China-Africa Health Silk Road:Practices,Challenges and Solutions

Zeng Aiping

Major changes unseen in a century are taking place in our world， and the COVID-19 pandemic has even accelerated this process. Global governance faces a real test of multipolarity versus unipolarity， openness versus isolation， and cooperation versus confrontation. With the changing international landscape， the fourth session of the 13th National Peoples Congress in March 2021 adopted the Outline of the 14th Five-Year Plan （2021-2025） for National Economic and Social Development and the Long-Range Objectives Through the Year 2035. With a long-term and holistic perspective， the Outline echoes Chinas pursuit of high-quality Belt and Road cooperation.1 This requires China and other countries to empower the Belt and Road cooperation， among which there is a pressing need for global health governance cooperation. When COVID-19 as a once-in-a-century health crisis broke out at the beginning of 2020， we human beings have once again witnessed how ruthless a disease can be and how precious lives are. Therefore， building the Health Silk Road is in urgent need and of particular significance during the pandemic.

Basic Connotations

The Health Silk Road was first introduced by Chinese President Xi Jinping during his visit to Uzbekistan on June 22， 2016. Xi called for building a Health Silk Road and deepening health cooperation， for timely updates on cross-border transmission of communicable diseases， disease prevention and control， medical assistance， and exchanges of traditional medicine.2 The Health Silk Road has thus become a new concept in the Belt and Road construction. On March 21， 2020， in a message to French President Emmanuel Macron， President Xi proposed for the first time the concept of building a global community of health for all to improve global public health governance.3 On June 17 of the same year， Xi put forward the building of a China-Africa community of health at the Extraordinary China-Africa Summit on Solidarity Against COVID-19. There are at least four aspects in building the China-Africa Health Silk Road.

First， medical care and health cooperation is the foundation and core agenda of the China-Africa Health Silk Road. As the first line of defense against all diseases and epidemics， a powerful public health system is the prerequisite for meeting peoples health needs. Essential components of such a system include the medical infrastructure， the production and distribution of medical supplies， medical education and personnel training， disease response and vaccine development， accumulation of medical knowledge and technology， pharmaceutical R&D and manufacturing capacity， medical security and commercial insurance， and public health at ports. To cooperate in these areas is integral to Chinas joint efforts with African countries in building the Health Silk Road.

Second， the Health Silk Road is more systematic and larger in scale compared to other medical cooperation. It upholds a concept of overall health for all， echoed by the Outline of Healthy China 2030 Plan issued in October 2016 by the Chinese government. This concept is more inclusive than the traditional principle of treating the illness and saving lives. It is not only about the development of a public health system but focuses more on disease prevention by advocating a healthy lifestyle and good eating habits， and hence is closely related to the economic and social development， food and nutrition policies， family planning and development， health care system reform， the modernization of national governance system and governance capacity， and environmental governance in urban and rural areas.4

Third， the China-Africa Health Silk Road should adopt a peoplecentered approach. The World Health Organization （WHO） and the United Nations （UN） define health as “a state of complete physical， mental and social well-being and not merely the absence of disease or infirmity”and “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”5 Health， as a basic human right， is closely related to， and even the foundation and prerequisite for， a persons comprehensive development. Therefore， the health strategies of China and African countries， as well as the African Unions Agenda 2063 and the UNs 2030 Agenda for Sustainable Development， have all set healthrelated development goals. The China-Africa Health Silk Road is to achieve these goals and to ensure overall health for all. Since health issues concern everyones livelihood， the China-Africa Health Silk Road is naturally peoplecentered and ultimately， its success depends on the participation of people from both sides.

Fourth， building the China-Africa Health Silk Road should uphold the basic principles of Belt and Road construction. Specifically， China and African countries will promote connectivity in the five priority areas of policy， infrastructure， trade， finance， and people-to-people ties， guided by the principle of achieving shared growth through extensive consultation and joint contribution. To this end， both sides need to strengthen connectivity in public health policies， medical infrastructure， trade of health products，finance in health industries， and people-to-people exchanges in the common fight against diseases.

