Hello CHP readers,

It’s been a while since I last sat down to write something for this newsletter. A wonderful reason for this is that I’ve been fulfillingly busy: travelling to Kenya and Ethiopia in East Africa in June and more recently, in August, all across Brazil, as well as preparing for the launch of my new book.

Some of these adventures have been strictly professional: on-the-ground insights and engagements for my consultancy, LINTRIS Health, and other strategic analysis. Some has fed into my ongoing policy and academic research. However, much of it also contributes towards my ever-expanding aspirations to make more sense of the whole of global health (the entire pie!) so that some of the fragments that sit apart today might be able to come together, better - and I would like to believe that such hopes are more than just the doctor in me talking!

Having now returned to London, I recently attended a policy conference, where, while well-organised and informative overall, I found that far too many of the panels and discussions still circled around the same topics we’ve all heard time and again: pressures, workforce, productivity, funding, digital transformation. It all reminded me how common it is, particularly in established, fragmenting systems, to keep debating within inherited assumptions about how things are organised. Inward-looking, tired. Too much talk, not enough solutions.

My travels had the opposite effect. Journeying far from home can bring you closer to it: to appreciate familiar things differently and see contrasts more clearly. Some approaches may travel well and others are inseparable from their political or cultural context, but looking at how very different systems approach familiar problems can make the questions themselves feel fresh again.

Having spent most of my professional career finding ways to bridge East and West on health and care, I found my Brazil trip especially interesting to reflect on. My travels began in Belém and Santarém in the northern state of Pará and then east to Bahia, travelling through the Amazon and learning about riverine communities, remote access and primary care; on to Brasília and the centre of federal health policy; and finally to São Paulo, where I met hospitals, pharmaceutical companies, research and policy organisations and philanthropic foundations.

As a gigantic and sophisticated middle power with its own institutions, interests and bargaining power, Brazil nevertheless shares many health system challenges with China, as a similarly continent-sized country: from vast geographies and uneven access, to large populations, public-private divides, pressure on health workforces and the increasingly urgent question of how technology can help health systems scale.

This trip also provided me with a much more concrete way to think about an argument I recently made in a commentary in Nature: that China’s growing role in global health should be judged not only by the speed, investment and technical capability it can bring, but by whether those partnerships strengthen local capacity, preserve sovereignty and leave countries better able to shape their own health systems afterwards. Governments, industry and global health institutions across the West, and indeed everywhere, should pay closer attention in both directions.

As I reflect more deeply about what I have been observing and learning, consider this an informal first attempt at pulling together some thoughts on health systems, technology, culture, power - and of course, China.

I will be continuing to develop this research as the 2026-27 Alistair Horne Visiting Fellow, at St Antony's College, University of Oxford, which supports the writing of significant works of non-fiction for a general audience. I will be working on my second book, which explores patient journeys across healthcare systems. Bringing together perspectives from medical anthropology, history and sociology, the book will examine how culture, politics and healthcare systems influence people’s experiences of illness, treatment and care, including in Asia, Africa and of course - Latin America.

I very much look forward to making the most of St Antony's distinctive resources and regional centres, which will be hugely valuable to my research and progress, and to joining the illustrious AH fellows community✨

I’ll be in Oxford most weeks, when I’m not London - please do reach out to catch-up in person! I will be doing a book talk for CHINA CURE at University of Oxford’s China Centre, Weds 21st Oct lunchtime.

Brazil’s health needs more attention

Most of us already understand certain aspects of Brazil’s global importance. It is Latin America’s largest economy and country, a key member of BRICS, a major Western Hemisphere power and longstanding partner of Western nations, and one of China’s most important economic relationships in Latin America. Brazil’s agriculture feeds global supply chains at extraordinary scale, while the Amazon and its biodiversity have become central to any serious discussion of climate, food security and the environment.

And yet, Brazil’s health receives far less international attention, despite it running one of the largest universal health systems in the world across more than 200 million people, alongside a gigantic pharmaceutical, hospital, research and private-health economy. On my travels across the country, I kept returning to several features of the system that I think deserve much greater reflection.

System optimisation at scale

At the centre is the Sistema Único de Saúde (SUS), which places health in the Constitution as a right and gives every Brazilian access to a universal public health system free at the point of use. Perhaps because of my background as a doctor trained and practising in the UK’s National Health Service, almost everyone I met spoke to me about how SUS had been inspired by the NHS. Built some decades after the NHS through Brazil’s own health reform movement, democratic transition and 1988 Constitution, SUS developed into something distinctly Brazilian: decentralised delivery, community health and federal responsibility across a country of vastly different scale and complexity (we will come back to how that federal architecture in particular has impacted the Brazil-China relationship, later).

During my meetings in Brasília with Brazil’s Vice Minister of Health, Executive Secretary Adriano Massuda, I was struck by the size and variation of the portfolio he and his teams are managing. Brazil now encompasses nearly 5,570 municipalities, each holding substantial responsibility for services on the ground while collectively belonging to one “universal” system. The same SUS that encompasses transplantation, oncology, advanced diagnostics and major academic hospitals in São Paulo also has to reach remote populations across immense distances.

In Pará and Bahia, I saw services travelling by boat towards riverine communities because geography makes the conventional model of patients travelling towards fixed facilities impractical. What I found particularly interesting comparatively was how much the reality of universality therefore depends on local implementation: the competence, workforce, infrastructure and ingenuity of individual municipalities can determine what a national constitutional right looks like on the ground.

But decentralisation does not mean that each municipality functions as a self-contained health system. Conversations with local leadership, including the director of Santarém’s municipal hospital, made clear how quickly weaknesses elsewhere in the network can accumulate at a referral centre: patients travelling long distances, limited specialist capacity closer to home, pressure on beds and theatres, and the constant challenge of moving people between primary, secondary and tertiary care across a huge geography. Local autonomy therefore sits alongside deep regional interdependence.

This piece has relevance far beyond Brazil. That decentralised structure has produced enormous variation in how services are organised and how well municipalities perform, which creates inequalities, but also an unusually rich environment for understanding which combinations of primary care, management, financing, workforce and local adaptation actually work. Institutions such as IEPS and Umane are operating in precisely that space: trying to turn variation into evidence, identify interventions that can improve system performance, and work out what can be scaled without assuming that an intervention successful in São Paulo will simply transplant into Pará.

