With the recent ratification of the pandemic treaty, our study offers a timely and distinctive contribution to pandemic response literature by analyzing China’s COVID-19 aid in the context of its expanding development assistance portfolio in Africa [22, 23]. The findings carry important implications for global health stakeholders, highlighting the scale of investments needed to strengthen pandemic preparedness and response systems. This is particularly crucial for Africa, a region that remains highly vulnerable to emerging infectious diseases of pandemic potential due to persistent challenges such as inadequate health infrastructure, political instability, and economic insecurity [24]. Addressing these vulnerabilities requires sustained global collaboration and solidarity to strengthen prevention, mitigation, and treatment efforts.
China’s growing presence in African and other low-income countries has prompted discussions about the motivations behind Chinese foreign aid. While some believe Chinese foreign assistance is altruistic in nature, others maintain that it is rooted in strategic interest. Like many other donors, foreign aid has been an important component of China’s foreign policy, shaping its global engagement and diplomatic relationships for decades. For example, China has been supporting Sri Lanka’s healthcare system since 1967, demonstrating its long-standing involvement in international health initiatives [25]. Additionally, China has prioritized the control of the cross-border transmission of infectious diseases since the 2003 severe acute respiratory syndrome (SARS) outbreak [26]. In fact, in recent years, China has set an impressive pace for funding projects in low- and middle-income countries (LMICs) [14]. However, some observers note that China often directs funding toward politically and economically less stable countries, which has led to interpretations that China may have broader geopolitical objectives [27, 28]. Ongoing analysis also explores how China’s health aid efforts may contribute to enhancing its soft power and strategic presence in Africa relative to other nations [29]. Overall, there have been instances of both gratitude and concern expressed on behalf of recipient countries.
While the underlying motivations behind China’s global health funding remain unclear, its role in pandemic response remains significant and must be considered in future preparedness planning. Our analysis reveals notable disparities in the distribution of aid across African countries, with 12.94% of all identified projects concentrated in just three countries: South Africa, Zimbabwe, and Cameroon. This uneven allocation raises critical questions about the underlying drivers of aid distribution, whether they reflect geopolitical considerations, historical bilateral relationships, recipient country capacity, or differential need.
South Africa, a vast country with a dense population, suffered the most reported deaths during the pandemic in Africa [30]. It expectedly received the largest number of Chinese COVID-19 aid. However, the South African case is an exception to the broader trend. When the data are compared with epidemiologic data from Worldometer and Statista, there is little evidence to suggest a consistent relationship between disease burden and the volume of aid received. For example, although Morocco and Egypt had many more deaths during the pandemic, they received exceptionally less aid than Zimbabwe and Cameroon [30, 31]. This suggests that China may have motivations other than providing assistance to countries that suffered the most from the virus. Additionally, if aid was consistently provided based on high numbers of COVID-19 deaths, Tunisia, the country with the most deaths per capita, should have received more projects than it was given (15 projects). These findings highlight the need for greater transparency and equity in global health assistance, especially in times of crisis when resource allocation has critical implications for health outcomes.
That being said, it would be irresponsible to neglect the possibility that the number of reported deaths may not accurately reflect the disease burden of each country. Although South Africa accounted for nearly half of the COVID-19 deaths on the continent, it also had a disproportionately high testing capacity, conducting over 26 million tests—more than twice that of Morocco, which ranked second with approximately 13 million tests [30, 31]. This may indicate that South Africa’s elevated mortality figures may reflect its stronger ability to detect and report cases and deaths, rather than a uniquely severe outbreak.
Although difficult to quantify, there is reason to suggest that China may prioritize donations to countries with which it maintains historically strong political ties, as illustrated by the case of Zimbabwe. China publicly supported the Zimbabwe African National Union in the war of liberation (1964–1979) and was therefore among the first international bonds with Zimbabwe in its infancy [32]. In more recent years, Zimbabwe has actively sought to rekindle this relationship, particularly in the context of Western sanctions. In 2006, then-President Robert Mugabe declared a strategic reorientation toward China, stating the country was “returning to the days when our greatest friends were the Chinese” and that Zimbabwe would “look again to the East where the sun rises and no longer to the West where it sets” [33]. Echoing this sentiment, former Finance Minister Herbert Murerwa identified China as Zimbabwe’s “single largest investor” and emphasized the importance of leveraging Chinese partnerships to develop the country’s natural resources [34].
