Along with China’s active engagement in global affairs over the past decade, China’s public health engagement (CPHE) has become an essential element of China’s 60th anniversary of health aid and cooperation with Africa. Through analysis, we found that CPHE in Africa reflects a new shift in the content and form of China’s foreign health aid. Compared with China’s medical teams which only involve bilateral cooperation, CPHE has a number of substantive characteristics, mainly including the construction of public health infrastructure, malaria control, participation in public health emergencies and the provision of global public goods. This complexity necessitates that CPHE be implemented in a different form from China’s medical teams, by adopting inclusive multiparty cooperation involving African and international partners. However, CPHE in Africa still faces a number of challenges in its practices. In particular, these challenges arise from the cross-cultural practice process, the African sociocultural context, the experience of public health and its participants. While the reasons for these challenges are diverse, this study argues that the main reason is the lack of multidisciplinary engagement in the Africanisation of the Chinese experience that corresponds to cross-cultural practice. On the Chinese side, a systematic strategy is needed to critically refine these challenges.
- Health policy
- Public Health
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China’s public health engagement (CPHE) has become an essential element of China’s 60th anniversary of health aid and cooperation with Africa.
A comparative approach was used to analyze the characteristics of content and implementation form of CPHE, and the challenges in practice.
CPHE in Africa reflects a new shift from only involving bilateral cooperation to the construction of public health infrastructure, malaria control, participation in public health emergencies and the provision of global public goods by adopting inclusive multiparty cooperation.
However, CPHE in Africa still faces a number of challenges in its practices caused by cross-cultural practice process mainly.
Beginning in 1963, when the Chinese government sent its first medical team to Algeria, the China-Africa health cooperation (CAHC) has existed for over 60 years. In the early years, CAHC was generally based on sending medical teams, mainly for the purpose of establishing and maintaining diplomatic relations with Africa.1 In the past 20 years, China has actively participated in Africa’s public health governance. In particular, the 2003 severe acute respiratory syndrome (SARS) epidemic in China, made China aware of the importance of public health security for social development and stability,2 and then the Chinese government invested 750 million yuan (about US$102 million) and sent more than 1000 medical personnel and scientists to the Ebola-affected areas to help the three West African countries control the epidemic in 2014–2015.3 The Ebola epidemic made China aware that major emerging epidemics in the other world can also affect China, leading to increasing global attention on China’s public health, which has accelerated and strengthened China’s participation in global health security. After the Ebola epidemic, medical teams and public healthprogrammes are also important elements of China-Africa cooperation, and are included in the Beijing Action Plan (2019–2021) the Forum on China-Africa Cooperation (FOCAC).4 In this sense, CAHC requires significant changes in content and form, and creating a supportive policy environment compatible with China’s public health engagement (CPHE) in Africa is needed.
From China’s perspective, CAHC is accelerating toward a ‘Community of common health’ (卫生健康共同体), which was introduced in depth in the China State Council’s White Paper on ‘China-Africa Cooperation in a New Era’ published in 2021.5 Regarding CAHC, the FOCAC in 2000 was a strong platform, and the Belt and Road Initiative (BRI) in 2013 marked a new political commitment by China’s government, especially in CPHE, with significant funding and resources.6 In particular, the China-Africa Public Health Cooperation Plan of the 2015 Johannesburg Summit of the FOCAC states that China will participate in building public health prevention and control systems and capacities, including the Africa Centers for Disease Control and Prevention (Africa CDC). Meanwhile, China’s second Africa policy paper points out that to enhance the prevention and control of infectious diseases, China will increase its assistance in preventing and controlling malaria, cholera, Ebola, AIDS, tuberculosis and other infectious diseases.7 The ‘Beijing Action Plan’ adopted at the FOCAC Beijing Summit in 2018, integrates the BRI with the African Union’s Agenda 2063, the United Nations’ 2030 Agenda for Sustainable Development and the Development Strategy of African countries. It proposes to help African countries control and eliminate malaria and re-emerging infectious diseases, and strengthen the construction of public health systems.8 Africa has become a main area for China’s foreign health aid and cooperation. From 2000 to 2017, of the 1749 programmes of China’s foreign health aid, 1226 were in Africa, accounting for 70.10%.9 China’s financial investment in health aid to African countries exceeds that of all developed countries except the USA.10 In the 60 years of CAHC, two major phases are evident—sending medical teams to Africa, and CPHE in Africa. And now, the two phases coexist.