The wider lesson is therefore about what has to remain strong at each level for decentralisation to work: capable local management, usable data, adequate financing, referral networks, workforce and mechanisms for learning systematically from variation rather than allowing it simply to reproduce inequality. Health systems everywhere are wrestling with the same underlying problem of what can genuinely be delivered closer to communities, what still requires regional concentration, and how the two can function as one system. Brazil has the scale as well as decades of experience to make it an enormous laboratory for exactly that problem.

Distinctive funding and commitment

Such demands on the system must be supported by strong central commitment, and Brazil’s political prioritisation of health is indeed particularly striking. For all the justified debate within the country around whether SUS receives enough money (a familiar argument everywhere, for no health system ever believes it has enough resources) health still occupies an unusually prominent position within Brazil’s federal spending. The enacted 2025 budget allocated around R$245 billion to public health, and the Ministry of Health was described in Congress as holding the third-largest ministerial budget.

However, the actual composition of that spend does make things a little more complicated. It is to the chagrin of many of the policymakers and public health and policy researchers I spoke to, that while Brazil devotes 9-10% of GDP to health, government and compulsory schemes financed only 45% of the total. Voluntary private insurance still accounted for 27% - far above the OECD average and higher than in any OECD country - while roughly another 27% remains paid out of pocket.

Public-Private

That apparent contradiction is one of the features of Brazil I find most interesting. Health is highly prioritised politically and SUS remains foundational to the social contract, but a very large private health economy nevertheless sits alongside it. Finding an optimal balance between public purpose and private capital, expertise and provision is perhaps the hardest recurring health-policy question across every system.

Britain is watching private provision grow around a still predominantly tax-funded NHS under ever greater pressure. Discussions, like those at my recent London conference, too often begin with fiscal and workforce pressures and end with what the Treasury can afford to stretch, while increasingly visible two-tier care raises questions about faster access for those able to pay and how much fragmentation can occur before equity begins to erode. The US begins from a very different position: enormous flows of private capital support much of the world’s pharmaceutical, biotechnology and medical innovation, while affordability and unequal access remain persistent weaknesses at home.

Brazil has spent decades negotiating both sides of this equation at the same time, and at continental scale. It has not solved the public-private tension, but I do think that the particular institutional mechanisms it has developed to bring capability sitting outside government into public-system priorities are distinctive and interesting. My conversations with major pharmaceutical companies operating in Brazil showed just how deeply companies must understand SUS, public procurement and reimbursement while simultaneously operating across insurers, hospitals and commercial markets.

And Brazil’s philanthropic hospitals add another distinctive mechanism. At Hospital Alemão Oswaldo Cruz in São Paulo, I learned more about PROADI-SUS, through which recognised hospitals of excellence use resources associated with their tax immunity to work with the Ministry of Health on research, evidence generation, technology assessment, workforce development and management.

Other countries also use private and non-profit institutions to deliver public goals, but I was struck by how Brazil has built formal mechanisms through which organisations with advanced clinical, managerial, research and technological expertise can be asked to solve problems that matter to SUS. PROADI-SUS converts fiscal privilege into agreed projects intended to strengthen the capabilities of SUS itself.

The potential value lies in using institutions such as Oswaldo Cruz as capability multipliers: testing models, generating evidence, evaluating technologies, training people and developing management or digital approaches that can strengthen a much larger public system. And beyond capability itself, I think that trust is a large part of the equation.

Public-health traditionalists are often wary of private or philanthropic involvement for good reason: different incentives raise concerns around influence, commercial benefit, cherry-picking and the gradual erosion of public provision. The challenge is how to use outside expertise without surrendering control over priorities, accountability or equity. PROADI-SUS does not remove those tensions, and in some ways its existence acknowledges them. Rather than assuming that public and non-state incentives naturally align, Brazil has created formal mechanisms in which benefits, obligations and public priorities are made explicit. I think of this as a form of “governed trust”.

Every health system contains valuable expertise, technology and capital outside the state, while also having good reason to be cautious about how that capability is used. Brazil has accumulated useful experience in this difficult middle ground: aligning incentives, making obligations explicit and directing non-state expertise towards public-system goals.

Population diversity & scientific value

Brazil has another key asset which makes it distinctly attractive to global biopharma, life-sciences and healthtech companies, whether from West or East. It contains one of the world’s largest highly admixed populations, with richly complex combinations of Indigenous, African, European, Asian and other ancestry that vary substantially across regions.

As medicine moves further into genomics, precision medicine, large clinical datasets and AI, that diversity becomes increasingly scientifically valuable. Much of the world’s genomic infrastructure still disproportionately reflects people of European ancestry, limiting how well genetic associations, disease-risk models and precision medicine translate across populations. AI tools developed on narrow populations similarly need validation elsewhere.

Greater ancestral diversity can improve the underlying science, and Brazil offers real-world scientific value that is difficult to produce elsewhere. As global drug development heats up, these strengths give Brazil considerable leverage in deciding what it wants from those relationships: trial participation, research leadership, data infrastructure, scientific training, manufacturing and domestic clinical-development capability — and how much of the resulting value is retained for Brazilian patients and institutions.

Indigenous Health & Openness to Difference

A final feature that I noted was Brazil’s willingness to build and explicitly make cultural and geographic difference unusually visible within the health system itself. Brazil carries an immensely difficult history of indigenous dispossession, alongside vast contemporary differences in geography, language, culture and access.

After spending time in the Amazon learning about Indigenous communities, traditional knowledge and the practical difficulties of providing care across enormous distances, I met Secretary Lucinha Tremembé in Brasília, who leads the Secretariat of Indigenous Health, SESAI (and who also very kindly gifted me a pair of beautiful, colourful earrings from her community).