Since then, the Sino-Zimbabwean relationship has expanded through a series of technical, economic, educational, and tourism agreements. China has provided humanitarian aid during droughts and invested in key sectors such as agriculture, mining, and infrastructure development [35]. Military cooperation has also deepened, with China providing training to senior Zimbabwean military personnel—prompting observers to describe the defense partnership as among the closest China maintains on the African continent [34, 35]. Taken together, these longstanding and multifaceted ties suggest that the substantial volume of Chinese aid projects directed toward Zimbabwe during the COVID-19 pandemic may reflect an ongoing effort to reinforce and preserve these strategic political relationships.
Cameroon, the third largest recipient of Chinese COVID-19 aid in Africa, further illustrates how strong diplomatic relations can influence aid allocation. Since severing ties with Taiwan in 1971, Cameroon has maintained robust bilateral relations with China, positioning itself as a strategic gateway for Chinese engagement across the continent [36]. The late 1990s and early 2000s marked a deepening of Sino-Cameroonian ties through a series of agreements covering investment protection, economic cooperation, and technical collaboration [37, 38]. President Paul Biya’s public invitation for Chinese investment in key sectors such as hydrocarbons, mining, and forestry underscored Cameroon’s receptiveness to Chinese engagement [37]. In the years since, China has significantly expanded its footprint in Cameroonian infrastructure, agriculture, trade, and education—including scholarships and language programs [38, 39]. These longstanding connections established an effective and trusted framework for the rapid delivery of Chinese aid during the COVID-19 pandemic.
Regional analysis reveals significant disparities in the distribution and efficiency of China’s COVID-19 aid to Africa. North Africa, despite receiving the second-highest monetary allocation, exhibited the lowest average number of projects per country, indicating a possible misalignment between financial resources and tangible programmatic activities. Central Africa’s average project count is inflated by Cameroon’s outlier status; when excluded, the region’s aid engagement appears limited both in scale and scope. This discovery mirrors findings from previous research on China’s malaria aid in sub-Saharan Africa, where Central African countries also received limited support relative to their disease burden [40]. Conversely, Southern and Western Africa demonstrated a more cost-effective distribution, with a greater number of projects implemented per dollar spent compared to Eastern Africa, which expended over $600 million with comparatively fewer projects. These findings suggest that political alignment, logistical convenience, or existing bilateral agreements may be stronger determinants of aid allocation than epidemiologic need.
China’s selective allocation of COVID-19 aid across African regions mirrors broader patterns observed among OECDs Development Assistance Committee (DAC) members, who also heavily prioritized Eastern Africa. From 2020 to 2022, DAC countries donated over $1.3 billion in pandemic supplies to Eastern Africa alone, representing nearly half of all African aid, while Northern and Central Africa received less than half that amount [41]. The United States exemplifies this trend, contributing over $660 million to Eastern Africa but only $34 million to Northern Africa, alongside a disproportionate distribution of vaccine doses favoring countries like Nigeria over others with comparable population sizes [41, 42]. These patterns suggest that geopolitical interests and strategic partnerships strongly influence the distribution of health aid across Africa. For future pandemic preparedness, it is imperative that health aid—particularly from major global actors—be guided by transparent, data-driven criteria that align resources with disease burden and regional vulnerability. This will ensure that limited resources are deployed in ways that maximize public health impact and strengthen health system resilience across all regions.
China’s strategic deployment of aid mechanisms during the COVID-19 pandemic not only underscores its geopolitical priorities but also reveals a deliberate focus on areas where it holds comparative advantages in global health. Historically, China has played a central role in combating infectious diseases such as malaria, schistosomiasis, and tuberculosis by contributing cost-effective diagnostic tools, medications, and vaccines [11, 40]. Our analysis of COVID-19 aid projects confirms that China has continued to leverage these strengths as reflected in its aid portfolio. Notably, Personal protective equipment (PPE) was the most widely distributed aid (43.33% of projects), followed by diagnostic and medical technologies (26.00%) and vaccinations (17.88%). Many projects combined multiple aid types, with PPE and diagnostic technologies often paired. This pattern suggests a strategic focus on providing cost-effective, complementary resources aligned with China’s manufacturing/industrial capabilities to deliver bundled, scalable interventions. In doing so, China has demonstrated an ability to offer high-impact, cost-effective solutions that complement the broader global health landscape. This presents an opportunity for future global health frameworks to integrate China’s contributions more effectively, particularly in areas where resource efficiency and rapid deployment may be critical.