A number of studies tended to analyse both China’s medical teams and CPHE from the single perspective of health diplomacy,11 but did not explore the differences between the two, and failed to see the dynamic nature of CPHE and the complexity of practices, and lack reflections on CPHE in the context of cross-cultural practices. By definition, China’s medical teams to Africa refer to dispatching medical doctors from China to Africa to provide fixed medical services in recipient countries. These medical doctors go to fixed countries and workplaces in Africa to practice clinical medicine, with a 2-year or 1-year rotation, and with the doctors’ assistance from one province of China to one African country and practice in some fixed hospitals.12 Its primary purpose is to serve China’s diplomacy with Africa and is a unilateral act between China and Africa, but CPHE focuses on the public health sector. Most of CPHE programmes are temporary assistance projects requested by China in the case of public health emergencies (eg, the Ebola epidemic) or infectious disease epidemics (eg, the malaria epidemic) in Africa, and are not permanent and fixed, and their operation is under the framework of China’s participation in global health security. Therefore, CPHE usually involves the WHO and other international partners and is the China-led multi-participation programme and a part of China’s global diplomatic strategy in the South–South with South–North.
In addition, based on the definition and scope of CPHE, we developed four criteria for inclusion in CPHE projects: (1) The Chinese participating institutions are public health-related institutions, such as the CDC, university schools of public health and public health institutes; (2) The Chinese participants are public health professionals; (3) The project not only concerns treating diseases but also about targeting relevant groups, and communities in Africa; (4) The projects involve non-Chinese partners, such as African public health institutions, the WHO. We then collected basic information on CPHE programmes in Africa through the websites of China’s Ministry of Commerce, Ministry of Foreign Affairs, National Health Commission, the agencies of CPHE programme implementation and China International Development Cooperation Agency, as well as information on China’s health development assistance events to Africa (2000–2014) in the China Economic and Social Development Database with World. We also used the keywords ‘Chinese health aid/assistance to Africa, health diplomacy, global health governance, and Africa or specific African countries’ to identify CHPE-related papers and academic reports in English from Google Scholar and in Chinese from the China National Knowledge Infrastructure. In the process of data collection, we found that from the end of the last century to the present, CPHE projects in Africa include at least 19 programmes, mainly from China’s health development assistance events to Africa (2000–2014) and China Economic and Social Development Database with World, the agencies of CPHE programme implementation such China’s CDC, etc, covering most African countries (see table 1). After acquiring a general snapshot of the programmes, we used a comparative approach to analyse the characteristics of content and implementation form of CPHE, and the challenges of these programmes in practice.
Basic characteristics of content of China’s public health engagement in Africa
This paper identifies four characteristics by categorising the content of CHPE projects and comparing them with China’s medical teams’programme. First, it is focused on developing the required infrastructure for Africa’s public health system. Clinical medical infrastructure assistance was a component of China’s medical team programme such as hospitals or treatment centres, however, CPHE in Africa mainly offered support through public health infrastructure. A prime example was the support and participation in the construction of the headquarters of Africa CDC, the mobile Ebola diagnostic laboratory used in 2014–2015 in three West African countries to combat the Ebola outbreak and the P3 laboratory in Sierra Leone set up in 2014 that is still working today. Meanwhile, China assisted 30 malaria control centres in Africa in 2007–2009 and a Schistosomiasis Laboratory at Pemba of Zanzibar, established from 2016 to 2019. In addition, in all of its aid programmes, China has focused on the training and cultivation of local African experts in disease prevention and control as the public health manpower infrastructures.