Great importance was attached to the building of the Health Silk Road at the fifth plenary session of the 19th CPC Central Committee. According to the sessions communique， all-round efforts will be made to build a healthy China， deepen international health cooperation in the Belt and Road construction， and promote a global community of health for all. In particular， the communique states that the principle of extensive consultation， joint contribution and shared benefits should be upheld， connectivity of strategies， plans and mechanisms be strengthened， and policies， rules and standards be further harmonized to deepen practical public health cooperation.6 All this also guides the building of the ChinaAfrica Health Silk Road， and hence the vision of Healthy China and Healthy Africa can go hand in hand. The China-Africa Health Silk Road， Chinas 14th Five-Year Plan and its long-range objectives through the year 2035 will be mutually reinforcing. Meanwhile， for both China and Africa， the Health Silk Road is an integral part of advancing high-quality Belt and Road cooperation and building a community of health between the two sides.

Historical Background and Content

Although the Health Silk Road was proposed in 2016， health and medical cooperation between China and African countries started as early as the 1960s. In 1963， the newly independent Algeria was under threat from plague and lack of clothes and medicine. It appealed to the international community for emergency relief. The Chinese government commissioned a 24-member medical team from Hubei Province to Algeria， marking the beginning of Chinas medical aid to Africa. Since the establishment of the Forum on China-Africa Cooperation （FOCAC） in 2000， medical and health cooperation between the two sides has been institutionalized. Each FOCAC summit has launched a number of initiatives to strengthen health cooperation， which have also been actively implemented. Therefore， the China-Africa Health Silk Road is based on the previous health cooperation under the FOCAC framework， as reflected in the following seven aspects.

Sending medical teams and short-term expert groups to Africa. Chinas medical teams to Africa are the highlight of health cooperation between the two sides and will continue to be a brand of the China-Africa Health Silk Road. As mentioned before， China sent its first medical team to Africa at the invitation of the Algerian government in 1963. To date， China has sent 993 batches of medical teams and about 22，000 medical personnel to 48 countries and regions in Africa， treating at least 220 million patients. At present， China has 46 medical teams with nearly 1，000 personnel providing unpaid medical services in 100 sites of 45 African countries.7 After the 2012 FOCAC Beijing summit， China sent shortterm medical expert teams to carry out Brightness Action， providing free treatment for patients who suffer from cataracts in Africa. Since then， more mobile medical services such as Heart Action and Smile Action have been provided to patients with heart disease and dental defects. To combat the COVID-19 pandemic， China has sent medical expert teams to multiple African countries， continuing the successful approach of short-term medical campaign.

Building medical infrastructure in Africa. Medical facilities include general hospitals， specialized hospitals， health clinics， malaria control centers， etc. Large-scale projects were mainly carried out after the 2006 FOCAC summit. According to the FOCAC Beijing Action Plan （2007-2009），China was to build 30 hospitals and 30 anti-malaria centers in Africa. After the 2014 Ebola outbreak in West Africa， China helped set up a biosecurity laboratory in Sierra Leone and an Ebola treatment center in Liberia. At the 2015 FOCAC Johannesburg summit， China pledged to build the African Centers for Disease Control and Prevention （CDC） and support 20 hospitals each in China and Africa to pair and cooperate. The 2018 FOCAC Beijing summit focused on flagship projects such as the construction of the African CDC headquarters and the China-Africa Friendship Hospitals. As of November 2020， China has assisted in building at least 130 medical facilities in Africa.8 In terms of specialized departments in African hospitals， China has helped develop centers or departments for critical care， cardiology， traditional Chinese medicine （acupuncture）， minimally invasive surgery， ophthalmology， urology， trauma treatment， as well as maternal and child health in African hospitals.

Providing medical supplies for Africa. These include medical equipment， medicines， and medical materials. China has focused more on providing medical supplies for the sustainable development of African medical facilities with Chinese assistance. For example， China pledged to provide 300 million yuan of anti-malarial drugs to African malarial control centers for free at the 2006 FOCAC summit in Beijing. At the 2009 FOCAC summit in Sharm el-Sheikh， China pledged another 500 million yuan in medical equipment and anti-malarial materials for African hospitals and malarial control centers. At the 2012 Beijing summit， China further announced to upgrade the hospitals and laboratories it helped build in Africa.

Training medical specialists for Africa. China has trained health officials and administrators， doctors， nurses， and medical specialists for Africa， mainly by providing government scholarships for African medical students studying in China， short-term training courses for African health officials and specialists， and mentoring programs led by Chinese medical teams in Africa. For the sustainable development of medical infrastructure in Africa， China has increasingly focused on training medical specialists for African hospitals， health centers， and malaria control centers with Chinese assistance.

