China’s complicated role in malaria control in Africa

Ghana has taken a remarkable step in the fight against malaria by becoming the first country in the world to approve the R21/Matrix-M vaccine. It’s poised to be highly effective in young children from 5 months to 36 months, the age group with the highest risk. The approval highlights the continued urgency required to combat this disease, which remains a significant threat to human health and a considerable social and economic burden.

Low- and middle-income countries like Ghana record hundreds of thousands of malaria deaths each year. According to the World Health Organization, roughly 619,000 people globally died from malaria in 2021, 96% of them from vulnerable populations in Africa, where the disease is both endemic and perennial. Africa is home to some of the most effective malaria vectors, which are known for their high capacity to transmit the malaria parasite to humans, and incorporating vaccines into the elimination strategies will help bring the continent closer to eliminating malaria.

In order to elevate the fight to a higher level, it is critical for nontraditional donors, especially China, to get involved. However, China also has to address some serious questions.

In 2022, the World Health Organization estimated that $7.3 billion is necessary to sustain anti-malaria efforts, including harnessing innovation and improving vaccine research. However, as of 2021, only $3.5 billion had been invested. This has left a significant funding gap that needs to be addressed to ensure that the disease is effectively controlled and prevented from spreading. The current funding landscape for global malaria programs heavily relies on a limited number of major donors. Unfortunately, it is unlikely that these donors will increase their contributions significantly. This puts a greater strain on the already limited resources and makes it more challenging to achieve the necessary funding to sustain efforts to control the disease.

Traditional donors such as the U.S., U.K., Japan, and Australia have provided crucial financial and technical support to countries struggling with malaria, contributing to disease control and elimination efforts. In addition to these donor governments, institutions like the Global Fund and the World Bank have played a pivotal role in fighting malaria. Private sector entities and philanthropic funders have also contributed through support for research and development of new tools, interventions, and strategies.

That brings us to China, which achieved malaria-free certification from the WHO in 2021 after a 70-year sustained effort in malaria control and has increasingly played a role in fighting the disease in Africa. While many African governments have welcomed support from China, some Global North countries seem uneasy about it. One of the main criticisms of China’s involvement in malaria control in Africa is that it is part of a broader geopolitical agenda aimed at increasing China’s influence in the region. Some have argued that China’s investments in malaria control are motivated not by a desire to help those in need but rather by a desire to expand its political and economic power in Africa. This view is reinforced by the fact that China has been accused of using its aid and investment in Africa to gain access to valuable natural resources and to create new markets for Chinese goods and services.

But this skepticism concerning Chinese influence is not only worrisome but also dangerous. When funding for malaria programs is insufficient, the most vulnerable communities suffer the most, as they lack access to critical preventive and treatment interventions like mosquito nets and vaccines. This reinforces existing health inequalities and undermines efforts to address the burden of malaria in Africa. China’s financial resources, skilled personnel, and necessary materials will be crucial in facilitating the distribution of vaccines across Africa. Its past efforts to provide lifesaving insecticide-treated bed nets and anti-malarial drugs, as well as strengthen local and regional health systems for malaria diagnosis and treatment, serve as a strong foundation for this endeavor.

China’s efforts to combat malaria began in approximately 1963 and have predominantly involved the funding of medical teams and the provision of supplies such as antimalarials. However, China has been relatively reserved in publicizing these initiatives. Our work at the Ignite Global Health Research Lab has analyzed China’s hidden role in malaria control efforts. China has become the world’s largest provider of official sector development financing — and it’s offering double the U.S.’s annual spending.

Most of its aid has been directed toward Western and Eastern Africa countries, with Central and Southern Africa receiving a smaller proportion. The Democratic Republic of Congo, the Central African Republic, and Uganda were the countries with the highest number of medical teams from China.

There could be several reasons why China has kept quiet about how it funds health in Africa. One is that China’s approach to health funding in Africa is not aligned with international norms and standards. For example, the critics might be right — China’s health funding may be due to its broader strategic interests in Africa, rather than solely focusing on improving health outcomes in recipient countries.

China may also be concerned about being perceived as interfering in the internal affairs of African countries. By being quiet about its health funding activities, China may be trying to avoid accusations of neo-colonialism or undermining the sovereignty of African governments. Or China’s lack of transparency on this work may simply be due to a lack of effective communication channels or a focus on maintaining confidentiality as a core tenant of its foreign aid activities.

Whatever the reason, China’s quiet approach to health funding in Africa could have negative consequences. Without clear information about China’s health funding priorities and activities, it is difficult for other countries and organizations to coordinate their efforts effectively and maximize the impact of health funding. Additionally, it makes it difficult to assess the effectiveness of China’s health funding initiatives and ensure they are aligned with international norms and standards.

Other countries and funders have some very legitimate concerns about China’s involvement in Africa. One is that China’s approach to investment and development might not prioritize the long-term interests of African countries and their people. For example, critics have accused China of engaging in debt-trap diplomacy, where loans are extended to African countries with high-interest rates and harsh conditions attached, ultimately leading to unsustainable debt burdens. Additionally, there are concerns about China’s lack of transparency and accountability in its dealings with African governments, which could enable corruption and undermine governance. In particular, regarding health, there is a concern that China’s approach to development in Africa may not align with the United Nations’ Sustainable Development Goals and could hinder progress toward achieving them.

Nevertheless, it is undeniable that Chinese officials and medical experts have extensive knowledge of infectious diseases in Africa, partly due to the success of malaria elimination efforts within China and a long-term medical cooperation with African countries characterized by an existing network of doctors and medical staff. Most recently, Chinese researchers discovered artemisinin-based combination therapies, which have been recommended by the WHO as a treatment for malaria, and China is the largest manufacturer of insecticide-treated bed nets, which have been instrumental in preventing an estimated 68% percent of malaria cases in Africa between 2000 and 2015. It is imperative that we leverage these resources to keep Africa on track with its malaria control efforts. Failure to do so could have dire consequences, including a surge in malaria cases and preventable deaths.

The fight against malaria is a global effort requiring all stakeholders’ collaboration. While China’s involvement in malaria control in Africa brings valuable resources, its approach must be transparent, accountable, and aligned with African nations and their people’s needs and priorities. Chinese investments in malaria control cannot come at the expense of vital development priorities. But by working together and providing that all stakeholders are on the same page, we can make significant progress toward eliminating malaria in Africa and improving health outcomes for millions of people.

Julius Nyerere Odhiambo is a postdoctoral researcher at the William & Mary Global Research Institute. Aaron Tavel is a research assistant at Ignite, a multidisciplinary research lab focusing on effective, efficient and equitable distribution of global health resources at the William & Mary Global Research Institute. Carrie Dolan is associate professor of kinesiology and director of Ignite.