Second, malaria control is an essential part of CPHE in Africa.13 Among the 19 public health programmes, there were at least eight malaria programmes covering most African countries, and there are community intervention programmes in Tanzania, Comoros, Sao Tome and Principe, Zambia, Togo, and Malawi.14 There are three main reasons why malaria programmes play an essential role in CPHE. First, artemisinin and its combination drug, such as compound dihydroartemisinin, which originated in traditional Chinese medicine (TCM), have played an essential role in malaria control globally, significantly reducing malaria morbidity and mortality.15 For this, Ms Tu Youyou, the inventor of artemisinin, was awarded the 2015 Nobel Prize in Physiology or Medicine. Second, malaria has been successfully eradicated in China.16 On 30 June 2021, China received the national malaria elimination certification from the WHO, and at the same time achieved the ability to share its experience in malaria prevention and control with high malaria prevalence regions such as Africa.17 Third, addressing the malaria threat in Africa cannot be done without the cooperation of the West, China and other key participants. However, because many Western countries have long been free of malaria epidemics and did not have much experience in malaria control, China, which has rich experience, has become an essential contributor to African malaria control. This has provided an excellent opportunity for cooperation between China and Western countries. In short, because of the global reputation of artemisinin and China’s successful experience in eradicating malaria, malaria control programmes have become an essential aspect of CPHE in Africa.
Third, China actively participated in the handling of public health emergencies in Africa. Since China’s aid to three West African countries to combat the Ebola outbreak in 2014, it has sent a large number of public health workers to many African countries for public health emergencies. For example, 10 public health workers were sent to Angola in March 2016 to help fight the yellow fever outbreak, and 15 public health workers were sent in three batches from October to December 2017 to participate in the control of the plague in Madagascar. China sent eight public health workers to help deal with the Ebola epidemic in Uganda and Burundi from 2018 to 2020. In addition, China also supported the control of schistosomiasis on Pemba Island in Zanzibar from 2016 to 2019.
Fourth, China was also involved in CPHE in Africa by providing global public goods, such as medicines and vaccines, and has exerted a degree of influence on global health. For example, Chinese biopharmaceutical manufacturers have produced antimalarial drugs based on artemisinin, provided to African countries18; China’s Sino Implant (II) of male contraceptive technology have been provided on a large scale to countries with poor reproductive health resources.19 In May and June 2021, the WHO approved China’s inactivated COVID-19 vaccine (Vero Cell) developed by Sinopharm and the Sinovac COVID-19 vaccine as two emergency vaccines, not only for use in the COVID-19 Vaccines Global Access (COVAX) programme but also to pave the way for China’s exporting and selling of the vaccines. By the end of December 2021, China had distributed of 1.28 billion doses of the COVID-19 vaccine globally, approved 1.58 billion doses for export and donated 120 million doses to foreign countries, which, together with production in other countries using Chinese technology or raw materials, still accounts for more than half of the global supply of COVID-19 vaccines. As of February 2022, China had directly supplied domestically-made COVID-19 vaccines to 115 countries and has also supplied its vaccines to 30 developing countries through the COVAX programme, including 189 million doses to 27 countries in Africa. It has completed joint localised production with Egypt, with an annual production capacity of roughly 400 million doses.20 China was the largest supplier of COVID-19 vaccines to Africa and various countries in other continents worldwide.
In short, from the content, we can see that CPHE is more complex than the medical teams’ programme. As CPHE in Africa increases yearly, it targets specific diseases and the construction of public health systems in Africa. There were country-specific programmes, community demonstrations and regional programmes. From the paradigm of cooperation to the programme’s running, it is clear that the content and scope of CPHE differs significantly from that of China’s medical team programme. The practical experience gained in China’s medical team programme is inapplicable to the CPHE programmes. The differences are evident in various aspects, including in cooperation, target groups, implementation approaches, languages used, implementation strategies, local knowledge and potential barriers. In summary, CPHE is overall more complex than China’s medical teams. It faces more complex sociocultural contexts than China’s affecting both collaboration and practice (see table 2).
Implementation forms of China’s public health engagement in Africa
The complexity of the content of CPHE makes it impossible for these projects to adopt bilateral aid methods such as medical team projects, and more joint and diverse project implementation forms should be adopted. This part concludes that the implementation forms of CPHE mainly include the following two points.
First, China was actively promoting the complementarity of South–South and South–North cooperation through the CPHE in Africa, and exploring multi-partner cooperation models. South–South cooperation refers to China’s cooperation with the Africa CDC, health institutes and related hospitals or communities in various African countries to enhance the strength and dynamism of local public health participation in Africa. At the same time, China was also actively promoting South–North cooperation. Of the 19 CPHE programmes in Africa identified in this paper, at least 7 programmes involve the participation of several international organisations. There were many international partners in CPHE in Africa, such as the WHO and its offices in African countries, the UK’s Department for International Development (DFID), Duke University, the Swiss Tropical and Public Health Institute and the Bill & Melinda Gates Foundation, among others. In addition, although China is a major provider of project funding, public health professionals and other resources, these international partners play a positive role, for example, DFID provided financial and project coordination for the China-UK-Tanzania Malaria Control Pilot Programme in 2015–2018, and WHO also provided project coordination, policy advice, consultation and technical support for most CPHE projects, among others.
