Chinese) and 14 books (includingchapters and translations). See Additional file 2 for moredetails.
Dissemination and trainingThe GHSP enhanced the skills of Chinese institutions interms of dissemination and training, for example in support-ing PIAs to develop training materials and basic textbooks
on DAH and global health governance; organizing short-term training courses, participating in international ex-change activities, and facilitating domestic English academicjournals in global health, etc. In total, the programme facili-tated 109 international exchange activities involving 349professionals. Those activities included attending inter-national conferences, sending experts to a few developingcountries to provide consultation services; and sendingyoung researchers to international research institutions oruniversities for short-term study or training (see Additionalfile 3 -1 for details). The GHSP assisted PIAs in organizing27 global health training and practice activities, totaling1020 person-times (see Additional file 3-2 for details). Par-ticipants included government officials, researchers, publichealth practitioners and managers of international cooper-ation projects.
Fig. 4 Categories of the CGHN members. Data source: The CGHN secretariat office report, May 2019
Fig. 5 Research outputs of GHSP by activity components. Data source: GHSP project completion report from PMO, Mar 2019
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The GHSP also played a key role in nurturing talent inrelation to global health in the Chinese universities. Forexample, Peking University set up two postgraduatecourses (Introduction to Global Health and Global HealthGovernance) on the basis of textbooks developed underthe GHSP; Fudan University developed the online MOOCcourse “Introduction to Global Health”; and through a co-operation with the GHSP, Global Health Research andPolicy, a professional English-language academic journallaunched and operated by Global Health Institute of Wu-han University, enhanced its own international influenceby helping to expand the international dissemination ofseveral GHSP outputs.
Policy consultationUnder GHSP’s support, PIAs provided the governmentsof China and a few other developing countries with atotal of 48 policy briefings in both English and Chinese,which were written on the basis of the policy researchresults and focused on significant global health issues.Figure 6 shows the topics of the policy briefings, andAdditional file 4 gives their titles. A number of policybriefings also drew the attention of the Institute of Infor-mation Studies under the Chinese Academy of SocialSciences, and were modified and submitted to the high-est decision-making level of the central government ofChina in the form of internal reference materials.PIAs also provided professional expertise and consult-
ation to the central government of China and inter-national organizations by: (1) participating inconsultation activities and drafting a number of globalhealth documents, such as China Global Health Strat-egy, Healthy Asia-Pacific 2020 Initiative, China Belt andRoad Initiative Health Exchange and Cooperation Imple-mentation Plan (2015–2017&2018–2020), China Assist-ance in Building 100 Medical Institutions Plan,Cultivating Health Talent Programs in Developing
Countries and Healthy China 2030 Plan; (2) giving ad-vice to the delegation of China NHC during the WHOExecutive Committee Meeting and the World HealthAssembly; (3) serving on the technical committees ofinternational organizations such as WHO, and providingadvice on maternal and child health, the prevention andcontrol of malaria and tropical disease, etc.
Overseas practiceThe GHSP supported one malaria control pilot projectin Tanzania, two maternal and child health pilot projectsin Myanmar and Ethiopia (see Additional file 5), andother related overseas capacity building activities. Forexample, assigning a few cadres to some internationalorganizations on secondments, assisting Sierra Leone toenhance its public health surveillance capacity, and con-ducting consultations and co-sponsoring seminars withinternational public health partners who are working inAfrica. The above activities have improved the ability ofChinese institutions to act overseas in three ways:
(1) By applying the Chinese experience to otherdeveloping countries, PIAs tried to tailor theChinese experience to the local environment in thedesign and implementation process, which helpedimprove the projects’ applicability and contributedto achieving the expected objectives. For example,based on China’s “1–3-7″ model on malariaelimination, a community-based 1, 7-mRCT modelwas established in the malaria control pilot. Thenew model rapidly reduced the malaria burden inthe pilot areas of moderate and high transmissionin Tanzania with a verified decline in the prevalenceof malaria of over 70%. The maternal and childhealth pilot adopted the typical Chinese “three-ringstrategy”, which required finding a linker to connectthe demand, supply and payment together. In
Fig. 6 Topic distribution of GHSP policy briefings. Data source: GHSP project completion report from PMO, Mar 2019
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China, traditional family midwives were trained totake the responsibility as a linker. While in Ethiopiaand Myanmar, depending on their situation, pilotsselected health extension workers (HEW) and as-sistant midwives (AMW) to play the role as linkersrespectively, whose efforts significantly increasedthe provision of RMNCH services in the pilot areas.In Ethiopia, the institutional delivery rate improvedfrom 28 to 55% within the project period, and thesame indicator also saw an increase in Myanmarfrom 30 to 53%.