SESAI coordinates a dedicated indigenous-health subsystem within SUS that serves over 821,000 indigenous people across the nation. Its 34 Special Indigenous Health Districts, or DSEIs, are organised around territory, population and ethnocultural relationships rather than municipal or state boundaries, where care is formally designed to be participatory and differentiated according to epidemiological and sociocultural needs. Universal health systems everywhere often struggle to reconcile equal entitlement with populations whose geography, language, culture or relationship with the state require different forms of care. But in Brazil, we see already how some of that adaptation has been built into the institutional architecture itself.

Implementation remains difficult, of course, and remote access, staffing, diagnostics, specialist referral, continuity and trust still create large gaps between formal recognition and consistent delivery, all impacted further by Brazil’s history of Indigenous dispossession. But I think there is something important in the attempt itself: for universality to still allow for the possibility that different populations may need different routes towards the same entitlement to health. Brazil has spent decades confronting questions of cultural pluralism, remote care, community participation and differentiated provision that increasingly diverse societies elsewhere are only beginning to address. The Brazilian experience is useful to analyse because increasingly diverse societies everywhere should take seriously the idea that equality of access may require different forms of delivery.

All in all, Brazil already has the scale, institutions, scientific assets and political commitment of a major health power. It therefore enters its relationship with China with considerably more bargaining power, scientific capability and health-system experience than simply a story of “Chinese influence”.

Brazil and China

Brazil and China are two continent-sized states, together home to more than 1.6 billion people, with enormous domestic markets, large scientific and industrial systems and unusually consequential roles within their respective regions. China is Brazil’s largest trading partner; Brazilian exports to China reached US$100 billion in 2025 and bilateral trade around US$171 billion. In the first eight months of 2026 alone, China accounted for more than 30% of Brazilian exports.

As Latin America’s largest economy, population and territory, Brazil encompasses established pharmaceutical and vaccine institutions, an internationally experienced regulator, substantial manufacturing capacity and a gigantic health market through both SUS and the private sector. It sits in the Western Hemisphere, in overlapping time zones with North America, while maintaining deep relationships with the US and Europe as well as considerable diplomatic autonomy of its own.

That combination makes Brazil quite different from a conventional “Global South recipient” of Chinese health diplomacy. It can certainly consume Chinese technology, but it can also test it, regulate it, manufacture it, improve it, bargain over it and contribute assets of its own. The two are increasingly capable of building regionally as well as globally consequential health partnerships without necessarily being mediated by Western or multilateral institutions.

Health diplomacy has been building for years

Brazil-China health cooperation increasingly sits across several layers at once: government-to-government diplomacy, BRICS institutions, regulators, scientific organisations, companies and research networks. The main bilateral mechanism is COSBAN, the China-Brazil High-Level Commission for Consultation and Cooperation. Created in 2004 and co-chaired by the two countries’ vice-presidents, it is Brazil’s principal mechanism for regular dialogue with China and one of its broadest structures with any international partner, spanning trade and investment, industry, science and technology, agriculture, finance and other strategic areas. Health therefore sits inside a much larger relationship through which both governments are already discussing economic development, industrial capacity and technology.

The two countries also meet through BRICS, where health cooperation has progressively widened from infectious disease and vaccines towards regulation, local production, research, AI, data governance and health-system resilience. Under Brazil’s BRICS presidency in 2025, the two health ministers agreed to strengthen regional production and expand research and development, deepen cooperation between public-health institutes and regulators, and work together on AI and data governance. The world’s largest emerging health markets are developing their own ideas about production, regulation and technological capacity rather than waiting for frameworks to be designed in North America or Europe. Standards, supply chains and research partnerships are increasingly being discussed through institutions in which Western governments are not necessarily at the centre.

Related:

The story of CoronaVac

One of the most distinctive examples of how the Brazil-China health relationship has already played out in practice is CoronaVac. Beyond the familiar story of Chinese vaccine diplomacy, it is a much richer case of politics, institutions and Brazil’s subnational paradiplomacy: China provided an important technological asset; Brazilian federalism allowed an institution capable of using it to act; and Brazil’s national public-health machinery ultimately enabled scale.

In June 2020, the São Paulo state government under Governor João Doria and the state-owned Instituto Butantan announced a partnership with Chinese pharma giant Sinovac to test and produce the COVID vaccine, CoronaVac. Brazil’s Butantan brought clinical-trial infrastructure, vaccine expertise and institutional credibility; China’s Sinovac brought the candidate vaccine, production know-how and technology. The Brazilian Phase III programme eventually involved around 13,000 volunteers across multiple research centres.

Then the politics became extraordinary. President Bolsonaro’s federal government and the São Paulo state government disagreed sharply over pandemic measures broadly, and CoronaVac specifically. In October 2020, Brazil’s health minister announced plans to acquire 46 million doses from Butantan, but Bolsonaro publicly overruled the move the following day, and questioned the Chinese vaccine. But the federal government’s opposition did not stop São Paulo itself from continuing.

Brazil’s distinctive constitutional architecture helps explain why. Because health responsibilities are shared across federal, state and municipal levels, the Supreme Federal Court reaffirmed the authority of states and municipalities to take their own public-health measures rather than allowing the federal executive to monopolise the response. Butantan added another layer of autonomy – though it is a state institution rather than a federal agency, it had enough scientific expertise, manufacturing infrastructure and international standing to negotiate directly with a Chinese biotechnology company, and run a major clinical programme.

The second half of the story is perhaps even more remarkable. Within eight months of Brazil’s regulator, Anvisa, authorising CoronaVac for emergency use,Butantan delivered 100 million doses via the National Immunisation Programme across the entire nation. So a Chinese technology negotiated through a Brazilian state institution, despite opposition from the country’s president, eventually became one of the pillars of Brazil’s national vaccination campaign. The closest intuitive comparison would be something like California or New York pursuing a vaccine partnership directly with a Chinese biotech company while the White House publicly opposed that vaccine - and then Washington later purchasing it for nationwide distribution. The legal systems are different, so it is not an exact analogy, but it gives some sense of how unusual the political sequence was.

This is also an interesting case in how the national identity of a health technology can change once it enters another country’s institutions. Chinese origin did initially matter: surveys found greater rejection of Chinese-origin vaccines, with country of origin itself associated with vaccine hesitancy. But in a later survey in January 2021, reported confidence in CoronaVac at 76.4%, almost equally comparable with 80.1% for the Western vaccines Oxford-AstraZeneca and Covishield.