Helping strengthen Africas public health system against the threat of infectious diseases. After 2014 when Africa experienced the largest ever outbreak of Ebola， China has attached greater importance to strengthening the public health system in Africa， and began to help build the African Centers for Disease Control and send medical experts to Africa. China has been working on malaria and schistosomiasis prevention and control projects in Comoros and Zanzibar respectively in recent years， reducing the number of malaria deaths in Comoros to zero and the incidence rate by 98 percent， and basically eliminating schistosomiasis in Zanzibar. These results have gained high attention and full recognition from African countries and the World Health Organization.9 From 2016 to 2018， China also helped countries including Angola， Madagascar， the Democratic Republic of the Congo （DRC）， and Uganda in responding to epidemics such as yellow fever， plague， and Ebola. In Sierra Leone， China created a surveillance network of febrile syndromes and diarrhea based on the Sierra Leone-China Friendship Biosafety Level 3 Laboratory to strengthen the countrys public health system.

Promoting cooperation in traditional Chinese and African medicine. Over the years， acupuncture has been most successfully promoted in Africa as a traditional Chinese medical practice， to which Chinese medical teams in Africa and African students studying traditional Chinese medicine （TCM） in China have contributed the most. Chinese medical teams are usually staffed by TCM doctors who are good at acupuncture and Chinese massage and bring African patients the miraculous effects of acupuncture. Hence， more African countries including Tunisia， Guinea，South Africa， and Zimbabwe have set up acupuncture centers to train TCM doctors. Some African students who received Chinese government scholarships have successfully become skilled acupuncturists and TCM doctors， with Sekou Camara in Guinea and Diarra Boubacar in Mali being prominent among them. Camara has been practicing acupuncture since returning to Guinea and even made acupuncture rehabilitation a mandatory medical school course at the University of Conakry. Boubacar facilitated the worlds first Luban Workshop of TCM in Mali to promote the integration between Chinese and African traditional medicine.

Encouraging Chinese pharmaceutical enterprises to invest and produce in Africa for larger capacity and more cooperation. Since the mid-1990s， Chinese pharmaceutical companies have started to invest in Africa， but they are still exploring and searching for opportunities with no investment boom yet.10 Since the 2015 FOCAC Johannesburg summit， pharmaceutical investment in Africa and China-Africa cooperation in capacity building has received increasing attention.

In general， China-Africa medical and health cooperation has been expanding to more areas covered by the Health Silk Road， laying a deep historical foundation for strengthening the China-Africa Health Silk Road. The 8th FOCAC ministerial conference is to be held in Dakar， Senegal in 2021. New initiatives in medical and public health cooperation are expected to be the focus， which will add impetus to the building of the China-Africa Health Silk Road.

China-Africa Joint Fight against COVID-19 as a Practice of the Health Silk Road

In January and February 2020 when China was hit by the first wave of the COVID-19 epidemic， the African Union （AU） and African leaders were the first to offer their sympathy and support for China， believing that “China will win the battle against the epidemic.” 48 African heads of state， 12 prime ministers， and 11 speakers of parliament sent messages of condolence to Chinese leaders. More than 30 foreign ministers and heads of six regional organizations， including the AU Commission and the Common Market for Eastern and Southern Africa （COMESA） sent messages of solidarity and support to China by all means. Many African countries， including Egypt， South Africa， Morocco， Algeria， Equatorial Guinea， Ghana， Djibouti and Comoros， donated funds and medical supplies to China. The African people， African students studying in China， and overseas Africans supported and cheered for China through slogans， banners， and videos. Many African medical students and doctors in China joined the front line of Chinas fight against the epidemic， and actively introduced Chinas successful experience to their home countries. Moreover， many Africans studying or living in China volunteered in Chinese cities and universities， and helped the world know the Chinese peoples fight against COVID-19 via social media to fight back attempts of smearing， scapegoating， and interference from officials and media in the United States and other Western countries.

Similarly， after the first confirmed case appeared in Africa on February 14， 2020， China was the first to help and support African countries to fight against the epidemic through an “all-government， all-society” approach， as demonstrated in the following aspects.

