The necessity of good programme design to ensure the achievements of expected goals
The GHSP had consecutively been scored A or A+ in each of the annual reviews by the DFID. The 2018 annual review report concluded that: “Experience to date suggests that the GHSP represents even greater value for money than was expected in the business case”. In fact, all the successful achievements had benefited from the good design, which is shown in three features as below.
A well-structured design team. The whole design process had lasted for more than 1 year. Composed of experienced experts from the UK, China and Africa, the design team had a comprehensive understanding of the policies and practices of international development assistance and British development cooperation, the challenges of China’s participation in global health, and the requirements of health development in Africa. The design team provided their expertise for the design of GHSP and ensured its rigor and rationality as much as possible. In order to maintain the capacities acquired through the GHSP in line with the actual needs of developing countries, the design team consulted relevant domestic management personnel and experts in China and took a field trip to Uganda. They visited government departments and senior leaders, professional institutions, and major local international partners. They also visited China’s health aided sites, such as local hospitals assisted by China, and the China medical team working there.
Accurate problem identification. The design team identified three main global health capacity insufficiencies concerned with China prior to the design.
Although the Chinese academic community has conducted a number of studies on China’s health development experience widely recognized by the international community, these studies lack the perspective of external applicability and are not fully reflected in the global pool of knowledge.
Although China has a long history in providing DAH to developing countries, the main types of DAH are limited to sending medical teams and building health infrastructures [33, 34]. China lacks understanding of the practices provided by other DAH actors, particularly the best practices of contemporary international DAH. Therefore, China urgently needs to learn from the mature experience of some Western countries, improve its ability to implement public health interventions for serious diseases and other major health issues in developing countries, and enhance its ability to coordinate actions with other development partners.
China has a strong will to actively participate in global health governance and contribute to global health solutions with China’s wisdom, especially in studying, negotiating and formulating relevant international standards, norms, guidelines, etc., however, China still lacks the capacity to participate in global health governance and policy development.
Logical correlations established among different activities.
In order to solve the problems identified by the design team, the GHSP’s activities in Components 1–3 were proposed to enhance capacity in Chinese experience distillation, DAH, and global health governance respectively. Component 4 was designed to set up partnership pilots, i.e. applying China’s experience distilled under Component 1 and international best practices of DAH learned under Component 2 to one or two selected Asian or African countries. Therefore, Component 4 could be considered as an experiment of the results of Component 1 and 2. In addition, the enhanced capacity at national level under Component 3 was also expected to provide policy support for the pilot projects in Component 4. It turned out that the rational interaction among different components could be helpful to achieve the final goals.
Building up sustainable development partnerships through pragmatic cooperation
“Strengthen the means of implementation and reinvigorate the global partnership for sustainable development” is one of the important goals of The United Nations 2030 Agenda for Sustainable Development. The Agenda states that, “we will not be able to achieve our ambitious goals and targets without a revitalized and enhanced Global Partnership”. The specific statement of the capacity building goal in SDGs is to “Enhance international support for implementing effective and targeted capacity-building in developing countries to support national plans to implement all the sustainable development goals, including through North-South, South-South and triangular cooperation” . In this regard, the GHSP provided a good example, particularly in the following two aspects.
Firstly, the GHSP explored a specific path to transform “North-South Aid” to “North-South Cooperation”. While China and the UK represent the South and North respectively in many typical ways, the GHSP has transformed the traditional goal of DAH from “the development of the recipient countries” to “improving the contribution of the recipient countries to global health”, to which the approach was also transformed from the “providing financial support” to “building up long-term cooperation partnerships”. Therefore, the bond between the two countries was successfully transformed from “Aid” into “Cooperation”.
Specifically, the GHSP partnerships were established at two different levels:
Global health policy dialogues at the national level. The GHSP established regular high-level dialogue between China and the UK. This facilitated the exchange of views on key current global health issues and increased mutual understanding between the two governments. It also provided a platform for seeking consensus on major health issues in global health and for exploring collaboration in global health governance.
Technical cooperation at institutional level. The GHSP facilitated institutions and individuals from both China and the UK to take joint actions, such as overseas pilots in Asian and African developing countries, flagship training workshops on DAH, global health policy research, and managing projects under trans-cultural environment. In addition to close contacts between the two governments, the Chinese PIAs established ties with more than ten British institutions (academic institutes, think tanks and civil society organizations). Those relations have evolved into substantial partnerships, and the outputs generated through the partnerships have become public goods, contributing to the international community and other developing countries.
In fact, during the implementation of the GHSP, China-UK cooperation had not only entailed discussing principles, exchanging opinions and reaching basic consensus, but more focused on pragmatic and down-to-earth actions, such as holding regular dialogues at a national level and conducting joint activities at an institutional level. These nurtured the authentic transformation from initially being total strangers to becoming closely-knit partners with a mutual understanding. The partnership created in the process would be helpful to contribute to the sustainable development. The GHSP’s “North-South Cooperation” could be a model for cooperation between the UK and other emerging countries, and provide references to further cooperation between China and other western countries in both health and other development fields.
