China’s health silk road construction during the COVID-19 pandemic

ABSTRACT China has been contributing to new approaches to global governance. The Health Silk Road (HSR), a significant component of the Belt and Road Initiative (BRI), was proposed by China in 2016. This paper claims that HSR is a new institution introduced alongside the existing WHO-led multilateral health system, and its relationship with the existing system can be described as layering. Having explored the new development of HSR during COVID-19, this paper further argues that while HSR has its unique strength in making contributions to global health governance and economic recovery, it faces a prominent issue of securitisation in the context of China-U.S. strategic competition, suspicion of the quality of medical products and sectoral fragmentation.


Introduction
In 2015, the Chinese National Health and Family Planning Commission revealed the 'Three-Year Plan for Belt and Road Health Exchange and Cooperation (2015-2017)', indicating the direction for building the Health Silk Road (HSR) (CIDCA, 2017).In June 2016, Chinese President Xi Jinping proposed for the first time 'working together to build the HSR' when visiting Uzbekistan (Xinhua Net, 2016).During the general debate session of the 72nd World Health Assembly, Ma Xiaowei, the Minister and Secretary of the Leading Party Members' Group of the National Health Commission of China, claimed, 'for building the HSR and joining hands with relevant countries to address health challenges, we will continue to actively advocate and promote global health cooperation under the framework of the United Nations and WHO, and make positive contributions to seeking the health and well-being of all human beings and building a community of shared future for mankind' (CCTV, 2019).This is an explicit official statement made by the Chinese government on the relationship between implementing the HSR and promoting global health governance.
At the end of 2019, the coronavirus pandemic broke out and began to spread globally.A few months later, the WHO Director-General announced the new coronavirus pneumonia (COVID-19) as a 'global pandemic' (WHO, 2020).On March 16, 2020, Chinese President Xi Jinping mentioned the concept of HSR in a telephone call with Italian Prime Minister Giuseppe Conte.Xi said, 'China stands ready to work with Italy to contribute to international pandemic cooperation and the building of the Health Silk Road' (China Daily, 2020).
The HSR, proposed initially as an integral part of the Belt and Road Initiative (BRI), has aroused scholarly attention.On the one hand, some scholars argue that the BRI is a product of China-U.S. geostrategic competition (Clarke, 2020;Demir, 2020), which has led to growing anxiety in the West about Beijing's new geopolitical master plan to overturn the existing world order and rebuild a nascent one (Hong, 2017;Silvius, 2021).Accordingly, HSR is depicted as an initiative of China to pose a significant challenge to western-designed norms of global health governance, which has exacerbated pre-existing tensions between China and the West (Hillman & Tippett, 2021;Zoubir, 2020;Zoubir & Tran, 2022).
On the other hand, some other scholars contend that Beijing designs BRI to shoulder the responsibilities of a great power with no intention to replace the existing liberal order (Jones, 2020;Qin & Wei, 2018;Zheng & Zhang, 2016).In particular, the HSR, rather than a new geopolitical strategy within the BRI framework, is regarded as an emerging diplomatic initiative for enhancing health cooperation under the existing system (Cao, 2020;Tillman et al., 2021).Additionally, some scholars also point out that HSR is set further to advance China's leading role in global health governance.However, it cannot fundamentally challenge U.S. leadership in health-related development assistance due to limited professional and organisational capabilities (Huang, 2022;Tang et al., 2017).These scholars thus argue that Beijing has neither the intention nor the ability to replace or overthrow the existing health governance system.
This paper contributes to the study of the HSR by further exploring its nature and impacts.We argue that the HSR is designed neither to alter the existing architecture of global health system fundamentally nor to maintain the status quo, but rather to improve the established institutions by layering gradually.We collect qualitative materials on HSR's practices in three ways.First, we deploy HSR-related documents, research reports, and expert inquiries on HSR's interaction with existing health systems and new developments of HSR after the outbreak of COVID-19 as qualitative data.Second, we collect data relevant to HSR's practices and Chinese leader's speeches from official websites (e.g.State Council of the People's Republic of China, Ministry of Foreign Affairs of the People's Republic of China, Embassy of the People's Republic of China in the Republic of Indonesia), and news reports (The Washington Post, Xinhua Net, BBC).Third, we interviewed public health authorities, staff of Chinese biopharmaceutical companies, and experts from top universities in China. 1  This paper is structured as follows.First, we expound on the 'layering' relationship between the HSR and the existing global health governance system from the perspective of institutional change.Through tracing the development of the HSR and the interaction between China and WHO, we demonstrate that overthrowing or reinterpreting WHO-centre norms of the existing health system is not an intention of Beijing in designing and implementing HSR.Second, we analyze the contribution made by the HSR as a new institutional layer during COVID-19.In this section, we further illustrate the unique role of HSR in promoting global health governance and economic recovery and development.Finally, we examine the obstacles in the construction of the HSR.A conclusion follows by summarising the findings.