We cannot claim that CoronaVac permanently changed Brazilian attitudes towards Chinese products, but certainly, there is a relevant piece here about how, as Chinese-origin assets are increasingly licensed and move into foreign pipelines, including European or American biopharma companies, they may eventually have very little visible “Chinese” identity at the point of care. This means that even if geopolitics may shape how governments and industries talk about these medicines, patients still encounter them through regulators, hospitals, physicians and trusted pharmaceutical brands, and will form their own responses towards what they are receiving.

From Chinese pipelines to global medicine

Chinese biotech companies increasingly need international clinical-development networks to turn drugs discovered in China into medicines that can be registered and commercialised globally. I described earlier why Brazil’s large and genetically diverse patient population gives it particular value at this upstream stage of global biopharma, and indeed, Western pharmaceutical companies have used Brazilian investigators, hospitals and patients in global trials for decades. But Chinese biotechs are increasingly entering those same international networks as their pipelines become more innovative and internationally ambitious.

A good example is BeOne Medicines (formerly BeiGene) a China-founded and now Swiss-domiciled, global biopharma company. Its PD-1 oncology drug tislelizumab was developed through an international clinical programme, with the Phase III RATIONALE-303 lung-cancer trial including numerous Brazilian oncology centres. The resulting evidence supported subsequent regulatory approval in Brazil. And Brazil’s involvement extended beyond patients and trial sites: the first author of the 2026 long-term analysis was Brazilian oncologist Pedro de Marchi, working alongside Chinese investigators and BeOne scientists.

China is now highly capable in biomedical discovery, early development and running sophisticated trials at home. But many gaps remain further downstream, in global multicentre development, foreign registration, international medical affairs, commercial channels and building overseas operating teams. Indeed, China’s 2026–30 pharmaceutical-industry plan (published 18^th September) is unusually explicit in acknowledging that its international expansion still relies heavily on licensing assets out, and sets out ambitious targets for Chinese companies to move further into joint development, co-commercialisation and their own overseas clinical and commercial operations.

This is part of the extraordinary rise in Chinese licensing to Western multinationals. Out-licensing gives Chinese biotechs capital, shares the cost and risk of late-stage development, and plugs their science into the global regulatory and commercial infrastructure Western pharma has spent decades building. The trade-off is that Chinese companies also give up some downstream economics, control and the organisational learning that comes from taking a medicine through global development themselves.

Brazil could become one useful part of the international operating experience that Chinese biotechs now need to build for themselves, exposing them to sophisticated foreign regulators, international investigators and a health system whose institutions, reimbursement structures and market-access pathways are very different from China’s own, to complement the much deeper capabilities that they still urgently need to build in the US and Europe.

There is useful learning in the other direction too, for Brazil. China’s biotech sector has become particularly notable for development speed, cost discipline, rapid patient recruitment and tightly connected CRO, hospital and manufacturing ecosystems. Brazil already has extensive experience with Western multinational pharma, but Chinese partnerships offer different operating models of speed and efficiency for Brazilian institutions to incorporate into their own system.

Related:

Digital health: learning selectively

I should first state my own bias here: I believe meaningful digitisation of healthcare is absolutely necessary. Every health system I have worked in is dealing with some combination of fragmented information, workforce shortages, rising demand, increasingly complex patients and expensive expertise concentrated in too few places. I cannot imagine solving those problems at scale without much better use of data, interoperability, digital pathways, remote care and, increasingly, AI.

Yet the gaps remain enormous. The barriers are cultural, structural and political all at once. Health data is deeply sensitive, and societies make very different judgements about privacy, data-sharing and algorithmic decision-making. At the same time, developed country systems carry decades of incompatible records, legacy software, procurement systems and organisational structures that were never designed to communicate with one another. Bureaucracy adds further layers as responsibilities for technology, budgets, data and clinical services are often scattered across different institutions, none able to compel the others to move at the same speed.

And then there is the politics of money: tech transformation requires governments to spend substantially before the benefits can become visible. Governments therefore have to invest now in infrastructure, integration and workforce change, in order to save money, improve productivity or avoid future costs later (often beyond the same budget cycle, ministry or even government). That can be a much harder sell than the short term options of another hospital wing, hiring more staff or addressing an immediate waiting list.

This is one reason I have written so much about China’s digital-health ecosystem, which has been unusually willing to experiment at scale with internet hospitals, connected hospital networks, AI and digital platforms, driven partly by enormous patient volumes, specialist concentration and uneven access. There is much that other systems should not copy wholesale, but observe and selectively learn.

Brazil is already doing exactly that. Its Ministry of Health has been actively sending multiple delegations to study China’s health technology and hospital models over the past few years. Last October, Health Minister Alexandre Padilha travelled with a federal delegation whose programme included Chinese smart hospitals being studied as references for Brazil’s own plans. This March, Anvisa joined another government mission focused specifically on technology transfer, visiting pharmaceutical and medical-device manufacturers as well as online hospitals using AI, connected devices and robotics. When I met Vice Minister Adriano Massuda and his team in Brasília, I was therefore not surprised that smart hospitals and China’s digital-health development formed much of our conversation.

I was struck by the level of pragmatism. Brazilian policymakers recognise that Chinese experience can be studied, adapted, rejected in part or combined with their own technology and institutional practice. Brazil’s smart-hospital programme is already moving into implementation through SUS, including intelligent ICUs and a planned major smart hospital; the Ministry has explicitly linked parts of that work to experience and technological cooperation with China. As of last month, six intelligent ICUs had been connected to a national command centre using continuous monitoring and AI-supported risk assessment, with further expansion planned.

As I recently wrote in Nature, other health systems could afford to be equally pragmatic. Privacy, governance and technological sovereignty matter enormously, but they should not become excuses for permanent digital paralysis. If China has developed a better way to connect hospitals, move expertise remotely or use data at scale, study it. Adapt what fits local institutions and reject what does not.

