When it comes to global health, China is on President Trump's mind, and on the mind of his critics.
On inauguration night, Trump signed an executive order aimed at pulling the U.S. out of the World Health Organization. As he did, he spoke about one thing: China. He said China doesn't pay its fair share to the U.N health organization. At other times, he's said China "controls" WHO.
Trump's critics point to the same concern — China — when condemning Trump's decision to sever ties with the WHO.
"We won't be at the table. China will," says Lawrence Gostin, a professor of global health law at Georgetown University.
Similarly, Trump's executive action aimed at pausing almost all foreign aid for 90 days and hobbling much of the United States Agency for International Development's work have raised concerns about China.
"[Freezing aid] is going to destabilize countries [who received U.S. aid]," says Andrew Natsios, who led USAID under President George W. Bush. "You know what they're doing? They're going to China and Russia. Now, why would we help China?"
Experts say the dynamic between the U.S. and China's global health aid must be placed in the broader context.
"The key to understanding what's going on here [is] it has nothing to do with global health. It has everything to do with the competition and the rivalry between those two powers," says Nadège Rolland, a distinguished fellow on China Studies at The National Bureau of Asian Research.
Historically, the U.S. has been the single largest donor to global health work — and China has not factored prominently. However, over the past two decades, China has ramped up its investments in low- and middle-income countries. And while much of that investment is in mining, transportation and energy, there is a growing focus on health, including through an initiative called the Health Silk Road.
It is "very hard" to figure out exactly how much the Chinese government puts toward global health, says Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations and a professor at Seton Hall University's School of Diplomacy and International Relations. Not only does China not disclose how much it spends or what it's trying to achieve, he says, but the money is flowing from various different branches of the Chinese government and not consolidated under one roof. For example, money could come from the National Health Commission or the China International Development Cooperation Agency. And the aid is not going to just a few international organizations but to scores of different countries.
Academics have scoured official records and news stories to build a database called AidData that found China invested over a trillion dollars in more than 20,000 foreign development projects between 2000 and 2021. This includes over $5 billion in health aid between 2000 and 2017.
These estimates do indicate that China puts far less into global health than what the U.S. had spent before Trump's freeze on foreign aid. But, experts say, China is an emerging force with a very different approach than the U.S., so it's worth understanding — and their strategies raise concerns among U.S. experts.
How does China give health aid?
The U.S. tends to invest its aid dollars through big, international organizations and nongovernmental organizations.
For example, before Trump's second term, the U.S. was WHO's biggest donor, giving $1.284 billion during 2022 and 2023 — hundreds of millions of dollars more than second-place Germany. China is not even in the top 10 contributors. For the 2024-2025 budget, WHO says the U.S. is contributing a little over $700 million and China just over $180 million.
The nongovernmental organizations range from large to small, all of them working directly with aid recipients. For example, the U.S. funds numerous programs run by Save the Children, which is on the ground in 120 countries, all the way down to small charities like the medical group Vykhid in Mykolaiv, Ukraine, which treats HIV and tuberculosis patients.
By contrast, China, often gives aid directly to another country, moving funds from one government straight to another.
Public health scholars debate which approach is better for global health. They say China's approach means a lot less red tape and administrative demands for those receiving aid.
"U.S. funding can be a huge burden in terms of reporting requirements," says Carrie Dolan, the director of Ignite Global Health Research Lab at William & Mary, who studies Chinese international health aid. "If you're working in a low- and middle-income country, it can take away from your ability to actually do the work."
However, China's tactic also means a lot less information about what's going on. "They don't value transparency [and] accountability," says Huang.
The U.S. has historically sought to cultivate good governance in recipient countries, he says, including supporting independent media outlets that hold authorities accountable as well as pro-democracy groups.
As Dolan has examined specific health projects in several African countries, she's found that recipient nations often like the Chinese approach — but it may not lead to better health outcomes.
"What we're seeing isn't that these countries are taking the money and then using it strategically within their public health needs. We see it being more subject to corruption," she says, perhaps because there is little public oversight and accountability.
What kind of health aid does China give?
Going back to the 1960s, China has sent medical teams to treat people in other countries.
"It was part of a strategy that was meant to promote the solidarity between oppressed people and countries of the Third World — that's how Mao called them — so that was a very politically motivated effort," explains Rolland.
China continues to send medical teams but it now does a lot more than that.
"Their focus has been on building infrastructure — like hospitals, clinics, the provision of medicines," says Huang.
And researchers are finding that these brick-and-mortar donations are often located near China's other investments.
"We see them popping up near areas where they're building infrastructure, like big roads," says Dolan.
Starting in 2013, China has undertaken a huge effort to build infrastructure around the world, called the Belt and Road Initiative. This can be beneficial to the recipient country, but it also helps Chinese companies gain access to valuable resources such as minerals, oil and ports.
But, Dolan notes, there's often no plan to maintain hospital equipment such as MRI and x-ray machines. In her work in the field, she's seen plenty of machines donated by China that are now broken and collecting dust.
Up until the sudden freeze in foreign aid under President Trump, the U.S. approach has been very different from China's.
The U.S. is more focused on working with local partners "to help them learn about the kinds of public health initiatives we're doing and then help them adopt those strategies," says Dolan, adding that the goal is that local partners can then continue doing the work long-term on its own without continued U.S. involvement.
What does China gain from global health work?
For both the U.S. and China, global health work is often part of a broader political and economic agenda. One of the main things the countries have aimed to achieve with foreign assistance is goodwill and influence in recipient countries.
Natsios, the former USAID head, worries that Trump's halt to foreign aid is damaging the U.S. at a critical moment as it competes with China, Russia, Iran and others.
"We just lost the battle. And it's not because we were fighting and we lost. We took our troops and we went home. That's what we did," he says.
China is also looking for goodwill as well as the ability to exert political muscle. For example, in 2021, when COVID vaccines were in high demand and short supply, China sought to supply vaccines it developed to Latin American countries in exchange for strengthening ties with China and severing relations with Taiwan.
Experts say there's another goal: Market share.
When China builds a hospital or gives a country a lump sum of money, it can exert more control over where the country buys supplies like medications, vaccines and medical equipment.
"China wants to become a leader in [the] biotech and pharmaceutical sectors," says Rolland. "And the promotion of this vision for global health is supporting this very concrete business activity — like selling vaccines."
Many experts have raised concerns about this goal since Chinese medications and vaccines do not undergo testing as rigorous or transparent as in the U.S.
There's another Chinese end-game regarding aid recipients, Rolland adds. These hospitals, clinics and medical imaging centers are sending something to China: data.
"[China says] 'we can build a hospital, but we can also offer the digital architecture that will help you collect medical files' — that [data] will then be hosted in a cloud that is located in China," Rolland says.
"Being able to harvest that kind of data — that is diverse and massive — is a huge advantage in developing scientific hypotheses and advances," she says.
China's approach to health aid is "very systematic and strategic," says Rolland. And Trump's sudden suspension of U.S. foreign aid — including most types of health assistance — "just plays very well in the narrative and image that China wants to project to the outside world as the adult in the room," she says.
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