Relationship between the HSR and the existing global health governance system
There are four types of relationships between new institutions and old ones: displacement, layering, drifting, and conversion.Displacement refers to the removal of existing rules and the introduction of new ones; layering occurs when new rules are introduced on top of or alongside existing ones; drifting is present when rules remain formally the same, but their impact changes as a result of shifts in external conditions; and conversion occurs when existing rules remain the same in form but are interpreted and enacted in a new way (Mahoney & Thelen, 2010).
In the above four modes of institutional change, displacement implies that new institutions are designed to replace the old ones.With drifting, new rules remain unchanged in form but grow out of the failure of the old institution to adapt in a changing environment.With conversion, actors often actively exploit the inherent ambiguities of the old institutions for reinterpretation.In contrast to the other three types, layering is the only mode that allows for the coexistence of old and new institutions.More importantly, the new institution does not replace or reinterpret the old but is parallel to it (Mahoney & Thelen, 2010).By tracing the development of the HSR and its interaction with WHO, we can find that the HSR, different from WHO in form, is created alongside the existing WHO-led multilateral health system that is not removed, and its relationship with the existing system can be described as layering (Hanrieder, 2014).

Development of the HSR
Layering generally occurs when reformers cannot or do not alter core institutions because of legal lock-in and graft additional components upon the institutional core instead (Mahoney & Thelen, 2010).In the case of China, it has firmly supported WHO, which is legally empowered by member states to play a leading role in international health cooperation (State Council Information Office of the PRC, 2020).The HSR Initiative was also proposed by Beijing in 2016 to strengthen cooperation with the WHO and to comprehensively improve the health of people in China and countries along the Belt and Road, which is in line with the mission of WHO on 'achieving good health for all' (State Council Information Office of the People's Republic of China, 2017b).
To carry out such a mission, China has built multifaceted health partnerships with most countries and international organisations along the Belt and Road, emphasising strengthening international public health capacity.China has been promoting the institutionalisation of the HSR by organising several multilateral high-level forums, for example, the Silk Road Health Forum, the China-ASEAN Forum on Health Cooperation, the China-Central, and Eastern European Countries Health Ministers Forum, and the China-Arab States Health Forum (Central People's Government of the PRC, 2016; Central People's Government of the PRC, 2019;Cao, 2020).As presented in Table 1, various platforms have also been established for hospital cooperation.
China has signed a series of bilateral cooperation agreements with HSR countries. .Cooperation with HSR countries and regions was mainly conducted in the following issues: (1) strengthening cooperation in the prevention and control of acute infectious diseases and provision of technical support; (2) strengthening infrastructure building; (3) enhancing medical personnel training; (4) promoting international cooperation in Traditional Chinese Medicine (TCM).In concrete terms, plenty of medical teams have been sent by Beijing to provide technical assistance for controlling infectious diseases, bringing China's experience in combating SARS and HINI influenza in 2003and 2009, respectively (Tillman et al., 2021).After the Ebola outbreak, China also pledged $20 million for pandemic control along the HSR in 2017 (Tang et al., 2017).
Additionally, China has improved its financial capacities and skills on hard infrastructures to provide health aid projects, for instance, aiding the establishment of the Africa Center for Disease Control and Prevention (Africa CDC).China has also invested nearly $4 million to train more than 930 professional medical personnel in ASEAN countries (Xinhua Net, 2018).Furthermore, in May 2018, Belt and Road International Medical Education Alliance (BRIMEA) was formally established to strengthen cooperation in medical personnel training in countries along the route (BRIMEA, 2020).Moreover, as a unique medical diagnosis and treatment approach 2 , TCM has spread to 183 countries.Nearly 100,000 overseas TCM institutions have been opened in more than 30 countries so that people along the HSR could benefit from high-quality and inexpensive Chinese medicines.In addition, 86 TCM cooperation agreements have been signed with HSR countries and regions (Xinhua Net, 2017).In June 2018, the Chinese Traditional Medicine Foreign Exchange and Cooperation Alliance was officially established to exchange and cooperate with countries along the Belt and Road in TCM (NATCM, 2018).