Secondly, the GHSP explored a model for triangular cooperation in global health. Triangular cooperation in development assistance, traditionally speaking, refers to cooperation among three sides: a developed country (or international organization) that provides funds and has rich experience in traditional development assistance, a developing country with certain knowledge and capabilities (such as China and India), and another developing country or a group of developing countries who receive development assistance .
An increasing number of stakeholders believe that triangular cooperation is not only a useful channel to connect “North-South Aid” and “South-South Cooperation”, but also useful to enhance the effectiveness and efficiency of development cooperation. In the past, China has carried out triangular cooperation in non-health fields with international organizations. However, there have been very few cases of triangular cooperation between China and developed countries in health before the launch of the GHSP. The GHSP has supported three overseas pilots with funding, in which China, the UK and the PCAs of pilot countries jointly determined the pilot themes, while the PIAs of China and the PCAs of the pilot countries were responsible for the project design and implementation, and the UK provided technical support and management guidance as needed.
The ultimate success of the overseas pilots can be attributed to the organic triangular cooperation, i.e. funding and consulting from the UK, technical and practical skills in RMNCH and disease control, and development experience from China, along with the willingness and efforts of the PCAs of the pilot countries.
However, there are several limitations. First, the triangular cooperation had involved many stakeholders with different concerns, which consequently increased the time and communication costs. Second, in the pilots, although the PIAs had respected the will of the host countries, the local or national governments of those countries were not fully involved in the cooperation because the initiators of the triangular cooperation were China and the UK, while the pilot projects were designed by the PIAs of China and the PCAs of the pilot countries rather than the local governments. A number of actions had to be taken to fix this deficiency in the later stage. Therefore, it is suggested that the communication and engagement of local government should be fully considered in the initial stage in future triangular cooperation.
Extending global health engagement through multi-sector reforms
When the GHSP began, China’s knowledge, research and training capacity in relation to global health were still in its infancy stage. Few policy makers and professionals in the health sectors paid continuous attention to contemporary global health issues. Thanks to the implementation of the GHSP, global health concepts and theories have been widely disseminated in China’s health sector. GHSP-funded policy research activities, especially the strategy research, have enabled the Chinese government to engage in global health governance with a clearer vision and better mission, and to improve the approaches of DAH.
The GHSP has implemented health intervention pilots in three Asian and African countries, exploring new models for China’s health development cooperation, which is a breakthrough and provides valuable lessons for China’s DAH. For example, pilots have explored how to set up public health projects in developing countries, how to improve the effectiveness of DAH through triangular cooperation, and how to coordinate with various local civil society organizations (including international NGOs working locally). During the implementation of the programme, the GHSP managers and the PIAs encountered difficulties as well. In the process of solving these problems, both the GHSP managers and the PIAs gained a deeper understanding of some bottlenecks affecting China’s global health participation and the directions for future efforts.
Firstly, relevant system and mechanisms are urgently needed to be developed to match the emerging needs for new type of DAHs. In recent years, the Chinese government has made many commitments on the global health, such as cooperating with countries and international organizations who have welcomed the Belt and Road Initiative, supporting the African CDC, and launching programmes to deal with new and re-emerging infectious diseases, preventing and controlling schistosomiasis, AIDs, and malaria in Africa, etc. [37, 38]. In order to fulfill these commitments, new and innovative means for providing DAH are required.
To ensure that the Chinese health experience and its technical advantages can be fully exerted in other developing countries, the following three issues need to be addressed:
An innovative system for “going out”. There is a lack of supporting mechanisms and policies for domestic institutions and personnel “going out” in foreign exchange control, rules for public institutions regarding overseas trips, exit-entry administration, the legal status and remuneration of personnel, staff health and security, and insurance policies, etc.. In fact, some current policies and regulations are not fully able to meet the actual needs of staff working overseas for a long-term, which for example, delayed working progress, increased management costs, and even posed much higher risks to health workers. These problems cannot be solved by the PIAs themselves, and require national coordination. Therefore, many of the policies and regulations need to be updated.
More comprehensive selection of “going out” institutions. The PIAs of the GHSP overseas pilots mainly came from universities and public health institutions. They were characterized by strong technical advantages but with relatively insufficient management capacities. With the rising demand for “going out”, in addition to universities and public health institutions, China also needs to learn from the general practices of the international community and provide more opportunities to domestic civil society organizations that have a comparatively high level of internationalization and sustainable “going out” capabilities for overseas engagement.