First， China has made generous donations to Africa and facilitated African purchases of Chinese medical supplies. From CPC and government departments to the military， from the central government to provincial and municipal governments， and from Chinese enterprises， nonprofit foundations to overseas Chinese in Africa， China has generously donated large quantities of needed supplies to Africa， including masks， protective suits， testing kits， respirators， goggles， forehead thermometers， infrared thermometers， and other diagnostic equipment and devices. As of early September 2020， the Chinese government had delivered more than 400 tons of medical supplies to 53 African countries and the AU，and African purchases of Chinese medical supplies from 21 countries had amounted to more than US$54 million.11 With the support of China， the AU launched the Africa Medical Supplies Platform （AMSP） in July 2020. The platform enables African governments to make online purchases of needed supplies and future vaccines.

Second， China has dispatched medical teams to Africa to share treatment plans and medical experience. As of October 2020， the Chinese government had sent medical teams to 15 African countries.12 Chinese medical teams visited health authorities， designated hospitals for COVID-19 treatment， and other medical institutions in African countries， sharing experience with local healthcare workers in case screening and tracing， epidemic prevention and control， clinical treatment， community health management， and laboratory work. They helped the African governments in assessing the situation and submitted detailed countryspecific proposals for epidemic prevention. These proposals include targeted recommendations on commanding systems， social mobilization， medical isolation， community screening， nucleic acid testing， epidemic surveillance， clinical treatment， protection in hospitals， and integrated development. Chinas National Health Commission （NHC） publicly released seven editions of the Diagnosis and Treatment Protocol for COVID-19 and six editions of the Protocol for Prevention and Control of COVID-19 in multiple languages for use as a reference by African countries and the world.13 The Chinese Ministry of Foreign Affairs and the NHC held five consecutive video conferences for technical exchanges on COVID-19， during which Chinese medical professionals shared their know-how with officials and experts from 42 African countries and the AU on epidemic prevention and control， clinical diagnosis and treatment， test methods， management of makeshift hospitals， border quarantine， and risk assessment.14

Third， China has helped upgrade hospitals and other medical infrastructure in Africa. The first is to fully support the building of designated hospitals for coronavirus patients in Africa， such as the Tengandogo Hospital and the Yalgado Ouedraogo University Hospital in Burkina Faso， the Kenyatta University Teaching， Referral & Research Hospital in Kenya， the Greater Accra Regional Hospital in Ghana， the Wilkins Hospital in Zimbabwe， and the Maternal and Children Hospital in Senegal. The second is to assist in building makeshift hospitals in Africa. Makeshift hospitals in Nigeria， Uganda， Cape Verde， Ethiopia， and Sao Tome and Principe were all built with support from Chinese enterprises， some of which were originally stadiums built with Chinese assistance. Chinese specialists also gave further support for the smooth operation of these makeshift hospitals. The third is to help build medical laboratories for nucleic acid testing in Africa. Chinas Huada Gene Technology built FireEye laboratories in Gabon， Togo， Benin and Angola， significantly improving the countries testing capacity by introducing the high-throughput automated nucleic acid extraction equipment. Last but not least is to implement the cooperation between pairs of Chinese and African hospitals. As of September 2020， 46 hospitals in 42 African countries had made initial confirmation to participate in the cooperation scheme.

Fourth， China is committed to working for greater accessibility of COVID vaccines in developing countries. China has four candidate COVID vaccines approved for Phase III clinical trials outside China， ranking among the top internationally. China has started cooperation in vaccine R&D with Egypt， Morocco and other African countries， and will further deepen vaccine cooperation in a way that respects the will of regional countries. On October 8， 2020， China signed an agreement with the Global Alliance for Vaccine Immunization （GAVI） and officially joined the COVID-19 Vaccines Global Access Facility （COVAX）. This is an important step for China to uphold the concept of a community of health for all and fulfill its commitment to turning COVID-19 vaccines into a global public good.15 With the largest number of developing countries， Africa will benefit from that. On October 15， 51 ambassadors and senior diplomats from African countries visited the Beijing Institute of Biological Products of China National Pharmaceutical Group （Sinopharm）， and exchanged views on Chinese vaccine technology and development.16 China is willing to strengthen anti-epidemic cooperation with Africa including vaccine cooperation to win the common battle against the virus， and has repeatedly pledged that COVID vaccines will be first provided to developing countries as a global public good once they are developed and operational.