Overall, the initial mission of the HSR was to strengthen health cooperation with Belt and Road countries under the leadership of WHO, such as organising high-level regional forums for health officials and establishing a public health network in BRI countries.In specific projects like building international hospital alliances, HSR is primarily driven by the Chinese government while allowing for the participation of social sectors like hospitals and research institutions.However, the HSR during this period was less known than other BRI projects.
After the outbreak of COVID-19, the construction of HSR was accelerated.On June 18, 2020, a Joint Statement of the High-level Video Conference on Belt and Road International Cooperation stated that HSR should be strengthened through the sharing of timely and necessary information and best practices for diagnosis and treatment of the COVID-19, the equitable access to health products, and the investment in building sound and resilient health-related infrastructures (Ministry of Commerce of the People's Republic of China, 2020).
On November 24, 2020, The 3rd China-ASEAN Forum on Health Cooperation towards a Health Silk Road was held in Nanning, with an announcement to continue to support WHO's leadership role in fighting together against the COVID-19 (China- ASEAN Panorama, 2021)., 2021).Apart from significant announcements or notices, the HSR has been constructed by implementing various projects, such as supplies of medical products and vaccine cooperation, which we will discuss in detail in the next section.
From the timeline for the development of HSR (see Figure 1), the objectives of HSR have been highly aligned with WHO to improve people's health along the Belt and Road, shifting the focus to fighting against global infectious diseases after COVID-19.

Interaction between China and WHO
We can find support for the 'layering' relationship between HSR and the existing system in the interactive process between China and the WHO.Specifically, WHO's officials are invited regularly to attend HSR-relevant seminars and meetings, such as the China-Central and Eastern Europe Countries Health Ministers' Forum, the China-Arab Countries Health Ministers' Forum, the BRICS Health Ministers' Meeting, and the BRICS High-Level Meeting on Traditional Medicine (State Council Information Office of the PRC, 2017a).
On On January 18, 2017, President Xi and former WHO Director-General Margaret Chan signed the Memorandum of Understanding between China and WHO on the BRI regarding health cooperation.Chan recognised China's long-standing contributions to global health and WHO's work and its leadership in global health governance.She expressed WHO's willingness to strengthen cooperation with China under the BRI framework to improve the health and hygiene of countries along the Belt and Road (State Council Information Office of the PRC, 2017a).On May 13, 2017, China and WHO signed an action plan for cooperation (National Health Commission, 2017).
In addition, Dr. Tedros Adhanom Ghebreyesus, the Director-General of the WHO, led a delegation to the Belt and Road High-Level Meeting for Health Cooperation in Beijing, where he stressed China's role in global health and how future leadership can make a solid contribution to its health and the well-being of others (WHO, 2017a).In an article entitled 'Building a Safe and Healthy Silk Road Together', published in China Daily, Dr. Ghebreyesus said that 'China can share its successful experience and best practices with other countries' and that 'WHO and China aim to build a safe and healthy Silk Road' (WHO, 2017b).
After the outbreak of COVID-19, China deepened its cooperation with WHO.By August 2021, Beijing had provided two batches of $50 million as cash assistance to the WHO, assisted it in procuring personal protective equipment, and established a stockpile of supplies in China.Furthermore, Beijing donated through the COVID-19 Solidarity Response Fund for WHO and participated in its Access to COVID-19 Tools Accelerator (ACT-A) and COVID-19 Vaccines Global Access (COVAX) (Ministry of Foreign Affairs of the PRC, 2022).Meanwhile, Dr. Ghebreyesus stated that the WHO should not be afraid of the increasing pluralist landscape of global health institutions, and pluralism in global health leadership strengthened the WHO (Horton, 2019).