Related:

And the curious case of Traditional Chinese Medicine

The Brazil-China health connection I found most surprising was actually the oldest. As early as 2006, Traditional Chinese Medicine and acupuncture were formally incorporated into Brazil’s national policy for integrative and complementary practices within SUS. Today, SUS recognises 29 such practices, including acupuncture, medicinal plants and phytotherapy.

Chinese medical practices first reached Brazil through Asian migration much earlier. Acupuncture then spread gradually through professional networks and practitioners, and by the 1970s the Brazilian Acupuncture Association had been established, and professional councils began recognising acupuncture before its eventual incorporation into national SUS policy and medical school training. Professional organisations estimate that hundreds of thousands of people now practise acupuncture in Brazil, while physicians, physiotherapists, nurses and other Brazilian health professions have incorporated it into mainstream professional practice, serving huge population demand.

I became increasingly curious about this fascinating phenomenon. Why has Brazil become so comfortable with giving a foreign medical tradition from halfway around the world such formal space inside a publicly funded universal health system? I asked academics, SUS policy specialists and TCM practitioners as I travelled across the country, but no one gave me one completely satisfying answer, and several shared honestly that they simply did not know!

I suspect there probably is no single reason. Immigration, professional regulation, the role of non-medical practitioners, and the fact that Brazilian healthcare itself developed through a heterogeneous mixture of Indigenous, African, European and other therapeutic traditions may all have contributed to gradual institutional acceptance over more than a century.

And I do think that the cultural piece is key. Brazil seems to be distinctively willing to accommodate plurality, including medical plurality. Chinese medical practices entered a society and health system with a long history of absorbing, contesting and adapting ideas from elsewhere, alongside its own rich traditions of Indigenous and other forms of therapeutic knowledge. The interesting point here is about how a health system decides what to do with practices that sit outside its dominant methodologies: to ignore, prohibit, leave unregulated, or actually bring them into a formal framework where evidence, professional standards, safety and public accountability can at least be debated.

This complicates a common perception about China’s global health influence. Not everything Chinese that becomes embedded abroad is about contemporary state strategy, or economic diplomacy. Some forms of influence develop slowly through migration, professional communities and local demand, and are then absorbed into domestic institutions on local terms. Those may ultimately become the forms of foreign influence that people encounter most closely in everyday life.

What now, and what next?

I am publishing this only days before Brazil goes back to the polls. The first round of its presidential election takes place on 4th October, with a second round on 25th October if required.

Whoever wins will inherit many of the same difficult health-system problems I encountered throughout my trip. SUS has to finance universality while demand and technological costs rise; specialist waiting lists remain long; responsibility is fragmented across federal, state and municipal government; workforce and access vary enormously by geography; and ambitious plans for digital integration still have to be made to work across thousands of different institutions.

A timely analysis published this week by IEPS, one of the organisations I met in São Paulo, makes this point in stark terms. It examined 95 health proposals across the six presidential programmes with at least 2% support and found that 95% require additional resources, 83% depend on coordination between different levels of government, and 56% substantially overlap with policies or programmes that already exist within SUS.

The political choices are nevertheless meaningfully different. Lula largely proposes to deepen the current direction: investing in public capacity and primary-specialist care integration, developing digital-health infrastructure, and continuing to treat health as industrial policy, using SUS purchasing, domestic production and technology transfer to reduce technological dependence. Flávio Bolsonaro places relatively greater emphasis on revising SUS reimbursement, using private capacity to tackle waiting lists, and integrating public and private services digitally. Both therefore confront many of the same problems, but through rather different ideas about where additional capability should come from.

And internationally, the election could substantially change the political framing of Brazil-China cooperation. Lula explicitly supports deeper engagement with BRICS and the Global South, and his government has spent the past four years expanding cooperation with China while emphasising Brazilian sovereignty, industrialisation and technology transfer. Flávio Bolsonaro has signalled much closer alignment with the United States and has questioned Brazil’s continued participation in BRICS and Chinese dependence in strategic sectors, while still promising pragmatic commercial engagement “from China to the European Union, from the United States to Asian markets”.

Brazil is making those choices just as China itself has set out a much bigger global pharmaceutical ambition.

On 18 September, ten Chinese government departments published the country’s pharmaceutical-industry plan for 2026–30. I have been keenly analysing it all for my consulting work, because some of the targets are extraordinary.

By 2030, China wants its innovative-drug industry to grow by at least 20% annually, Chinese-developed first-in-class medicines to account for at least 25% of the global total, and at least five Chinese-developed drugs to achieve more than US$1 billion each in annual global sales. More broadly, the plan calls for a major increase in the international influence and competitiveness of China’s pharmaceutical industry.

These targets make much more concrete something that has been debated for some time, particularly amid Western - and especially US - conversations around competition and security: the scale of China’s global ambitions in biotech and pharmaceuticals.

The plan makes clear that China no longer measures success only by whether it can build a sophisticated industry at home. It increasingly wants Chinese-discovered medicines, companies and technologies to hold significant positions in healthcare markets around the world. The plan may be concentrated around industrial policy, but it is also an ambitious statement about where China intends to stand in the global pharmaceutical system.

Western pharmaceutical companies will encounter Chinese competitors, partners and assets across more therapeutic areas and markets. Governments will have to distinguish ordinary pharmaceutical competition and scientific exchange from genuine questions of technological dependence, sensitive data and national security. And countries like Brazil in Latin America, as well as across Africa, the Middle East and Asia will have more potential partners competing over markets and relationships that were once much more heavily shaped by European and American companies.

Brazil’s next government will therefore be negotiating with an increasingly outward-looking China at the same time as the US and Europe have their own strategic reasons to remain deeply engaged with a major Western Hemisphere power. The practical response is to pay attention to what China is building, distinguish genuine risks from ordinary competition, learn where something works better, and remain useful enough so that countries with real choices still want to work with them.

Pre-order my new book - CHINA CURE: The Rise of a Biotech, AI Medicine and Global Health Superpower.

I will be launching the book in London (KCL, 19th Oct) and Oxford (21st Oct), with more dates to come, as well as in the US East Coast in November - so do keep an eye out, sign up and hope to see some of you there.

If you’d like to read or listen to more of my recent work on China, health and technology:

• Nature: China is changing the shape of global health. The terms are still up for negotiation - on China’s expanding health partnerships and how countries can preserve local capacity and sovereignty.