(2) By managing health development cooperationprojects. There are large differences between thepilot countries and China in terms of political andeconomic systems, social structures, languages andculture etc. The overseas pilot projects alsocommonly last for a long time period, involving alarge amount of funds and many stakeholders. Allthese factors entail potential risks and uncertaintiesin terms of project management. Consequently, theChinese PIAs continuously learned from practice,accumulated experience, and gradually improvedtheir professional expertise through cooperationwith local partners. Meanwhile, confronted with theChina’s current mismatch between the policies andthe need for “going out”, Chinese staff exercisedtheir ability to actively seek solutions to achieve thepilot’s objectives.
(3) By cooperating with the international healthcommunity. Through the GHSP, Chineseinstitutions were able to closely observe and learnhow international communities work. For example,the programme enabled officials from the NHC ofChina to participate in an on-site joint study tour inAfrica with expert groups from the UK and WHO.It also supported seven Chinese cadres to work onsecondment at the WHO and other internationalorganizations. Chinese institutions and individualshave gradually recognized the importance of main-taining close ties with all partners from the inter-national community and have improved theircommunication skills with the external world. Forexample, the Chinese public health team in SierraLeone established technical communication mecha-nisms with local government, partners from theUK, the US and local branches of international or-ganizations to share work results over time.
Partnership buildingDuring the implementation of GHSP, six Centers of Ex-cellence established stable partnerships with a numberof domestic and international institutions (Fig. 7). Do-mestic partners included health-related governmentaldepartments, universities, research institutions, hospitals
and pharmaceutical companies. International partnersincluded international organizations, universities, profes-sional research institutes and other civil society organi-zations in over 20 countries. Through the GHSP, PIAshave enhanced their expertise by learning from eachother thereby achieving mutual benefits. Besides aca-demic achievements, PIAs have also improved theirmanagerial skills in support of the common goal ofcross-border, trans-cultural and multi-disciplinary teams.In addition, pilot projects have boosted the mutual un-derstanding among the governments of China, the UKand the pilot countries as well as other stakeholders.
Reflections and policy implicationsThe necessity of good programme design to ensure theachievements of expected goalsThe GHSP had consecutively been scored A or A+ ineach of the annual reviews by the DFID. The 2018 an-nual review report concluded that: “Experience to datesuggests that the GHSP represents even greater value formoney than was expected in the business case”. In fact,all the successful achievements had benefited from thegood design, which is shown in three features as below.
(1) A well-structured design team. The whole designprocess had lasted for more than 1 year. Composedof experienced experts from the UK, China and Af-rica, the design team had a comprehensive under-standing of the policies and practices ofinternational development assistance and British de-velopment cooperation, the challenges of China’sparticipation in global health, and the requirementsof health development in Africa. The design teamprovided their expertise for the design of GHSP andensured its rigor and rationality as much as pos-sible. In order to maintain the capacities acquiredthrough the GHSP in line with the actual needs ofdeveloping countries, the design team consultedrelevant domestic management personnel and ex-perts in China and took a field trip to Uganda. Theyvisited government departments and senior leaders,professional institutions, and major local inter-national partners. They also visited China’s healthaided sites, such as local hospitals assisted by China,and the China medical team working there.
(2) Accurate problem identification. The design teamidentified three main global health capacityinsufficiencies concerned with China prior to thedesign.1) Although the Chinese academic community has
conducted a number of studies on China’shealth development experience widelyrecognized by the international community,these studies lack the perspective of external
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applicability and are not fully reflected in theglobal pool of knowledge.
2) Although China has a long history in providingDAH to developing countries, the main types ofDAH are limited to sending medical teams andbuilding health infrastructures [33, 34]. Chinalacks understanding of the practices provided byother DAH actors, particularly the bestpractices of contemporary international DAH.Therefore, China urgently needs to learn fromthe mature experience of some Westerncountries, improve its ability to implementpublic health interventions for serious diseasesand other major health issues in developingcountries, and enhance its ability to coordinateactions with other development partners.
3) China has a strong will to actively participate inglobal health governance and contribute toglobal health solutions with China’s wisdom,especially in studying, negotiating andformulating relevant international standards,norms, guidelines, etc., however, China stilllacks the capacity to participate in global healthgovernance and policy development.
(3) Logical correlations established among differentactivities.
