Dollar Diplomacy Can Be Healthy For China

Beijing is handy at tapping into international funds for HIV/AIDS prevention and treatment. Here's why sending money to China also helps the rest of the world.


Ambassador Jack Chow’s recent FP article, China’s Billion-Dollar Aid Appetite, is misleading in its characterization that multilateral development aid sent to China to address HIV/AIDS, tuberculosis, and malaria comes at the expense of sub-Saharan countries. Undoubtedly, while China can and should commit more of its own resources to meeting domestic as well as global public health needs, U.S. development assistance, whether bilateral or through multilateral mechanisms, should not be seen as a zero-sum endeavor where one recipient benefits at the expense of another.

Further, the article overlooks the many ways — besides simply financial — that Global Fund dollars are good for China and the world. Proposed by former U.N. Secretary-General Kofi Annan in 2001 and established in January 2002, the Global Fund is a performance-based organization that awards grants based on individual need and the quality of proposals that it receives. It is also a values-based organization, requiring recipients to have transparent, accountable, and inclusive governance mechanisms. Grant applications and project implementation in each nation are overseen by an elected a board of governors, drawing representatives from government, U.N. and donor agencies, NGOs, businesses, and people living with the diseases. This board is known as the "Country Coordinating Mechanism" (CCM).

Ambassador Chow is correct in asserting that China’s Ministry of Health is weak in comparison to other Chinese ministries and that its initial motivation to apply for international funds was its inability to garner adequate support from its own bureaucracy. Yet his conclusion is incomplete. It is precisely for these two reasons, governance and resources, that the role of the Global Fund is particularly valuable for China, as well as for any country with a stake in a healthy, stable, and well-governed China.

Global Fund financing, which began to flow to Beijing in 2004, has helped China rebuild its health system, which failed so spectacularly during the SARS crisis in 2002-2003. Global Fund resources have been deployed quickly and efficiently to project sites in nearly 3,000 cities and counties throughout China, bypassing bureaucratic restrictions and political allocation processes that might have seen funds earmarked for health projects diverted elsewhere, particularly by local officials.

This relatively streamlined system enables health officials in China to demonstrate the value and effectiveness of investments in public health projects to top officials [KCD1] outside of the public health stovepipe. It is still true, however — as Chow rightly points out — that other inefficiencies and the sheer scale of China’s health-care system present challenges for governance; there is a growing need for improved oversight.

Fortunately, the Global Fund introduces important regulatory norms to the Chinese government; particularly the importance of public participation in policymaking, transparency, accountability and even aspects of human rights, such as international standards protecting for protecting the rights of human test subjects. The Global Fund’s commitment to governance and public participation has the potential to make a significant contribution to Chinese political reform over time. Ambassador Chow is correct that the bulk of Global Fund grants are channeled to Chinese government departments, while grassroots organizations working on HIV/AIDS preventions continue to face an array of restrictions on their activities in China. However, to begin to address thi
s concern, the Global Fund does require that recipient countries meet standards for transparency and citizen participation in governing organizations as well as programs. The Global Fund’s minimum requirements call for 40 percent of the board to come from the private sector. Non-government stakeholders should elect their own representatives in a transparent and well documented manner. (In 2005, Burma lost its grants because it did not meet the Global Fund’s governance expectations.)

In 2006, the Chinese Center for Disease Control and Prevention, under the Ministry of Health organized the election of a civil society representative to the CCM, causing an uproar amongst some AIDS nonprofit groups in China. Under pressure from U.N. agencies and the Global Fund secretariat in Geneva, China eventually permitted civil-society representatives to organize themselves and hold free elections to determine who would represent them on the committee. This is the first time that Beijing has allowed non-members of the Communist Party to organize a national, independent election process. The CCM represents a rare instance in which government officials sit as equals with civil society on a decision-making body in China.

To its credit, since the aftermath of the SARS outbreak in 2003, the health ministry has been outspoken in its support for "all sectors of society" playing a role in public health efforts; it has even provided grants to grassroots organizations to implement some AIDS prevention programs.  Previously, the government had never provided significant funding to grassroots groups to carry out public health work, which had previously been considered the government’s exclusive responsibility.

Granted, change has not come overnight. Engaging the Chinese government and encouraging public participation and democratic processes must be viewed as a long-term endeavor. Although individual officials, including many in Beijing, increasingly see the value of involving civil society in their work, there remains intense government pressure from other quarters to tightly control civil society.

The Global Fund represents a dialogue between the Chinese government and international community, not simply a flow of aid money. The interaction provides a unique opportunity to promote the uptake of such universal values as transparency, accountability and inclusion through democratic processes.

The United States should continue to support the Global Fund and its portfolio in China. It is undoubtedly in the U.S. national interest to contribute to China’s capacity to prevent the spread of infectious disease. With the relentless pace of economic integration and growth of people-to-people contacts, improving China’s health system benefits Americans, both directly and indirectly.

Finally, the U.S. contribution to the Global Fund and its continued support for China is an important manifestation of U.S. intentions toward China. It is particularly important at a time of heightened tensions in the bilateral relationship — over maritime sovereignty, human rights, Taiwan, Tibet and trade — that the United States signals that it welcomes China’s participation in the international community and seeks its acceptance and ultimately validation of international norms, such as those espoused by the Global Fund.

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