More awareness and expertise on cross-cultural environments. Although the GHSP overseas pilots achieved the expected results, the process had many twists and turns. In the early stage, the pilots progressed slowly, partly because the Chinese PIAs lacked professional management skills and a good understanding of international management norms, and therefore were unable to manage risks. In fact, project management skills are exactly the key to ensure effective utilization of resources in DAH. A long-term plan should therefore be developed for the gradual improvement of project management. It also suggested that China should intentionally learn project management practices from traditional donor countries or international organizations through triangular cooperation.
Secondly, global health governance requires multi-sectoral involvement. The experience of the international community, especially the UK and other leading countries, shows that global health requires full-scale coordination and the advocacy of stakeholders from the whole society. It is definitely not the sole responsibility of health authorities. Although the GHSP has played an important role in raising the awareness of China’s health sector in the concept of global health, the relative advocacy for other governmental departments (e.g. the Ministry of Foreign Affairs, the Ministry of Finance, the General Administration of Customs) has been very limited. The Healthy China 2030 Plan issued in 2016 clearly stated “Health in All Policies” . The Healthy China Action (2019–2030) released in July 2019 also clarified specific responsibilities of various departments . These government documents have laid a solid foundation for China’s multi-sectoral participation in global health governance. More actions need to be taken to encourage information sharing, negotiation and coordination among all governmental departments regarding global health issues, and to continuously develop and publish a whole of government global health strategy. In 2018, the Chinese government set up the China International Development Cooperation Agency (CIDCA), which is helpful not only to integrate health issues into the DAH domain, but also to formulate China’s global health action strategies, establish relevant mechanisms, and introduce future national policies that support these strategies.
Ample room for improvement in global health research and policy consultations
The development of relevant policies on global health requires a large amount of evidence-based knowledge and analysis. Therefore, the GHSP focused on improving researchers’ ability to provide a high-quality policy consultation. On the one hand, the programme encouraged them to build close ties with decision makers. One typical example was the research on China’s global health strategy. Government authorities were invited to participate in the design of the studies and to review periodical results. As a result, the research team was directly nominated to help the government draft the policy document “China Global Health Strategy”. The close ties between the researchers and decision makers not only facilitated the researchers’ understanding of the actual needs of the government, but also increased the governmental departments’ recognition of their research outputs, thereby catalyzing the transformation of research outputs into policies. In fact, shortly after the completion of the strategic research activities, the proposed “China Global Health Strategy” was also officially introduced as an internal policy document.
On the other hand, the GHSP provided professional training and guidance for writing policy briefings to all research teams. Therefore, in addition to the publications in domestic and international publishing houses and academic journals, the main research results were also presented in the form of the Chinese and English policy briefings. These policy briefings provided high quality information to decision makers, which enabled them to quickly understand the key issues.
Based on the GHSP’s limitations and findings in this regard, three suggestions for future global health research and consultation are recommended:
Both researchers and decision-makers are equally important in evidence-based decision-making. However, the GHSP mainly focused on “improving the researchers’ abilities to provide information and policy consultation”, and ignored the need to improve the decision makers’ abilities to select and use information. In fact, the latter is obviously more important in the process of translating research results into government policies. This aspect should be given more attention to any future similar programme.
Researchers need to realize that their close ties with decision makers bring both benefits and challenges. For example, researchers are expected to take into account the opinions of governmental officials and at the same time maintain the independence of the research team. Furthermore, they need to balance the “idealism” of scientific research and the “realism” of the opinions of decision-makers.
Global health-related research needs to be further extended. Although the GHSP funded a large number of studies on different topics, there are two research areas that still need to be further explored.
The external adaptability of the Chinese health experience. The GHSP has made groundbreaking attempts to support studies on international adaptation of China’s experiences in strengthening the health system, RMNCH, and disease control, etc. The final research outputs, however, did not fully meet the expectations due to difficulties in the methodology and implementation. In fact, accurate judgements regarding to what extent China’s experience can be adapted to the international context will become a prerequsite for China’s future DAH. The demand for this kind of research regarding health collaboration between China and other countries are likely to increase, especially giving that so many countries have welcomed cooperation with China through the Belt and Road Initiative.
China’s experiences in using funds from international DAH. The GHSP paid much attention to the research on “China’s previous efforts to provide health assistance to other developing countries”, while there has been little research on “how China has effectively used the funds provided by traditional donor countries and international organizations”. In fact, since its acceptance of World Bank loans to support domestic health projects in 1980s, China has benefited a lot from DAH. It is worth summarizing how China as a developing country has effectively used international DAH, by systematically analyzing the specific practices of both China and international partners in development assistance. For example, what strategies has China taken to ensure the effective use of foreign assistance? What concessions have been made by the international development assistance partners to fit in with China’s context? It is believed that recipient countries will gain constructive knowledge from China’s best practices in relation to development assistance. Further research on the above topics may help provide useful implications for China’s upcoming collaboration with other developing countries, and thus contributing to global health.