• Journal of Medical Internet Research: When the Algorithm Starts Seeing the Patient First: China and the Changing Role of Physicians — on what China’s rapid adoption of AI in healthcare means for doctors and health systems elsewhere.

• Rest of World: China is excelling in health tech. That’s good news for the world - a recent interview on China’s biotech and digital-health rise, and what it means internationally.

• Sinica podcast: From Barefoot Doctors to Biologics:

  Sinica

  From Barefoot Doctors to Biologics: Dr. Ruby Wang on China's Healthcare Revolution

  This week on Sinica, I sit down with Dr. Ruby Wang, whose new book, China Cure: The Rise of a Biotech, AI Medicine and Global Health Superpower (Agenda Publishing, out October 31, with a foreword by Kerry Brown), is the explanation general readers have been missing for one of the most consequential and least understood transformations in China today. Ru…

  Listen now

  17 days ago · 9 likes · 1 comment · Kaiser Y Kuo

• Prof G Podcast with Scott Galloway/China Decode: I joined Alice Han and James Kynge to discuss my book and the economic and security implications of China’s rise in biotech.

Stay tuned for my upcoming book on the global impact of China’s biotech and digital health revolution, out in the latter half of this year.

新年快乐! Wishing everyone good health and wellbeing in the New Year of the Horse.

Last week, I was interviewed by Bloomberg News about China’s AI-powered health platform: Ant Group’s Afu 蚂蚁阿福. I thought I would expand on my comments further at China Health Pulse, to break things down for all of you here.

Afu may only be seven months old, but it has already become the most consequential development in China’s digital health landscape of the past few years.

Though I’ve been tracking its impressive growth for some time now, two recent moments finally crystallised for me how fully Afu has evolved from industry innovation to national phenomenon.

The first was last month, when my father, who actively avoids anything to do with health or medicine, but cannot resist a trend, jumped on the bandwagon. Normally the last person to download, let alone advocate for an app like this, he had heard about it from all of his friends, and uncharacteristically began to send screenshots of Afu’s various capabilities to our family WeChat group, entirely unprompted.

The second was cultural, and it came just two days ago, when Afu featured as the central storyline in one of the main comedy skits during CCTV’s 2026 Spring Festival Gala.

For those unfamiliar, this infamous New Year’s Eve broadcast is a annual five-hour holiday extravaganza that can perhaps be described as somewhere between the Super Bowl halftime show and a Christmas Harry Potter film marathon - but on an even greater scale. It is a garishly choreographed and predictably tedious spectacle of music, dance and comedy that nevertheless remains mandatory viewing each year for well over a billion people across China and the global diaspora - endlessly loved, mocked and debated in equal measure.

Having suffered through decades of watching these Galas every new year’s eve, I can confidently attest that I had never seen any health product or topic feature on stage before, let alone so prominently. I found myself suddenly attentive to the show, for the first time in a long time - and certainly not because any of the humourless jokes were entertaining. Afu’s presence on the Gala stage this year signified just how much this groundbreaking platform has moved beyond early adoption or product trend, to firmly enter the mainstream public consciousness of Chinese consumers right across the nation.

A series of mind-boggling numbers back this up. Since launch, Afu has consistently ranked as the most-downloaded medical app on Apple’s China App Store. Roughly 400 million Chinese were already using digital healthcare services, but according to Ant, though it is only still seven months old, it has gained over 30 million monthly active users, who submit over 10 million health-related questions each day.

I’ve written before about China’s AI health landscape, the rise of its internet hospitals, as well as Alibaba’s health strategy (Ant Group’s affiliate parent company and Chinese tech giant - Part 2 of that analysis is still to come).

Afu sits at the intersection of all three threads, but beyond its record-breaking popularity, I am even more interested in what its rise reveals about where China’s health system is heading more broadly. These matter enormously for everyone watching and working in healthcare and technology both inside China and beyond it.

Let’s unpack:

• What Afu actually does.

• Why this was the platform that took off, and not any other.

• The implications of its rise - including for policy, capital, and industry strategy.

• Where I think might all head next.

Related:

Subscribe now

What is Afu?

To understand Afu, you first need a quick map of the players.

Read more

Last month, I wrote about China’s health payer, the National Healthcare Security Administration, and why its control of the National Reimbursement Drug List (NRDL, 国家医保目录) gives it such extraordinary influence. The NRDL is the national catalogue that determines which medicines are covered by China’s public insurance system - and, in practice, which drugs can reach patients at scale.

This post looks more closely at the NRDL itself, and at what this year’s update reveals about how China’s reimbursement system now works.

The majority of Chinese patients (95–98%) are publicly insured, and so any company wanting to access the market at scale needs their drug on this list. Each year, from early summer through to December or January, foreign and domestic firms alike must model scenarios, engage stakeholders and negotiate intensively in an effort to persuade the state over price. The outcome is well known to be harsh. Discounts of 60–90% are common, and when the final decisions arrive - as they did this year on 7 December 2025 - they are definitive.

This system has been in place since 2018, when the NHSA was established, and the experience has not softened. Deliberations remain closed, and rationales remain unpublished. For outsiders, the system continues to feel compressed and difficult to read: an unforgiving black box with material commercial consequences.

What has changed is who is able to navigate that opaque progress. After eight annual cycles, patterns are now visible. Certain types of product continue to move through the system, while others still stall. Price expectations have become marginally easier to anticipate. Signals are accumulating even if rules remain unwritten.

Familiarity now matters. While inexperienced teams may continue to focus narrowly on headline discounts, and struggle when outcomes follow a logic they did not fully anticipate; others can now enter NRDL season with a clearer sense of where an asset sits, which pathway it is likely to require, and which constraints will matter most. No guarantees exist, of course, but uncertainty has become increasingly manageable.

This is visible in the numbers. Overall success rates remain historically low at around 37%, but negotiation success among drugs that reached the formal negotiation stage rose to approximately 88%, the highest level seen in recent cycles.