In order to solve the problems identified by the designteam, the GHSP’s activities in Components 1–3 wereproposed to enhance capacity in Chinese experience dis-tillation, DAH, and global health governance respect-ively. Component 4 was designed to set up partnershippilots, i.e. applying China’s experience distilled underComponent 1 and international best practices of DAHlearned under Component 2 to one or two selectedAsian or African countries. Therefore, Component 4could be considered as an experiment of the results of
Component 1 and 2. In addition, the enhanced capacityat national level under Component 3 was also expectedto provide policy support for the pilot projects in Com-ponent 4. It turned out that the rational interactionamong different components could be helpful to achievethe final goals.
Building up sustainable development partnershipsthrough pragmatic cooperation“Strengthen the means of implementation and reinvigor-ate the global partnership for sustainable development”is one of the important goals of The United Nations2030 Agenda for Sustainable Development. The Agendastates that, “we will not be able to achieve our ambitiousgoals and targets without a revitalized and enhancedGlobal Partnership”. The specific statement of the cap-acity building goal in SDGs is to “Enhance internationalsupport for implementing effective and targetedcapacity-building in developing countries to support na-tional plans to implement all the sustainable develop-ment goals, including through North-South, South-South and triangular cooperation” [35]. In this regard,the GHSP provided a good example, particularly in thefollowing two aspects.Firstly, the GHSP explored a specific path to transform
“North-South Aid” to “North-South Cooperation”. WhileChina and the UK represent the South and North re-spectively in many typical ways, the GHSP has trans-formed the traditional goal of DAH from “thedevelopment of the recipient countries” to “improvingthe contribution of the recipient countries to globalhealth”, to which the approach was also transformedfrom the “providing financial support” to “building uplong-term cooperation partnerships”. Therefore, thebond between the two countries was successfully trans-formed from “Aid” into “Cooperation”.
Fig. 7 Partnerships established with six Centers of Excellence under the GHSP. Data source: The GHSP project completion report from PMO,Mar 2019
Wang et al. Global Health Research and Policy (2020) 5:13 Page 12 of 17
Specifically, the GHSP partnerships were established attwo different levels:
(1) Global health policy dialogues at the national level.The GHSP established regular high-level dialoguebetween China and the UK. This facilitated the ex-change of views on key current global health issuesand increased mutual understanding between thetwo governments. It also provided a platform forseeking consensus on major health issues in globalhealth and for exploring collaboration in globalhealth governance.
(2) Technical cooperation at institutional level. TheGHSP facilitated institutions and individuals fromboth China and the UK to take joint actions, suchas overseas pilots in Asian and African developingcountries, flagship training workshops on DAH,global health policy research, and managingprojects under trans-cultural environment. Inaddition to close contacts between the two govern-ments, the Chinese PIAs established ties with morethan ten British institutions (academic institutes,think tanks and civil society organizations). Thoserelations have evolved into substantial partnerships,and the outputs generated through the partnershipshave become public goods, contributing to the inter-national community and other developing countries.
In fact, during the implementation of the GHSP,China-UK cooperation had not only entailed discussingprinciples, exchanging opinions and reaching basic con-sensus, but more focused on pragmatic and down-to-earth actions, such as holding regular dialogues at a na-tional level and conducting joint activities at an institu-tional level. These nurtured the authentictransformation from initially being total strangers to be-coming closely-knit partners with a mutual understand-ing. The partnership created in the process would behelpful to contribute to the sustainable development.The GHSP’s “North-South Cooperation” could be amodel for cooperation between the UK and other emer-ging countries, and provide references to further cooper-ation between China and other western countries inboth health and other development fields.Secondly, the GHSP explored a model for triangular
cooperation in global health. Triangular cooperation indevelopment assistance, traditionally speaking, refers tocooperation among three sides: a developed country (orinternational organization) that provides funds and hasrich experience in traditional development assistance, adeveloping country with certain knowledge and capabil-ities (such as China and India), and another developingcountry or a group of developing countries who receivedevelopment assistance [36].