Second, is the diversity of Chinese programme implementation and participating parties in CPHE. Unlike the members of China’s medical team, who were from clinical medical hospitals, the members of the public health programmes are from the schools of public health at Chinese universities, China’s CDCs and various medical science research institutions. Some examples include China’s CDC being part of the team that assisted the Africa CDC in preventing diseases, especially infectious diseases, the Guangzhou University of Chinese Medicine as the implementing party for the programmes of rapid control of malaria with compound artemisinin in Comoros and other countries, the National Institute of Parasitic Diseases of China’s CDC as the executing party for the programme of malaria control in several African countries, the Jiangsu Institute of Parasitic Diseases as the executing party for control of schistosomiasis at Pemba Island in Zanzibar; and the maternal and child healthcare programme in Ethiopia being implemented by the School of Public Health of Fudan University. These research and academic institutions were actively involved in and led CPHE in Africa. They avoided the institutional drawbacks of bilateral government cooperation with a professional approach and facilitated the implementation of programmes with flexible cooperation mechanisms. The experiences and lessons learnt during the implementation of these programmes should be explored and shared on a global scale, all the while enriching the channels and forms of South–South and South–North cooperation. In addition, the participation of Chinese universities had also promoted the construction and development of global health disciplines in China’s education system and also trained a number of cross-cultural public health practitioners.
From the content and form of CPHE, many aspects of CPHE in Africa were not static but rather dynamic. In particular, after China actively participated in assisting three West African countries to fight the Ebola epidemic in 2014, China’s foreign public health engagement underwent a significant change. The concept of CPHE had shifted from health diplomacy based on health aid between China and Africa to participating in global health governance of the South–South with South–North. With this change in concept, CPHE in Africa became more diverse in content, emphasising multilateral participation and cooperation, the role of African parties and actively inviting international partners to participate. Further, China’s disease prevention and control systems and schools of public health at universities gradually become primary programme implementers, while also paying attention to the role and influence of African society and culture in practice (see table 3).
Challenges of public health engagement from a China perspective
The sustainability of CPHE programmes depends on the degree of Africanisation of the Chinese experience, which involves reaching out to African communities and engaging with local governments, communities and even individuals. Corresponding to the content and implementation form of the project, the challenges of the CPHE programmes mainly exist in the implementation process. So, we ought to focus more on the challenges that affect the sustainability of CPHE. In the horizontal dimension, we compare with China’s medical teams’ programme (see table 2) and then explore the differences of challenges from the perspective of African or international partners (table 4); in the vertical dimension, we compare the CPHE program before and after 2014 (see table 3). On this basis, we summarise five main challenges that can affect the sustainability of CPHE programmes.
First, the context of the history and social culture of public health in Africa has not been given sufficient attention. Compared with China’s medical teams, which only involve the treatment interaction between Chinese doctors and African patients, CPHE programmes must face the community, groups and even African public health experience in the context of history and social culture. For example, in the TCM trial treatment of AIDS in Tanzania from 1987 to 2018, the China Academy of China Medical Sciences sent 16 batches of 63 doctors to Tanzania.21 However, the programme failed to uncover the most sensitive medical ethical issues in Africa. In 1987, before antiretroviral therapy was introduced in Africa, Tanzania took the initiative to seek the involvement of TCM in the treatment of patients with AIDS. At that time, the number of patients with AIDS in China was extremely low, and TCM had not yet been applied to the AIDS treatment.22 The assistance to Tanzania was the first time TCM was used to treat AIDS. In practice, the lack of interaction with Tanzania and the lack of attention to the role of the Tanzanian partner, coupled with the mysteries surrounding TCM’s seemingly strange ingredients, aroused the distrust of Tanzanian patients with AIDS and even the ethical questioning of Tanzania as an AIDS treatment ‘guinea pig’.23 The social suffering of Africans due to the numerous drug and vaccine experiments conducted in Africa during the Western colonial period still negatively affects African attitudes toward foreign aid. The rejection of vaccines and foreign aid in Tanzania during the early years of the COVID-19 epidemic is related to this historical context.24 The reasons for this challenge are related to the lack of attention to multidisciplinarity in CPHE in Africa, particularly the lack of involvement in the humanities and social sciences.
