Facing forwards along the Health Silk Road

Abstract

Last month, China made a significant move towards the consolidation of its role as a major player in global health policy. At the Belt and Road High-level Meeting for Health Cooperation in Beijing, delegates from between 20 and 30 countries plus WHO, UNAIDS, the GAVI Alliance, and the Global Fund signed a communiqué aimed at increasing collaboration on research, health security, and education among the countries of China's proposed Belt and Road Initiative. Those still in the dark about this initiative, also known as One Belt One Road, should bring themselves rapidly up to speed. The brainchild of President Xi Jinping, One Belt One Road is a colossally ambitious developmental infrastructure project which China hopes will engage 64 countries grouped loosely along the course of the ancient Silk Road—the cross-continental trade route linking Asia with Europe and Africa that operated under a spirit of “peace and cooperation, openness and inclusiveness, mutual learning and mutual benefit”. If all 64 countries eventually commit to the project, which China is careful to pitch as a collaborative, partnership-style venture, not one that is dictated by Beijing, the project will encompass nearly two-thirds of the world's population and a third of its GDP. Thus the formal inclusion of health in what is essentially a gigantic trade deal, is good news indeed. Signatories to the so-called Health Silk Road communiqué affirmed their commitment to the core missions of health systems strengthening and universal health coverage, including to “formally incorporate training, remuneration and integration of community health workers into national health systems”. Such commitment adds to the growing momentum around formalising the vital work of community health practitioners, as we highlighted earlier this year. The role of traditional medicine within the health system was also championed in the communiqué, via support for WHO's 2014–23 traditional medicine strategy. Elsewhere the focus was on the importance of reproductive, maternal, and child health and of emerging infectious diseases. China has made great strides in population health in recent decades. Since the 1990s, for example, China's under-5 mortality rate dropped from around 51 to 11 per 1000 livebirths (in 2015) and its maternal mortality ratio decreased from 97 to 27 per 100 000 livebirths. In line with this, the latest estimate for the proportion of births attended by skilled health personnel is 99·9%, and the figure for households covered by health insurance is 96%. Malaria is on the way to being eliminated and the Millennium Development Goal target for tuberculosis was met 5 years ahead of schedule. China has a more troubled history when it comes to HIV/AIDS, with early denials threatening to lead to catastrophe; however, it has since proven a success case once again, with only recent rises in men who have sex with men marking a point needing additional attention. Non-communicable diseases, however, were distinctly absent from the High-level Meeting agenda and the Health Silk Road communiqué. Yet these conditions represent 87% of total deaths in China; risk factors such as hypertension, obesity, and hyperglycaemia continue to increase; and road traffic injuries now represent a top ten cause of death. In fact, the meeting and communiqué both have a distinctly pre-2015 feel to them, in contrast to China's ambitious Healthy China 2030 strategy, which it unveiled last year. Here the focus is firmly on healthy lifestyles and healthy environmental conditions, including healthy cities—ie, those that promote physical activity, provide easy access to healthy food and health care, and reduce noise and pollution. China's engagement in global health, mainly in Africa, has so far drawn on its unique strengths to deliver assistance through hospital construction, malaria control, education and training of health workers, drug donation, and cross-border infectious disease control (based on its experience with severe acute respiratory syndrome). It should now take the next step and ensure that the One Belt One Road initiative, with its emphasis on development via infrastructure, does not conflict with the admirable aims set out in its own Healthy China 2030 strategy. “We can all learn something from China”, said WHO Director-General Tedros Adhanom Ghebreyesus at the Belt and Road High-level Meeting. We hope China shares its recent lessons as well as those from the past.