Substitution, Complementarity, or Transformation? China’s Engagement After Traditional Donor Retrenchment

Abstract

Global development assistance for health declined by 21% between 2024 and 2025, led by sharp reductions among traditional Western donors. As traditional financing contracts, China has become an increasingly prominent participant in global health, raising the question of whether it substitutes for, complements, or transforms the prevailing donor model. Existing scholarship rarely examines how Chinese actors themselves interpret this retrenchment. This qualitative study used semi-structured interviews with 11 global health stakeholders from academia, government, research and philanthropic institutions, spanning Chinese and non-Chinese communities, analyzed through iterative thematic coding. Thematic analysis showed that participants framed China's engagement as driven by its own developmental logic rather than as a reactive response to Western withdrawal, while candidly acknowledging concerns over transparency and evaluation. These findings suggest China's role is best understood not as wholesale substitution or simple complementarity, but as an emerging and still-contested paradigm: selective complementarity at the multilateral level coexists with a more transformative, development-integrated model at the bilateral level. The future of global health cooperation may depend less on whether China replaces traditional donors than on whether multiple models can coexist and remain accountable.