In contrast to its strength in the manufacturing and distribution of PPE and diagnostic technologies, this study does not find compelling evidence to support the prioritization of vaccine donation as an optimal strategy for China. While China allocated an estimated $4.17 billion—nearly 91% of its total $4.6 billion COVID-19 aid budget—toward the manufacturing and donation of vaccines at a cost of approximately $18 per dose, the United States spent less overall while donating substantially more vaccine doses: over 683 million compared to China’s 239 million [43]. These figures highlight a significant efficiency gap, suggesting that China’s vaccine initiative, while ambitious, has not yielded proportional returns in volume.
Given China’s demonstrated capacity for cost-effective production in other sectors, it may consider reallocating a portion of its resources away from vaccine manufacturing and toward areas where it can deliver higher impact per dollar, such as PPE and diagnostic medical technologies. However, geopolitical realities complicate this calculus. Should China cease vaccine development and find itself excluded from global vaccine-sharing initiatives—whether for political, diplomatic, or supply-related reasons—it could compromise its ability to protect domestic and partner populations. Thus, any reallocation of aid strategies must balance fiscal efficiency with strategic autonomy and preparedness.
Furthermore, the importance of long-term health systems strengthening cannot be overstated. Although health infrastructure represented only 2.34% of the projects captured in this study, it remains a foundational component of sustainable public health capacity in Africa. China’s historical role in building hospitals across 38 African countries since 2000 exemplifies a model of structural investment that has the potential to outlast short-term pandemic responses [44]. Future aid strategies should continue to incorporate infrastructure development as a means of reinforcing regional resilience, supporting local health systems, and facilitating the integration of other aid modalities. By complementing short-term emergency response with long-term structural investment, China can help shape a more sustainable and equitable global health architecture.
While this study emphasizes the strategic allocation of Chinese aid toward cost-effective modalities such as PPE and diagnostic technologies, it is critical to consider these conclusions within the broader, shifting context of global health financing. The first 100 days of the 2025 Trump administration have witnessed profound reductions in funding, personnel, and program operations across key public health institutions. Within hours of inauguration, an executive order was signed mandating the United States’ withdrawal from the World Health Organization (WHO), effective January 22, 2026 [45]. Simultaneously, a stop-work order was issued to the United States Agency for International Development (USAID), disrupting efforts to combat infectious diseases such as Marburg virus, avian influenza, poliomyelitis, Mpox, Ebola, and neglected tropical diseases [46, 47]. Additionally, significant cutbacks to the President’s Emergency Plan for AIDS Relief (PEPFAR) have limited access to HIV treatment programs for thousands across Africa [47]. Funding for multiple US vaccine initiatives has also been withdrawn, including the cancellation of $590 million awarded to Moderna to develop vaccines to combat avian influenza and $258 million pledged to the Center for HIV/AIDS Vaccine Development (CHAVD) [48, 49]. These developments threaten progress toward key United Nations Sustainable Development Goals (SDGs) 3.3, 3.7, and 3.8, which focus on ending epidemics, ensuring universal sexual and reproductive health access, and providing quality essential health services and medicines [50].
In light of this retreat by a historically dominant donor, the role of nontraditional actors such as China in global health diplomacy will become increasingly salient [29]. Future pandemic preparedness and response will likely depend on China’s capacity to sustain and scale vaccine production and distribution, ideally improving cost-effectiveness to compensate for diminished US involvement. This may necessitate a strategic recalibration of China’s aid priorities, diverging from the previously dominant international assumption that the United States would continue to lead on the global health stage [51]. Ultimately, China’s engagement in vaccine development and broader global health initiatives must be informed by the evolving geopolitical landscape to ensure effective and sustainable international health cooperation.