Challenges in Building China-Africa Health Silk Road

As mentioned above， the joint fight against COVID-19 since the beginning of 2020 has put the building of a China-Africa Health Silk Road on a solid footing. Having said that， it should also be noted that there is a long way to go before a China-Africa community of health can fully take shape， and there are challenges to be properly handled both from African and Chinese sides.

Challenges for Africa

The fragile public health system is the biggest challenge for building the China-Africa Health Silk Road and a community of health for all. With an explosive population growth and aggravating poverty and hunger， Africa faces a huge gap between the demand and supply of public health resources. Due to the limited public health services in Africa， helping African countries to resolve public health problems will be an arduous task for China and Africa in building the Health Silk Road.

First， Africa is burdened with multiple diseases. For a long time， African people have suffered from both communicable and chronic diseases （non-communicable diseases）. AIDS， malaria， and tuberculosis are the three most common infectious diseases in Africa， killing about 1.6 million people each year.17 Tropical diseases such as Lassa fever， dengue fever， river blindness （onchocerciasis）， schistosomiasis， trypanosomiasis， and leprosy are common in Africa.18 In addition to infectious diseases， the increase in chronic diseases such as cancer， coronary heart disease， diabetes， hypertension， oncology， and respiratory diseases are worrying. Africa has the highest mortality rate from chronic diseases and the average life expectancy of African population is among the lowest in the world.

Second， healthcare facilities and services in Africa are lagging behind. According to the WHO， between 2010 and 2018， Africa had the lowest density of healthcare human resources globally， with the number of doctors and nurses per 10，000 people at 3.0 and 10.1 respectively.19 In 2019， the public health system in Africa scored an average of 44， compared to the global average score of 63， on its ability to implement the 13 key provisions of the International Health Regulations. The score of Africa was also the lowest in the world.20 Also， the percentage of African population with access to safe drinking water， safe sanitation services， and hand-washing facilities is among the lowest in the world.

Third， Africa has low productivity in medical supplies. At present， there are fewer than 1，000 pharmaceutical manufacturers in Africa， more than half of which are concentrated in seven countries—South Africa， Nigeria， Algeria， Morocco， Egypt， Ghana， and Kenya. The remaining 47 African countries have much fewer pharmaceutical plants， some of which do not even have any. Most local pharmaceutical companies in Africa are small private businesses， and the drugs they produce can only meet 20 to 30 percent of the local demand.21 This has led to a shortage of medicine and a scarcity of laboratory and testing equipment in hospitals of most African countries.

Fourth， African health systems and industries are plagued by financing difficulties. With rising poverty， most African countries fail to invest effectively in their health systems. The WHO calls on all countries to spend at least nine percent of their fiscal expenditure on public health. In the 2001 Abuja Declaration， the Organization of African Unity， as predecessor of the African Union， committed to allocate at least 15 percent of its annual budget to public health.22 However， most African countries still have to rely on foreign aid to achieve the goal due to their tight fiscal balance or even fiscal deficit. Africa has suffered from 25 percent of global diseases， but its health expenditure accounts for less than one percent， and the African continent consumes less than two percent of the total global value of health products.23

Challenges for China

For China， building the Health Silk Road with Africa is also faced with multiple challenges， which are mainly related to the form， stakeholders， and mechanisms of China-Africa cooperation.

First， current cooperation between China and Africa focuses more on aid programs than on trade and investment. So far， the China-Africa Health Silk Road has brought about many kinds of Chinese aid programs to Africa， while trade and investment in health industries lag far behind. China has sent medical teams and short-term expert groups to Africa， helped build medical infrastructure， donated medical supplies， trained medical personnel， and strengthened African public health systems against the threat of infectious diseases. All these are part of Chinas assistance to Africa. However， Chinese pharmaceutical companies just got started with investing in Africa， and have not yet entered the mainstream pharmaceutical market. In 2017， the value of China-Africa pharmaceutical trade was$2.43 billion， accounting for only 1.4 percent of total China-Africa trade value （$170 billion） that year.24 In 2019， China-Africa pharmaceutical trade increased to $2.93 billion， but still accounting for 1.4 percent of total China-Africa trade， which had also risen to $208.7 billion.25 Chinese pharmaceutical enterprises have seen no significant market penetration， and their capital and technical strength are inferior to those of developed countries. Moreover， medical products from China are not well accepted by the African market， few of which have passed the WHO prequalification（PQ）. The African market is highly fragmented and regulatory standards are varied， making it difficult to have any large-scale investment and production.