An increasing number of stakeholders believe that tri-angular cooperation is not only a useful channel to con-nect “North-South Aid” and “South-South Cooperation”,but also useful to enhance the effectiveness and efficiencyof development cooperation. In the past, China has carriedout triangular cooperation in non-health fields with inter-national organizations. However, there have been very fewcases of triangular cooperation between China and devel-oped countries in health before the launch of the GHSP.The GHSP has supported three overseas pilots with fund-ing, in which China, the UK and the PCAs of pilot coun-tries jointly determined the pilot themes, while the PIAsof China and the PCAs of the pilot countries were respon-sible for the project design and implementation, and theUK provided technical support and management guidanceas needed.The ultimate success of the overseas pilots can be at-
tributed to the organic triangular cooperation, i.e. fund-ing and consulting from the UK, technical and practicalskills in RMNCH and disease control, and developmentexperience from China, along with the willingness andefforts of the PCAs of the pilot countries.However, there are several limitations. First, the tri-
angular cooperation had involved many stakeholderswith different concerns, which consequently increasedthe time and communication costs. Second, in the pilots,although the PIAs had respected the will of the hostcountries, the local or national governments of thosecountries were not fully involved in the cooperation be-cause the initiators of the triangular cooperation wereChina and the UK, while the pilot projects were de-signed by the PIAs of China and the PCAs of the pilotcountries rather than the local governments. A numberof actions had to be taken to fix this deficiency in thelater stage. Therefore, it is suggested that the communi-cation and engagement of local government should befully considered in the initial stage in future triangularcooperation.
Extending global health engagement through multi-sector reformsWhen the GHSP began, China’s knowledge, researchand training capacity in relation to global health werestill in its infancy stage. Few policy makers and profes-sionals in the health sectors paid continuous attention tocontemporary global health issues. Thanks to the imple-mentation of the GHSP, global health concepts and the-ories have been widely disseminated in China’s healthsector. GHSP-funded policy research activities, especiallythe strategy research, have enabled the Chinese govern-ment to engage in global health governance with aclearer vision and better mission, and to improve the ap-proaches of DAH.
Wang et al. Global Health Research and Policy (2020) 5:13 Page 13 of 17
The GHSP has implemented health intervention pilotsin three Asian and African countries, exploring newmodels for China’s health development cooperation,which is a breakthrough and provides valuable lessonsfor China’s DAH. For example, pilots have explored howto set up public health projects in developing countries,how to improve the effectiveness of DAH through tri-angular cooperation, and how to coordinate with variouslocal civil society organizations (including internationalNGOs working locally). During the implementation ofthe programme, the GHSP managers and the PIAs en-countered difficulties as well. In the process of solvingthese problems, both the GHSP managers and the PIAsgained a deeper understanding of some bottlenecks af-fecting China’s global health participation and the direc-tions for future efforts.Firstly, relevant system and mechanisms are urgently
needed to be developed to match the emerging needs fornew type of DAHs. In recent years, the Chinese governmenthas made many commitments on the global health, such ascooperating with countries and international organizationswho have welcomed the Belt and Road Initiative, supportingthe African CDC, and launching programmes to deal withnew and re-emerging infectious diseases, preventing andcontrolling schistosomiasis, AIDs, and malaria in Africa, etc.[37, 38]. In order to fulfill these commitments, new and in-novative means for providing DAH are required.To ensure that the Chinese health experience and its
technical advantages can be fully exerted in other devel-oping countries, the following three issues need to beaddressed:
(1) An innovative system for “going out”. There is alack of supporting mechanisms and policies fordomestic institutions and personnel “going out” inforeign exchange control, rules for publicinstitutions regarding overseas trips, exit-entry ad-ministration, the legal status and remuneration ofpersonnel, staff health and security, and insurancepolicies, etc.. In fact, some current policies and reg-ulations are not fully able to meet the actual needsof staff working overseas for a long-term, which forexample, delayed working progress, increased man-agement costs, and even posed much higher risks tohealth workers. These problems cannot be solvedby the PIAs themselves, and require national coord-ination. Therefore, many of the policies and regula-tions need to be updated.
(2) More comprehensive selection of “going out”institutions. The PIAs of the GHSP overseas pilotsmainly came from universities and public healthinstitutions. They were characterized by strongtechnical advantages but with relatively insufficientmanagement capacities. With the rising demand for
“going out”, in addition to universities and publichealth institutions, China also needs to learn fromthe general practices of the international communityand provide more opportunities to domestic civilsociety organizations that have a comparatively highlevel of internationalization and sustainable “goingout” capabilities for overseas engagement.
(3) More awareness and expertise on cross-cultural en-vironments. Although the GHSP overseas pilotsachieved the expected results, the process had manytwists and turns. In the early stage, the pilots pro-gressed slowly, partly because the Chinese PIAslacked professional management skills and a goodunderstanding of international management norms,and therefore were unable to manage risks. In fact,project management skills are exactly the key to en-sure effective utilization of resources in DAH. Along-term plan should therefore be developed forthe gradual improvement of project management. Italso suggested that China should intentionally learnproject management practices from traditionaldonor countries or international organizationsthrough triangular cooperation.
