This chapter lays out the existing conditions that shaped the country’s approach to overseas vaccine supplies during the pandemic. It first describes key aspects of China’s domestic health governance and its increasing importance to the partystate’s domestic legitimacy. It then chronicles the Chinese state’s role in international health aid and governance, from traditional bilateral aid to a rising (but still somewhat limited) engagement in multilateral global health. Finally, it discusses Chinese companies’ rapidly growing but still relatively weak pre-pandemic position in global pharmaceutical and healthcare markets, and their government’s ambitions for them to become leading innovators in this strategically important sector.

Health governance in China

China is the world’s most populous country, the world’s second largest economy, and highly interconnected globally. It has also been a focal point in various disease outbreaks with international ramifications, including severe acute respiratory syndrome (SARS) in 2002– 03 and avian influenza. China’s domestic health governance therefore has important implications for global health more broadly. China’s rapid economic growth and achievements in improving living standards of its population have greatly improved public health in the country (average life expectancy has increased by ten years since 1980, from 66 to 76 years). However, the government has also faced criticism for prioritizing the economy at the expense of both health and, relatedly, the environment (Huang, 2020a), and for the vast inequalities within China’s largely marketized healthcare system (Chan et al, 2009). A detailed overview of China’s domestic health governance system, which is highly complex and has substantial subnational and urban– rural variation, is beyond the scope of this book. The following paragraphs summarize the features that are most relevant to the main arguments of this book.

Performance legitimacy and infectious disease management

As laid out in the introductory chapter, China’s party-state relies on performance legitimacy (Yang and Zhao, 2015). Since the initiation of reform and opening in 1978, when the ideological foundations of legitimacy under Mao was largely abandoned, (the perception of) effective governance has been central to domestic public acceptance of the Communist Party’s right to rule China.