Second， health cooperation between the two sides is mostly between governments instead of between markets or societies. Because cooperation focuses more on aid programs than on trade and investment， governments naturally play a more dominant role than do the market or social organizations. For a long time， medical aid to Africa has served the Chinese governments global diplomatic strategy. Even though it has helped Africa improve its medical systems， enhance the health and well-being of the African people， and promote mutual people-to-people ties， its role has mostly been instrumental. However， the 2014-2016 Ebola outbreak in West Africa and especially the undergoing COVID-19 pandemic have greatly changed how countries around the world perceive health diplomacy. Peoples health is now considered as more an end in its own right than simply a means. Thus， the government alone can hardly meet the huge demand for healthy life and medical products， while the market and the society are expected to play a greater role.

Third， Chinas medical assistance to Africa is fragmented in terms of cooperation mechanisms. A united decision-making and implementation mechanism has yet to be developed.26 For example， public health aid programs and medical teams to Africa， after complicated evolution in history， are currently managed and deployed by the National Health Commission. As for human resources training， the Ministry of Education is responsible for managing academic degree education for African students in China， including medical students. The Ministry of Commerce is responsible for training programs for health officials and specialists， building African medical facilities， managing donations of medical equipment and supplies， and helping African countries strengthen their health systems against the threat of infectious diseases. The Ministry of Foreign Affairs and the Ministry of Finance are involved in health diplomacy and budget support respectively. Although there is a coordination mechanism between the ministries for decision-making and implementation of aid programs in Africa， differences remain when it comes to interests and managing systems， which are not conducive to the integration of resources to maximize the interests.

Challenges from third parties

The China-Africa Health Silk Road also faces challenges from third parties. Due to historical and linguistic ties， Western developed countries are more involved in Africas public health governance and have a greater influence on laws， regulations， systems， technologies， and product standards in the health sector of Africa. Many international institutions and non-governmental organizations playing an important role in African health systems are dominated by Western countries， including the International Committee of the Red Cross， the Global Fund to Fight AIDS， Tuberculosis and Malaria， Doctors Without Borders， the Global Alliance for Vaccines and Immunization， and the Coalition for Epidemic Preparedness Innovation.27 Besides， Western pharmaceutical companies hold about 70 percent of the African medical products market.

Western countries are dominant in medical aid programs. As the largest contributors to health development assistance in Africa， Western countries led by the United States are able to set the agenda of health and medical issues. The US has major influence on AIDS and malaria control in Africa through the Presidents Emergency Plan for AIDS and the Presidents Malaria Initiative， while the United Kingdom plays a prominent role in vaccine-related issues by leading the GAVI.28

Western countries are also leading the research on tropical diseases in Africa. The Pasteur Institute of France， the Institute of Tropical Medicine in Antwerp， Belgium， the Oxford Centre for Tropical Medicine and Global Health in the UK， and the US Naval Medical Research Center all have long-standing and multifaceted research collaborations in Africa.

In addition， emerging economies， particularly India， are also influential in the African health system. For example， the Aga Khan Development Network and its Aga Khan Health Services have been rooted in East Africa for more than 100 years. Its network of medical services， outreach services， medical education， and practical platforms cover the entire East Africa and are deeply integrated with local societies and cultures.29

Approaches to Advancing China-Africa Health Silk Road

Facing squarely and finding solutions to the above difficulties is the only way for China and Africa to advance the Health Silk Road and build a community of health for all. From another perspective， these challenges present opportunities and potential for cooperation. In fact， new highlights of China-Africa cooperation often lie in the process of problem-solving. To this end， China and Africa should work together to build a healthy China and a healthy Africa， guided by the concept of health for all and the principle of extensive consultation， joint contribution， and shared benefits.