Secondly, global health governance requires multi-sectoral involvement. The experience of the inter-national community, especially the UK and other leadingcountries, shows that global health requires full-scale co-ordination and the advocacy of stakeholders from thewhole society. It is definitely not the sole responsibilityof health authorities. Although the GHSP has played animportant role in raising the awareness of China’s healthsector in the concept of global health, the relative advo-cacy for other governmental departments (e.g. theMinistry of Foreign Affairs, the Ministry of Finance, theGeneral Administration of Customs) has been very lim-ited. The Healthy China 2030 Plan issued in 2016clearly stated “Health in All Policies” [31]. The HealthyChina Action (2019–2030) released in July 2019 alsoclarified specific responsibilities of various departments[39]. These government documents have laid a solidfoundation for China’s multi-sectoral participation inglobal health governance. More actions need to be takento encourage information sharing, negotiation and co-ordination among all governmental departments regard-ing global health issues, and to continuously developand publish a whole of government global healthstrategy. In 2018, the Chinese government set up theChina International Development Cooperation Agency(CIDCA), which is helpful not only to integrate healthissues into the DAH domain, but also to formulateChina’s global health action strategies, establish relevantmechanisms, and introduce future national policies thatsupport these strategies.
Wang et al. Global Health Research and Policy (2020) 5:13 Page 14 of 17
Ample room for improvement in global health researchand policy consultationsThe development of relevant policies on global health re-quires a large amount of evidence-based knowledge andanalysis. Therefore, the GHSP focused on improving re-searchers’ ability to provide a high-quality policy consult-ation. On the one hand, the programme encouraged themto build close ties with decision makers. One typical ex-ample was the research on China’s global health strategy.Government authorities were invited to participate in thedesign of the studies and to review periodical results. As aresult, the research team was directly nominated to helpthe government draft the policy document “China GlobalHealth Strategy”. The close ties between the researchersand decision makers not only facilitated the re-searchers’ understanding of the actual needs of thegovernment, but also increased the governmental de-partments’ recognition of their research outputs,thereby catalyzing the transformation of research out-puts into policies. In fact, shortly after the completionof the strategic research activities, the proposed“China Global Health Strategy” was also officially in-troduced as an internal policy document.On the other hand, the GHSP provided professional
training and guidance for writing policy briefings toall research teams. Therefore, in addition to the pub-lications in domestic and international publishinghouses and academic journals, the main researchresults were also presented in the form of theChinese and English policy briefings. These policybriefings provided high quality information to deci-sion makers, which enabled them to quickly under-stand the key issues.Based on the GHSP’s limitations and findings in this
regard, three suggestions for future global health re-search and consultation are recommended:
(1) Both researchers and decision-makers are equallyimportant in evidence-based decision-making. How-ever, the GHSP mainly focused on “improving theresearchers’ abilities to provide information and pol-icy consultation”, and ignored the need to improvethe decision makers’ abilities to select and use infor-mation. In fact, the latter is obviously more import-ant in the process of translating research resultsinto government policies. This aspect should begiven more attention to any future similarprogramme.
(2) Researchers need to realize that their close ties withdecision makers bring both benefits and challenges.For example, researchers are expected to take intoaccount the opinions of governmental officials andat the same time maintain the independence of theresearch team. Furthermore, they need to balance
the “idealism” of scientific research and the“realism” of the opinions of decision-makers.
(3) Global health-related research needs to be fur-ther extended. Although the GHSP funded alarge number of studies on different topics, thereare two research areas that still need to be fur-ther explored.1) The external adaptability of the Chinese health
experience. The GHSP has madegroundbreaking attempts to support studies oninternational adaptation of China’s experiencesin strengthening the health system, RMNCH,and disease control, etc. The final researchoutputs, however, did not fully meet theexpectations due to difficulties in themethodology and implementation. In fact,accurate judgements regarding to what extentChina’s experience can be adapted to theinternational context will become a prerequsitefor China’s future DAH. The demand for thiskind of research regarding health collaborationbetween China and other countries are likely toincrease, especially giving that so manycountries have welcomed cooperation withChina through the Belt and Road Initiative.