The above analysis suggests that overthrowing or reinterpreting WHO-centered norms of the existing health system, neither before nor after COVID-19, is not an intention on the part of Beijing to design HSR, which does not match the theoretical modes of displacement and conversion.Besides, as a regional initiative, HSR is formerly different from WHO and thus does not match the drift model.Therefore, the relationship between HSR and the existing system is in line with what institutional change theory called 'layering', which occurs when new institutions are attached to existing ones (Mahoney & Thelen, 2010).

The HSR as a new institutional layer during COVID-19
The initial focus of the BRI is economic development, while infrastructure construction makes up its core.From 2013 to 2019, China invested about $730 billion in countries along the Belt and Road (Nedopil, 2022).Among the most critical industries that receive BRI investments are energy (about 39%) and transport (about 26%), followed by real estate (about 10%) and metals (about 7%).The HSR, in the first place, was built with a much lower profile than other BRI projects.The outbreak of the COVID-19 pandemic, however, has led to the acceleration and expansion of the HSR.

Contributing to global health governance
As shown in Figure 2, the HSR created a new cooperation space for BRI (Zheng, 2021).At the 73rd session of the World Health Assembly in May 2020, President Xi promised a series of measures to help the world fight COVID-19, including providing $2 billion in assistance over two years, ensuring the security and efficiency of anti-epidemic supply chains by establishing global humanitarian response depot and hub in China in collaboration with the UN, accelerating construction of African CDC headquarters, providing Chinese-developed vaccine as a global public good, and so on (Xinhua Net, 2020).
Such  China and its HSR partners have held over 100 meetings to share their experience with COVID-19 prevention and control.Besides, 15 ad hoc medical expert teams and 46 Chinese medical teams have been sent to Africa to help with COVID-19 containment (Ministry of Foreign Affairs of the PRC, 2021a).Furthermore, in November 2021, the main building of the China-aided future headquarters for the Africa CDC also marked structural completion (Xinhua Net, 2021b).
Additionally, Beijing has donated $50 million to WHO and provided substantial anti-pandemic loans to HSR partners in 2020 and 2021.As presented in Table 2, China Development Bank (CDB) and the two new multilateral development banks, with China being the most important shareholder, i.e. the Asian Infrastructure Investment Bank (AIIB) and the New Development Bank (NDB), provided billions of COVID-19 related loans abroad.
When global multilateral approaches, such as WHO-led ACT-Accelerator and COVAX, have been criticised for being incompetent, multiple bilateral efforts under HSR appear to be more efficient (Huang, 2022).Beijing's health assistance has received positive feedback from partner countries.According to a 2022 assessment among ASEAN countries of global partners' vaccine support, China received a 57.8 percent positive perception score, compared with the EU's 2.6 percent and the United States' 23.2 percent (ASEAN Studies Centre at ISEAS-Yusof Ishak Institute, 2022).

Helping restore economy during the COVID-19
The emergence of COVID-19 confirms 'how disruptive health crises can be for trade, transport, and economic activities' (Taylor et al., 2020).The HSR was thus brought up again to build a community of shared future for mankind and to expand the BRI (People's Daily, 2020;Wang, 2019).In this regard, HSR, as a pillar of the BRI, is directly linked to economic recovery and development.
At an early stage of the pandemic, countries blocking their borders, and the economies of countries and regions along the BRI have all been impacted.As early as February 25, 2020, China's National Health Commission provided health guidance for the resumption of work and production (National Health Commission of the PRC, 2020).When China took the lead in containing the spread of the pandemic in March 2020, it began to actively help resume work and production in countries along the HSR.On June 17, 2020, President Xi emphasised at the Extraordinary China-Africa Summit on Solidarity Against COVID-19, the importance of 'strengthening the joint construction of BRI, focusing on health, resumption of work and production, and improvement of people's livelihood' (Ministry of Foreign Affairs of the PRC, 2020).That marks China's drive toward the resumption of work and economic production in countries along the BRI.