Elevating the importance of public health in China-Africa cooperation

The COVID-19 pandemic brings unprecedented global attention to health issues. On June 17， 2020， China and 13 African heads of state， and the chair of the AU Commission attended the Extraordinary China-Africa Summit on Solidarity against COVID-19. This was the first-ever meeting between Chinese and African leaders specifically on disease prevention and control， which highlighted the status of medical and health cooperation in China-Africa relations. In the future， top-level design and head-of-state diplomacy are still necessary in the building of the China-Africa Health Silk Road and a community of health for all. In their policy communication， China and African countries should pay particular attention to the following issues：

First， it is necessary to synergize the Outline of Healthy China 2030 Plan and health strategies of African countries， seek consensus with the AU and the African CDC through policy consultations， and formulate a development plan for the China-Africa Health Silk Road when conditions are ripe. Second， it is necessary to explore new approaches to managing the Chinese-built medical infrastructure in Africa， on the premise of respecting the ownership of the recipient countries and upholding the principle of mutual benefits. Third， it is necessary to harmonize regulations， standards and supervisory policies between China and African countries， and encourage more Chinese medical products to pass WHO prequalification， to unleash the potential in China-Africa health-related trade and investment. Last， it is necessary for the two sides to exchange views on improving public health systems and share their best practices in developing a multi-stakeholder and multi-level healthcare system in rural and urban communities， in order to build a universal healthcare system suitable for their respective national conditions and with a focus on protecting the health of vulnerable groups.

Enhancing cooperation in medical education and traditional medicine

Medical education in most African countries is underdeveloped. China should actively support medical education in Africa， offer more assistance to local medical and nursing schools， and train more local medical professionals to facilitate independent and sustainable development of Africas medical system. Following an “all-government， all-society” approach， governments， enterprises and societies in China and Africa should be encouraged to engage in the joint operation of schools， the introduction of Chinese medical education into Africa， and the integration of medical education between the two sides. Traditional medicine， as being practical， inexpensive and efficient， is more conducive to safeguarding the health and well-being of the general public. In Africas rural and urban communities， traditional medicine is still important in the treatment of diseases and is closely integrated with local religious beliefs and social customs. When introduced into African countries， Chinese medicine needs to adapt itself and integrate with Africas traditional medicine according to local conditions.

Promoting capacity cooperation and supporting Africas health industries

Economic backwardness and poverty are the direct causes of the underdevelopment of Africas health systems. Due to its structurally disadvantaged position in the global economy， Africa faces enormous challenges in developing its economy and lifting itself out of poverty. With colonial legacy and backward technology， Africa is still mostly a producer of raw materials at the end of global production and value chains. Therefore， to get out of the predicament in public health governance， African countries must truly address the economic and social conditions for large-scale outbreak of infectious diseases. This requires the building of an international political and economic order more equitable and reasonable for Africa. The African Continental Free Trade Area （AfCFTA） may be one of the few options for African countries. China should actively support AfCFTA and under the framework help African countries develop their health industries， to promote related investment cooperation between the two sides.

Giving full play to the role of social forces

Public health concerns everyone， and any actor alone can hardly respond to major epidemics and public health emergencies. Social organizations could effectively compensate for the failure of governments and markets， facilitate the betterment of peoples livelihood and enhance people-to-people amity， thus solidifying public support for building the China-Africa Health Silk Road and a community of health for all. The UN and the WHO have long supported social organizations and non-state actors to make greater contributions to global public health governance. China should also encourage Chinese non-state actors to participate in African public health governance， form partnerships with international non-governmental organizations in Africa， and enrich global public health governance with Chinese wisdom.

Strengthening international cooperation and actively participating in global health governance

Africa has long had capacity deficits in the medical and health field， and is hence a focus of global public health governance. The architecture of global health governance is composed of specialized agencies of the UN system， such as the WHO and the Joint United Nations Program on HIV/ AIDS （UNAIDS）， and international NGOs. The diverse partnerships formed between these organizations have been playing a major role in African health governance. Traditionally， developed countries， big pharmaceutical companies， and famous technological institutions provide more funding and hence have a greater say in global health cooperation.30 Given this， China should actively participate in Africas public health governance and forge closer partnerships with relevant international institutions and non-state actors through increased financial and technical support.

In conclusion， the building of the China-Africa Health Silk Road is a complex and systemic project involving multiple stakeholders and cannot be achieved overnight. Public health is not only a medical issue but is also closely related to economic and social development. Building a Healthy Africa requires a fundamental change of Africas marginalized position in the global political and economic system. The African continent needs unity and political and economic integration. Otherwise， it will be very difficult for African countries to change their unfavorable position in such a system. Therefore， the building of the China-Africa Health Silk Road must not be limited to medical and health cooperation， but should integrate public health into all areas of China-Africa cooperation and policy considerations. Only by overturning Africas structurally disadvantaged position in the global political and economic system can the vision of healthy Africa and healthy China be ultimately realized.