This year’s update combined two things at once:

1. Adjustment of the core reimbursement list, the gatekeeper which continues to prioritise therapies that can scale predictably through existing care pathways without destabilising budgets or delivery

2. The formal launch of a national Commercial Health Insurance Innovative Drug List (I first wrote about it here when it was announced last year), a new controlled-release valve, “Category C”, which is beginning to sort innovation by affordability profile and risk.

This post analyses:

• This year’s NRDL cycle - numbers, categories, the perennial foreign vs domestic drug debate

• “Category C” - the new Commercial List

• “Unwritten Criteria” - what I see in terms of how inclusion decisions are shaped behind the scenes

• Why listing does not equal access on the ground

  Subscribe now

Related:

This year’s NRDL

The numbers

This year’s NRDL was published on 7th December 2025, effective as of 1st January 2026. The competitive environment this year was among the tightest yet.

Read more

Part 1 covered China’s core Ministry of Health, the National Health Commission, Part 2 covered the drug regulators at the centre of Chinas biotech rise, the National Medical Products Administration, and my foundational explainer “Who Actually Runs Health in China?” mapped out the main stakeholders of health policy and power.

Winter in China is NRDL season.

For anyone working in China’s life sciences sector, it marks the most consequential period of the year. As the National Healthcare Security Administration releases China’s annual National Reimbursement Drug List, the biopharma industry collectively holds its breath.

Treatments need to be on this list to reach patients at scale in China. List inclusion allows drugs to be reimbursed through the public health insurance system, which today covers roughly 95–98% of the population. Getting listed is therefore essential to accessing the majority of China’s patients - but it comes at a steep cost. Savage price cuts averaging 60–90% are common.

Failing to list, meanwhile, means that most patients who want the drug will not be able to afford out-of-pocket costs, effectively shutting companies out of most of China’s otherwise immense patient market. As both a gateway to mass access and a source of relentless price pressure, the system forces biopharma companies to design their entire China strategy around anticipated price cuts and to make volume economics work on razor-thin margins - what is referred to as volume-based procurement (VBP).

This is why, from late summer onwards, anxiety begins brewing across the sector. Large and small companies alike, and foreign and domestic both, all start to reorganise themselves around this singular drive. Scenarios are modelled and remodelled. Prices are cut on spreadsheets, restored and cut again. Internal decks circulate. Board conversations are rehearsed across global and China teams.

When companies enter reimbursement negotiations, they arrive with internal “walk-away” prices based on what they are willing to give up, and what they cannot survive losing. And yet, despite all of that preparation, they cannot control the outcome.

The NHSA’s deliberations are not public, and the rationales of its judging panels are not published in detail. It’s not certain whether a drug will make the list. It’s not known how a final price will compare with competitors until after it becomes public. And there is no appeal process that resembles the transparency of Western drug pricing mechanisms. That is why the entire process still feels like a black box, particularly to players who are new to China, and fresh to this brutal game.

So when the public announcement comes (usually late December to mid-January), it arrives as a definitive, binary answer. If your drug does not enter China’s public health insurance system, you regroup and try again next year. If it does, the celebration is still often muted, because the next step is immediately unforgiving: sell enough volume to make enough returns, in order to survive.

This annual theatre of power and influence is concentrated within a single institution: China’s NHSA may be the most powerful health ministry of them all, because it decides what the system will pay for, at what price and on whose terms. I’ve already written about how the National Health Commission sets strategic direction and reform priorities, and how the National Medical Products Administration decides which products are safe and effective. But though policy can suggest, and regulation can approve, money ultimately disciplines behaviour.

And so, to understand how the entire health system behaves, we need to look at its hardest edge. This post focuses on the institution of the NHSA itself: how it came to wield this power, how it operates and where its limits lie. When the 2026 National Reimbursement Drug List is released, I will return to analyse what changed, who gained access, who absorbed the cost and what it reveals about the direction of China’s health reforms in practice.

Subscribe now

NHSA 101

Founded only in 2018, the National Healthcare Security Administration is one of China’s youngest ministries.

Its Chinese name 国家医疗保障局 is revealing. 医疗 yiliao refers to medical / healthcare, and 保障 baozhang refers to security, protection or guarantee, drawn from the same linguistic family as social security, pensions and employment protections. In everyday shorthand, the NHSA is simply referred to as 医保局, medical security. The emphasis is on protection as a system function rather than insurance itself as a product. The agency’s mandate is less about optimising individual coverage decisions, and more about ensuring that China’s healthcare can remain financially sustainable and socially reliable.

Read more

In Part 1, I covered China's core Ministry of Health, the National Health Commission, and previously, my foundational explainer “Who Actually Runs Health in China?” mapped out the main stakeholders of health policy and power.

Food and drug regulators are among the most powerful institutions in our daily lives. They decide whether the food on our shelves is safe, which trusted drugs reach us when we are sick, and which medical products are used in hospitals and clinics. Their approvals and timelines ripple far beyond the health sector, impacting public trust and influencing the direction of policy, not only in our home countries, but around the world.

The US Food and Drug Administration (FDA) has always been viewed as the global regulatory benchmark - but things are changing fast. For the first time in decades, the FDA’s independence (and by extension, its authority in global health) is under question. Leadership is unstable, and remit is becoming less reliable - the changes are dramatic. Since FDA Commissioner Robert Califf stepped down in early 2025 as Trump came into office, the new Health Secretary, Robert F. Kennedy Jr., overhauled the agency’s leadership and advisory structures: he dissolved the FDA’s entire vaccine advisory committee, and cut funding for mRNA programmes. These interventions have triggered lawsuits and open defiance from physician groups, raising doubts over whether the FDA can still act as a stable and technically trusted global authority.

In contrast, China’s equivalent to the US FDA has been moving in the opposite direction, approving ever-greater numbers of innovative medicines. China’s powerful National Medical Products Administration (NMPA) is responsible for the food and drug safety of a 1.4 billion population, and oversees the world’s second largest pharmaceutical market. Its reforms have been central to China’s biotech rise. Faster reviews, alignment with international trial rules and new priority pathways have allowed drugs to be brought to market in record time. Indeed, Scott Gottlieb, 2017-2019 head of the US FDA (Trump’s first term) recently warned: ‘If we’re not careful, every drug could be made in China.”