In particular, China's HSR did have a significant impact on the resumption of production among partner countries.For example, Indonesia has procured two batches of three million doses of vaccine and one batch of 15 million semi-finished doses from China to lay the foundation for the launch of vaccination.Both countries have jointly conducted a successful Phase III clinical trial of the COVID-19 pneumonia vaccine (Embassy of the People's Republic of China in the Republic of Indonesia, 2020).Under Beijing's health assistance before June 2020 (Table 3), COVID-19 in Indonesia was under control, revitalising the local economy, with companies resuming work and production (Embassy of the People's Republic of China in the Republic of Indonesia, 2020).In September 2020, the Java 7 Coal Fired Power Plant, built with Chinese investment, was brought back to service, marking the resumption of production by Chinese enterprises in Indonesia (PR Newswire, 2020).Also, in Brunei's case, when it was first hit with the infection, China assisted the country in setting up an emergency testing laboratory and enterprises to improve case tracking and quarantine management (Sidek & Halim, 2022).As Brunei suffered the second wave of COVID-19, China further donated 100,000 doses of the Sinopharm vaccine (Kon, 2021).Brunei's economy has thus recovered with Chinese health assistance.For example, as a significant project of BRI in Brunei, an oil refinery and petrochemical plant are operated by Brunei-China joint venture Hengyi Industries on Pulau Muara Besar (PMB).Despite the pandemic, this plant's aromatics production was expanded by a suite of technologies (Brelsford, 2021).According to the Department of Economic Planning and Statistics (DEPS) statistics, Hengyi Industries maintained a high workload in their first full year of operations and recorded $3.5 billion in revenue in 2020, accounting for 4.48 percent of Brunei's GDP (Wong, 2020).
The positive impact of HSR on the economic recovery of host countries with better political relations with China is more clearly pronounced than in other HSR countries (Yang et al., 2022).In addition, better political relations help China's HSR construction in host countries.Given that bilateral relations are more friendly, the host countries tend to have a higher level of trust with China, and the HSR will be advanced more smoothly there.Also, amiable political relations and similar diplomatic stances contribute to China's willingness to provide further support.As such, we chose the cases of Indonesia and Brunei maintaining benign relationships with China to illustrate the positive impact of HSR on the economic recovery of host countries.
With an international 'firewall' built by HSR against the pandemic, Chinese Foreign Minister Wang Yi said in June 2021 that since last year, the BRI cooperation has not pressed the 'pause button', but rather moved forward against the wind and showed strong resilience and vitality (Ministry of Foreign Affairs of the PRC, 2021b).As a result, in 2020, China's trade volume of goods with BRI partners reached a record high of $1.35 trillion (Xinhua Net, 2021a).In 2021, China's total import and export to countries along the BRI was up to ¥10.43 trillion, with an increase of 23.5% year-on-year (State Council of the PRC, 2021a).

Obstacles in the construction of the HSR
The HSR, as a new institutional layer, has contributed to global health governance and economic recovery during COVID-19 with its unique strength.Nevertheless, the construction of HSR has encountered several obstacles.

Date
Health Assistance from China to Indonesia March 28, 2020 Medical supplies, including test kits, masks, protective clothing, and ventilators.
April 14, 2020 Medical aids, including 26,000 N95 masks, 197,000 medical masks, 1,500 pieces of protective clothing, 30,000 pairs of medical gloves, hundreds of forehead thermometers, and oximeters.April 22, 2020 Video conference of medical experts on technical issues such as the treatment criteria for COVID-19 Pneumonia, clinical drug screenings, discharge criteria, re-positive cases, virus variation, vaccine development, etc. May 9, 2020 Video conference of medical experts on technical issues.May 14, 2020 Video conference held by China military medical experts to introduce the PLA's successful experience in fighting the COVID-19 pneumonia pandemic and to answer questions about the use of hormones, plasma, and Chinese medicines.June 8, 2020 Video conference of medical experts on discussing the use of traditional medicine in the treatment of COVID-19.June 1-3, 2020 Medical supplies, including 100,000 nucleic acid testing reagents, 1.3 million medical surgical masks, 70,000 medical protective masks, and 70,000 pieces of medical protective clothing.
Source: Embassy of the People's Republic of China in the Republic of Indonesia (2020).
First, HSR is challenged with a prominent issue of securitisation in the context of China-U.S. strategic competition (Mao, 2021;Mao & Wang, 2021).In particular, the U.S. has been prone to adopt security-related discourses, emphasising the possible security threats from the extension of the HSR to western and recipient countries.Moreover, driven by such logic of securitisation, the U.S. has maintained a precautious attitude toward Chinese health assistance abroad, attempting to limit the influence of China's HSR (Hillman & Tippett, 2021).