Second, is the participation of a single discipline and the lack of a multidisciplinary perspective. Unlike clinical doctors of China’s medical team who form a single discipline of clinical medicine, CPHE projects require personnel from multiple disciplinary. Despite the emphasis on international cooperation and multiparty engagement, CPHE in Africa came mainly from the fields of clinical medicine, epidemiology and public health. Before participating in African programmes, they had little to no experience in cross-cultural engagement. Cross-cultural public health programmes that rely on biomedical and preventive medicine disciplines have notable difficulties paying attention to the religious, historical and sociocultural factors that may be involved in the practice and development of healthcare in Africa and their impact on programme sustainability. In addition, these programmes generally suffered from language communication barriers and differences in working culture and project management approaches, which to some extent, affect the effectiveness of programme implementation.25
Third, there was a failure to notice that the development of healthcare in Africa has seen some progress. Although there are still many challenges for public health in Africa, there has been some change in attitude toward external assistance. For example, in the case of China’s medical teams in Africa, some African countries have asked that Chinese doctors not practice in city medical facilities but in remote areas where resources are scarce and there are fewer doctors. Similarly, with some of the public health programmes supported by China, the African countries involved may not just accept them wholesale, but demand that Chinese programmes be promoted on a pilot basis, involve multiple parties and increase the participation and autonomy of African parties. For example, the artemisinin combination rapid malaria control programme in Comoros was a great success, but its ‘island experience’ faced challenges when placed in different geographical and social contexts on the African continent.
The fourth challenge concerns how to grasp the scope of multiparty participation, particularly African autonomy. In most programmes, the Chinese side often plays the dominant role, and the binary relationship of ‘aid-receive’ is bound to encounter Africa’s long history of foreign assistance, and thus China’s ability to manage and respond to a range of challenges in implementing public health programmes will be critical to the success or failure of each programme. Further, building a suitable cooperation mechanism with African and international partners becomes the key to the sustainable development of the programme. As far as the African side is concerned, China’s experience comes from China’s domestic practice. In sharing its experience with Africa, it must be a ‘teacher’. Under this power relationship, how the African side can play a positive participatory role is related to the local practice and the effect of the Chinese experience. For example, when the TCM treatment programme for patients with AIDS began in Tanzania in 1987, the Tanzanian side was a facilitator. With a lack of understanding of TCM, communication barriers often occurred during programme implementation.26 Especially after the introduction of antiretroviral therapy in Tanzania in 2003, the effectiveness of the programme was significantly reduced. Therefore, it is necessary for the Chinese side to communicate and consult with the African side in a more equal and humble way, to value African suggestions and ideas, and to fully reflect the autonomy of African participation. As for international partners, although most of them do not provide financial and human resources support, they have the advantage in policy advocacy and programme monitoring and can create a more favourable international environment for the sustainability of programmes. In turn, African and international partners must find appropriate ways to interact and communicate with the Chinese side for public health programmes to be sustainable and effective.
Fifth, whether it is assisting clinical medical infrastructure or assisting public health infrastructure, there will be challenges in operation, management and maintenance. A case in point is the malaria control centre programme, in which China established 30 malaria control centres for African countries in 2007–2009.27 The programme failed to take into account the actual situation of African societies, primarily due to a lack of sustainable operating funds, poor management and infrastructure maintenance capacity, as well as water and electricity shortages and insufficient equipment maintenance, which led to the damage or closure of most malaria centres. In other words, public health infrastructure aid is also a systemic project, and its follow-up maintenance and operation management needs to be integrated into a systematic aid plan.