2) China’s experiences in using funds frominternational DAH. The GHSP paid muchattention to the research on “China’s previousefforts to provide health assistance to otherdeveloping countries”, while there has been littleresearch on “how China has effectively used thefunds provided by traditional donor countriesand international organizations”. In fact, sinceits acceptance of World Bank loans to supportdomestic health projects in 1980s, China hasbenefited a lot from DAH. It is worthsummarizing how China as a developingcountry has effectively used international DAH,by systematically analyzing the specific practicesof both China and international partners indevelopment assistance. For example, whatstrategies has China taken to ensure theeffective use of foreign assistance? Whatconcessions have been made by theinternational development assistance partners tofit in with China’s context? It is believed thatrecipient countries will gain constructiveknowledge from China’s best practices inrelation to development assistance. Furtherresearch on the above topics may helpprovide useful implications for China’supcoming collaboration with other developingcountries, and thus contributing to globalhealth.
Wang et al. Global Health Research and Policy (2020) 5:13 Page 15 of 17
Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s41256-020-00134-7.
Additional file 1. Chinese version of the full report
Additional file 2. The Main Academic Outputs and DeliverablesProduced by the GHSP.
Additional file 3. International Exchange Activities and TrainingActivities Supported by GHSP.
Additional file 4. The Full List of Policy Briefings Produced by the GHSP.
Additional file 5. Overseas Pilot Projects supported by the GHSP.
AbbreviationsAMR: Anti-microbial resistance; AMW: Assistant midwife; CGHN: China GlobalHealth Network; China CDC: Center for Global Public Health of China CDC;CIDCA: China International Development Cooperation Agency;CNHDRC: China National Health Development Research Center;CPSM: Center for Project Supervision and Management of National HealthCommission; DAH: Development assistance for health; DCIH: Developmentcooperation in health; DFID: Department of International Development;FUGHI: Fudan University Global Health Institute; FUSPH: Fudan UniversitySchool of Public Health; GHSP: Global Health Support Programme;HEW: Health extension worker; LICs: Low-income Countries; LMICs: Low-to-middle income countries; MDGs: Millennium Development Goals;MOFCOM: Ministry of Commerce; MoU: Memorandum of understanding;MSI: Marie Stopes International; NCDs: Non-communicable diseases;NGOs: Non-governmental organizations; NHC: National Health Commission;NIPD: National Institute for Parasitic Diseases of China CDC; PCAs: Projectcooperative agencies; PIAs: Project implementing agencies; PKUSPH: PekingUniversity School of Public Health; PMM: Programme Management Manual;PMO: Project management office; RMNCH: Reproductive, maternal and childhealth; SDGs: Sustainable development goals; SOC: Strategic oversightcommittee; TAG: Technical advisory group; TOR: Terms of Reference;UHC: Universal health coverage; WHO: World Health Organization
AcknowledgementsWe gratefully acknowledge all the people who directly or indirectlyparticipated in the GHSP: the officials, team leaders, designers, researchers,implementers, managers, evaluators, and consultants from China, UK, andother countries. Thanks for their foresight, determination, wisdom,dedication, and efforts, which created, facilitated and perfected the GHSP,and enabled us to gain the valuable opportunity to present it to globalaudience through this paper. We would also like to thank Ms. Lili Wang,Yujie Yang, and Yuexin Chen on part of data sorting and figure editing; Prof.Fei Yan, Ji Liang and Xu Qian of Fudan University and Dr. Duoquan Wangand Prof. Xiaonong Zhou of NIPD on providing the texts of two pilot casesin Additional file 5.
Authors’ contributionsXW and TX both conceptualized this report. XW and YC drafted the firstversion of the manuscript and completed all the following revisions. PL, TXand YY critically reviewed the manuscript and provided detailed suggestionsand revisions; XC and JC gathered and sorted the basic data of the GHSP; YCran all descriptive analysis and made the tables and figures; XC and YCprepared all Additional files. YC also contributed to the translation of theChinese version into English. ZZ supervised the whole work. All the authorsread and approved the final manuscript.
FundingThis work was supported by China-UK Global Health Support Programmefunded by UK DFID.
Availability of data and materialsPlease contact author for data requests.
Ethics approval and consent to participateNot applicable.
Consent for publicationNot applicable.
Competing interestsThe authors declare that they have no competing interests.
Author details1Center for Project Supervision and Management, National HealthCommission of the People’s Republic of China, Beijing 100044, China.2School of Public Health, Peking University, Beijing 100191, China. 3GraduateSchool of the Chinese Academy of Social Sciences, Beijing 102488, China.4School of Health Sciences/Global Health Institute, Wuhan University, Wuhan430071, China.
Received: 5 September 2019 Accepted: 13 February 2020
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