Since the outbreak of Covid-19, health assistance provided by Beijing through the HSR has been criticised by western media and academia about its hidden strategic and geopolitical purposes (Banerji, 2022;Huang, 2021;Karásková & Blablová, 2021;Kurlantzick, 2020;Kurtzer & Gonzales, 2020;Mardell, 2020;Pairault, 2021).At the beginning of the outbreak, critics noted that Beijing was using the HSR to 'shift the story away from China as the epicenter of the pandemic' and 'change the Covid-19 narratives' (Baier & Re, 2020;Culver & Gan, 2020;Rogin, 2020;Verma, 2020).Furthermore, with China's efforts to supply more countries with medical equipment and vaccines, the HSR was further labelled as 'Mask Diplomacy' or 'Vaccine Diplomacy' of Beijing to 'export its political system' and 'expand its political sphere of influence' (Karásková & Blablová, 2021;Mardell, 2020;Rudolf, 2021).As such, the HSR was regarded as a tool for Beijing to seek 'predatory' business interests and establish itself as an 'indispensable force' in the global health area (Heldt, 2020;Sibley, 2020).Moreover, China's vaccine donation was accused of reaping 'political dividends' by trading vaccine aid for other countries' support of China's core interests (Hillman & Tippett, 2021).
Perceiving the existential threat posed by the HSR, the U.S. has taken measures to limit the influence of Beijing in global health governance.In the early stage of COVID-19, the absence of the U.S. in providing health assistance abroad during Donald Trump's presidency fuelled a narrative that a battered and insular U.S. cannot help lead the world out of this crisis (Poling & Hudes, 2021).This situation, however, changed after Joe Biden took office.In June 2021, the Biden Administration unveiled a strategy for global vaccine sharing, announcing an allocation plan for the first 25 million doses to be shared globally (The White House, 2021).Specifically, the United States would share 75% of these vaccines through COVAX and share 25% for the immediate need to help with surges around the world.This vaccine strategy, as a vital component of the U.S. overall global strategy to 're-lead' the world to follow the U.S. value in defeating COVID-19 (Smith-Schoenwalder, 2021;The White House, 2021), has thus hedged against growing Beijing's influence abroad via HSR (Bartlett, 2021).Moreover, as in Latin America, by ramping up delivery of coronavirus vaccines to the area, the U.S. attempted to curb China's efforts to 'wield its vaccine exports'.
Secondly, skepticism of the West towards the HSR has partially shaped the perception of countries along the HSR, damaging the HSR's reputation.As in the case of Nigeria, part of its public showed opposition to Beijing's health assistance through the HSR (Adebowale-Tambe, 2020; Asaju, 2020).In April 2020, the Nigerian Medical Association (NMA) rejected the federal government's proposed invitation of an 18-member Chinese medical team to support the country in fighting against coronavirus, the reason that bringing in doctors from 'the hotbed of the plague' would expose Nigerian citizens to further risks (Onyeji, 2020).The concerns by Nigerian doctors about the arrival of a Chinese medical team also attribute to several different issues ranging from blaming China for the spread of the pandemic and perceiving Chinese medical aids as 'hypocritical' to growing 'anti-Chinese sentiment' in the country (Anadolu Agency, 2020;Olander, 2020).Although Nigerian National Orientation Agency (NOA) clarified that Chinese medical teams were only coming to share experiences (Premium Times, 2020), it still did not stop Nigerian doctors from opposing the invitation (Onyeji, 2020).
In Southeast Asian Countries, China's vaccine donation has also been labelled as the 'Vaccine Diplomacy' of Beijing to achieve geopolitical goals (Anh, 2021b;CNA, 2021;Nguyen An Luong, 2021;Strangio, 2021).Although early as 2015, Vietnam announced its participation in the BRI, it is the country where actual progress in the construction of BRI is relatively slow (Hong Hiep, 2018).The major challenges facing the BRI in this country are Vietnamese concerns about falling into a 'debt trap' or being threatened by Beijing's 'expanding political influence' (Van Huy, 2020).