Challenges for China’s public health engagement in Africa from a comparative perspective
CPHE was characterised by complexity, involving not only all aspects of the Africanisation of the Chinese experience but also multiple participating subjects in different contexts, and thus requiring a systematic understanding and consideration of the sustainability of the programme. In addition, because of the social and political connotations of health aid in Africa’s health development,28 China still lacks adequate experience in cross-cultural practice, which may pose obstacles to CPHE. Of the many challenges facing CPHE in Africa, we find that historical, social and cultural, as well as bilateral cooperation and multiparty engagement all have a notable effect on the sustainability and effectiveness of engagement. We believe that one of the main reasons for this is that the design and implementation of CPHE in Africa is mainly from the perspective of preventive medicine and public health, and lacks multidisciplinary participation from humanities and social disciplines, making it easy to fall into an empirical trap. However, the current academic summaries of CPHE experiences in Africa are still insufficient. Not all past experiences and lessons learnt have been noted in further practice. Likewise, because CPHE in Africa is a long-term cross-cultural practice, the participation of people with humanities and social science backgrounds is necessary to ensure the programme’s sustainability.
It is important to note that there are also some positive trends from China’s perspective. China’s malaria control programme in Tanzania invited a sociologist from Duke University to conduct a programme evaluation, and also focused on the role of medical teams assisting Africa in public health programmes. In recent years, the Yunnan medical team in Uganda, the Beijing medical team in Guinea and the Guangdong medical team in Equatorial Guinea have sent at least one doctor with a public health or epidemiology background. The Yunnan medical team in Uganda sent an epidemiologist with experience in AIDS control for two consecutive years in light of the widespread AIDS epidemic in Uganda. During the Ebola epidemic in Uganda in late 2022, China’s medical team printed many health information brochures on Ebola and distributed them at the China-Uganda Friendship Hospital.
In reviewing CPHE in Africa, we found that the concept and ways of China’s participation in the governance of global issues have changed significantly. CHPE is a form of public health governance in the sense of South–South and South–North cooperation and shares China’s public health experience with Africa.29 Compared with China’s medical teams, the content of CHPE is diverse and has multiple aspects, requiring more diverse implementation forms that also consider the programme’s cross-cultural practice, even recognising the importance of multidisciplinary participation. However, because of the complexity of CPHE, its challenges are not only in the historical and cultural contexts of African public health encountered in the Africanisation of the Chinese public health experience but also in the lack of multidisciplinary engagement and African participatory autonomy. This inspires us to think at both the theoretical and practical levels. CPHE in Africa is built on empirical knowledge, and its practice is inevitably influenced by the local context, especially in terms of history, social culture and experience in disease prevention and control.30 CPHE in Africa may even be interpreted or misinterpreted as opportunism or altruism.31 From the perspective of global health governance, we should go beyond the binary view of opportunism or altruism regarding CPHE in Africa. As global health issues are inherently global, it is above all a reflection of China’s active pursuit of multilateral health governance.
In this regard, from the perspective of policy advocacy, we believe that the understanding of CPHE in Africa should go beyond the narrative framework of South–South and South–North cooperation, and its role in global public health security from a more macro perspective. On the Chinese side, it is crucial to focus on the summary and application of China’s experience in CPHE in Africa, especially on the in-depth exploration of individual cases and practical experiences of different types of projects. The Chinese side also needs to avoid a one-dimensional view of ‘African needs’ that may lead to the ‘air-dropping’ of healthcare and needs to look beyond a single disciplinary perspective to understand African public health issues and focus more on the impact of African history, society, culture and development. As with all cross-cultural practices, attention needs to be paid to multidisciplinary participation and to the cultivation of a cross-cultural practice workforce. This means that China should build a suitable mechanism for multiparty cooperation, primarily focusing on the key role of the African side.
Overall, information and data on China’s aid to Africa, including China’s health aid to Africa, are still limited. All the documentation in this paper was drawn from various Chinese aid-related agencies as well as from published academic research in both Chinese and English. This paper highlights the general characteristics and common challenges of CPHE projects, but there are still other areas that need to be discussed. Because CPHE projects vary in size, duration and the participatory roles of African participants and international organisations, the ways in which these factors are manifested in projects still require further exploration.
Data availability statement
All data generated or analysed during this study are included in this published article.
Patient consent for publication
Handling editor Seye Abimbola
Contributors LG conducted the literature searches, reviewed the retrieved articles and reports and created the manuscript’s first draft. JX contributed to the critical revision of the research. Both authors read and approved the final manuscript.
Funding This work was supported in part by the China Medical Board (Project No. 20-391), the Fundamental Research Funds for the Central Universities and Special Research Program of Pharmacoeconomics and Health Technology Assessment Committee of Zhejiang Pharmaceutical Association.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.