The distrust in China impeded the promotion of the HSR in Vietnam during COVID-19.As for Beijing's vaccine donation, Vietnam, among Southeast Asia countries, is the most reluctant to choose the Chinese vaccines (Luong, 2021;Nguyen An Luong, 2021;Strangio, 2021).It was only in June 2021 that Vietnam approved the Sinopharm vaccines for emergency use (Nga, 2021a), while it had singled out Chinese vaccines from the vaccine procurement programme.Despite Hanoi accepting a donation of 500,000 doses of Sinopharm in June, an overwhelming majority in Vietnam said they would rather wait and pay extra money to get western vaccines (Hoang Thi Ha, 2021;Jennings, 2021).Many rejected the vaccines outright on local social media, either out of visceral anti-China attitudes or an entrenched distrust of made-in-China products (Zaini & Thi Ha, 2021).Vietnam thus relies primarily on western vaccines, such as AstraZeneca, Pfizer, and Moderna, in its vaccination drive (Viet Nam News, 2021).
Thirdly, numerous health products donated or exported by Beijing to the HSR partners, have been accused of 'poor' quality or 'limited efficacy', hampering the development of the HSR.For instance, a lot of foreign countries, including Spain, Czech Republic, Slovakia, Turkey, United Kingdom, Australia, and India, complained about 'faulty' coronavirus test strips and 'counterfeit' masks purchased from Chinese companies in the first half of 2020 (BBC, 2020a).Consequently, some countries, like Spain, Netherlands, Turkey, and India, have cancelled orders for Chinese test kits and masks afterward (Los Angeles Times, 2020).
In addition, the efficacy of Sinopharm and Sinovac, the two most widely distributed Chinese vaccines in the world, has come under scrutiny since late 2021 since concerns about the protection Chinese vaccines offer against both the Delta and the Omicron variants were raised (BBC, 2021;Brown, 2022).Many countries along the HSR, such as Indonesia, Malaysia, Thailand, and Singapore, have thus changed their vaccine procurement plans and shifted to Pfizer vaccines (Watanabe & Takedan, 2022;Taylor, 2022).As presented in Figure 3, the decline of both Sinopharm and Sinovac vaccines delivered by China through bilateral deals and donations since late 2021 has consequently been seen as the 'fallout from these efficacy questions' (Watanabe & Takedan, 2022).
Lastly, the expansion of the HSR, particularly during COVID-19, has been achieved mainly through short-term and fragmented assistance projects for medical products or teams (Beg, 2020).Therefore, the challenge lies in how to build long-term and coordinated multilateral health mechanisms along the HSR in the post-epidemic era (Xin & Wen, 2020).In the case of China-Africa HSR, Beijing has launched various medical assistance projects to African countries, including medical team sending, material donation, infrastructure construction, and expert training (Zheng, 2020).Such projects, however, were generally isolated from each other without coordination.For instance, China has supported many African nations, such as Côte d'Ivoire and Mauritius, through hospital construction, but its impact on the local health system is limited (Wang et al., 2015).That is because, in practice, projects to support hospital construction are not well integrated with other health projects, like medical team sending or hospital-to-hospital technical cooperation, to help with the follow-up operations of target hospitals (Wang et al., 2017).Chinese medical teams sent to partner countries are primarily managed by the Economic and Commercial Counselor's Office of the Chinese Embassy.At the same time, the Ministry of Commerce takes charge of the construction of local medical facilities and the donation of medical supplies (Zeng, 2021).Besides, China's Ministry of Foreign Affairs and Ministry of Finance are involved in health diplomacy and budget support, respectively.In the absence of an effective integration scheme for health assistance, sectoral fragmentation and divisional interests largely impede China from building a high-impact regional health initiative in the construction of the HSR (Zeng, 2021).

Conclusion
China's HSR aims to supplement the existing global health governance system to improve people's health among partner countries, leading to a layering relationship between them.Through flexible and intensive medical assistance, the HSR has shifted priority to the fight against COVID-19 with countries along the Belt and Road as a new institutional layer to the existing health system.Unlike other health-themed initiatives, the HSR also played a distinct role in helping partner countries to revitalise the economy and mitigate the negative impact of the COVID-19 pandemic on the BRI construction.
Although the HSR, with its unique advantages, has a positive impact on global health governance and economic recovery, it has encountered certain obstacles.Particularly in the context of China-U.S. strategic competition, the development of HSR has been facing a prominent issue of securitisation in the context of China-U.S. strategic competition.In addition, the distrust of several partner countries in HSR has hindered the implementation of relevant projects.Moreover, the HSR has been plagued with product quality issues and fragmentation of projects, preventing it from serving as a coordinated, institutionalised, and high-impact health initiative in the long run.Notes 1.We interviewed 16 actors involved in the HSR from September 2020 to April 2022, including staff members from Chinese vaccine companies Sinopharm and Sinovac, and members of the China Hospital Association, which takes charge of the China-ASEAN Hospital Cooperation Alliance.We participated in an academic conference entitled 'Medicine and International Relations' in October 2020.We exchanged views with Chinese officials and experts from top Chinese universities on topics such as TCM development under the framework of HSR. 2. According to an interviewee who specialises in traditional medicine,'TCM, with a long history of 5,000 years, is the most complete, influential, and widely used traditional medical system.As a holistic approach to combining prevention, health care, treatment, and rehabilitation, TCM has attracted widespread attention […] The unique advantages of TCM lie in lower costs, a more relaxing treatment process, and reportedly fewer side effects'.3.In the words of staff in Chinese vaccine companies whom we interviewed in September 2020: 'Few countries have R&D capacity for COVID-19 vaccines, most of them thus depend on vaccine imports […] In the context of the global scarcity of vaccines, many countries welcome our companies to do phase 3 clinical trials for earlier access to vaccines, and we are committed to prioritising them with COVID-19 vaccines after R&D success'.
Furthermore, on December 31, 2021, the State Administration of Traditional Chinese Medicine (SACM) formerly issued a notice on 'Promote High-Quality Integration of Traditional Chinese Medicine into the Development Plan of Belt and Road Initiative (2021 −2025)'.In highlighting the positive role of TCM in the global fight against COVID-19, the notice sets out the main task for the next five years to share the treatment and rehabilitation programme of TCM for infectious diseases (National Administration of Traditional Chinese Medicine

Figure 1 .
Figure 1.Timeline for the Development of HSR.Source: Made by authors.
pledges are delivered, with most medical and health assistance being provided through the HSR and BRI transportation networks.By May 2022, China has provided 4.6 billion pieces of protective clothing, 18 billion test reagents, 430 billion masks, and other anti-epidemic materials to 153 countries and 15 international organisations.In addition, as of March 2022, China-Europe freight trains have shipped 13.6 million pieces of pandemic prevention materials through 73 routes to 23 European countries, guaranteeing the stability of the global industrial chain and supply chain to fight the pandemic (State Council of the PRC, 2022).China-Europe freight trains have thus become a 'lifeline' and a 'link of destiny', as air and sea shipments have been blocked during the pandemic (State Council of the PRC, 2021b).According to data from the Chinese government, as of July 2022, China has kept its commitment by engaging in extensive vaccine cooperation with many countries 3 and has donated and exported over 2.2 billion doses of COVID-19 vaccines to more than 120 countries, most of which are HSR partners (UNICEF, n.d.).China has also cooperated with HSR partners, Egypt, for example, to build its local manufacturing capability for COVID-19 vaccine production (Central People's Government of the People's Republic of China, 2021).Besides, Cainiao, a Chinese cross-border logistics company, has launched two controlled temperature chain flights per week with Ethiopian Airlines to export vaccines (State Post Bureau of the People's Republic of China, 2020).

Table 1 .
International Hospital Alliances under the HSR.
Established in May 2019 to enhance and promote the health level of countries along the BRI through communication and cooperation among hospitals Note: The data were collected from various sources (State Council of the PRC, 2017; Xinhua Net, 2018).Source: Made by Author.
March 22, 2016, China and WHO jointly issued the China-WHO Country Cooperation  Strategy (2016-2020)in Beijing.Beijing clearly stated that 'the Chinese government has always attached great importance to cooperation with WHO, and China is willing to actively participate in global health with the support of WHO and work with the majority of developing countries to achieve sustainable development' (State Council of the People's Republic of China, 2016).Furthermore, the WHO affirmed its continued support for China's active participation in global health during 2010-2012, donating $285 million to multilateral institutions (State Council of the People's Republic of China, 2016; WHO, 2016).

Table 3 .
Health Assistance from China to Indonesia during COVID-19.