I have seen this transformation from up close. During the COVID pandemic, when I was Head of Health for the UK government’s Foreign Office in China, the UK’s regulator, the MHRA (Medicines and Healthcare products Regulatory Agency) had just become the first in the world to approve a COVID vaccine (AstraZeneca). At that point, the regulator was basking in global respect, and our team at the British Embassy in Beijing worked to channel this momentum to design and deliver bilateral programmes with the Chinese counterpart, the NMPA.

Our aim was to work collaboratively across both systems to strengthen responsible and safe regulatory standards for the world’s population, particularly at a time of such urgent health need. Indeed, during the tumultuous times of the pandemic, the UK was the only country to deliver any technical engagement with China on drug regulations, let alone at this scale. My team and I were extremely proud of the significant and timely impact we were able to make.

Our UK–China Regulatory Programme ran multiple sessions and workshops over the course of a year, and it opened with a hybrid leadership ceremony attended by MHRA Chief Executive Dr June Raine and NMPA Vice Commissioner Chen Shifei. At first, the format was predictable: British trainers, Chinese trainees. Our team built detailed agendas on first-in-human trials, post-market surveillance, and other technical domains. Though the technical sessions had to be online, hundreds of senior regulators attended and were trained across both countries. However, as the year progressed, we were surprised by what we found.

Initially, as expected, the UK MHRA regulators shared lessons honed over decades, offering well-worn case studies for the eager eyes and ears of Chinese counterparts. However, soon enough, I noticed that the dynamic began to change. The Chinese NMPA regulators began to request changes in the schedule, asking for session time to present their own approaches to the UK side. Working intensively with both sides, I could see where their confidence came from. Not only had the Chinese regulators now mastered the systems pioneered by the US and UK, but in many cases, they were already progressing past their Western counterparts, in speed and efficiency, as well as the capacity to deliver results at scale. By the final session, the Chinese side was often leading the stage.

For me, this phenomenon captures a broader and important trajectory. China’s NMPA has undergone significant reforms in past decades. It is now no longer a cautious learner, but an ambitious and confident agency. I’ve written before about China’s ever-accelerating biotech boom, where home-grown, high-quality drug innovations are now being exported and licensed abroad. Far beyond copies and generics, China’s NMPA is now becoming increasingly fluent in reviewing and approving these category-defining assets, and now not only influences the health of Chinese patients, but also the global population - and the trade flow of global medicines.

This is why it’s so important to better understand what China’s regulators do, and where the agency is heading next. This post takes a deep dive into the structure and history (including the scandals that triggered its reforms) of the NMPA, as well as the strengths and limits that define it today.

Let’s get into it.

Related:

Subscribe now

What is the NMPA?

The NMPA (国家药品监督管理局) is China’s national regulator for pharmaceuticals and biologics, from Western products to traditional Chinese medicines, as well as medical devices and cosmetics. The NMPA works alongside the National Health Commission (which sets system priorities and public health policy) and the National Healthcare Security Administration (which controls pricing insurance reimbursement) as one of China’s core health ministries, functioning as the key gatekeeper that oversees the entire health product lifecycle, to decide what can and cannot enter China’s health market.

Read more

Earlier this week, I went to a talk in London by Sir Jeremy Hunt, the notorious former UK Health Secretary. He’s since served as Foreign Secretary, Chancellor, and twice run for Prime Minister. But he remains best known for being voted Britain’s “most disliked frontline politician” during his time in health. In his opening remarks, he rather sheepishly recalled that the last time he had been in this auditorium, protestors had stormed the halls.

Hunt spoke at length about his colourful career, and at one point, he tried to joke that in each senior role - health, diplomacy, treasury - he’d started with zero subject knowledge: “On my first day as Chancellor, I knew nothing about economics or markets.”

An audience member didn’t let that slide: “There isn’t a CEO who knows nothing about their company. So why does Britain still let people lead entire sectors they’ve never worked in?”

The applause that followed was telling. No wonder: In 2022, Britain cycled through three Prime Ministers and four Chancellors in just four months. Between 2021 and 2022, five Health Secretaries came and went - none with any background in health, and none with any formal health role since.

Hunt responded with a smooth, politician’s answer - something about trusting his team of civil servants to guide him. But it laid bare a very real governance question: what qualifies leadership?

This isn’t just a British problem. In the US, public health leadership has become increasingly politicised. The NIH was led for 12 consecutive years by a physician-geneticist, but today, under Trump, public health appointments are vulnerable to partisan churn. RFK Jr’s appointment to HHS is a clear example of this. Even the US CDC has seen leadership instability and political pressure, particularly since the pandemic.

That said, there are signs of shift. In the UK, the new government under Keir Starmer has made efforts to appoint more grounded leaders. The current Health Secretary, Wes Streeting, spent nearly a decade in the health shadow brief. But the wider system still struggles with structural weakness: rotating politicians through ministries to make decisions affecting millions, despite having no firsthand understanding of the systems they’re trying to fix.

I first experienced this disconnect in 2016, as a fresh resident doctor. Hunt, then unpopular UK Health Secretary, introduced the controversial “Junior Doctor Contract”, imposing terms that were unsafe for patients and unsustainable for health staff. It triggered the UK’s first national doctor’s strike in 40 years.

I was elected by the British Medical Association to represent several hundred doctors across the Oxford and Thames Valley region. Between night shifts and national council meetings, I lobbied alongside fellow union reps for better terms. It was my first taste of how healthcare can be distorted by politics, to become collateral in a wider game of power.

Those experiences motivated me to step beyond clinical practice and engage more directly with systems and policy. During the COVID-19 pandemic, I joined the UK Foreign Office to lead the health team at the British Embassy in Beijing. We represented the UK in direct negotiations with China’s health ministry counterparts on pandemic preparedness, supply chains and outbreak data. It was a high-stakes and sensitive time to engage on public health, and provided me with an extraordinary window into how two very different governments approached a major health crisis.

The contrast was stark.

Every Chinese counterpart we met had deep sector knowledge. These technocrats weren’t career politicians parachuted in for a two-year term. They were trained clinicians, public health officials and scientists who had risen through local health bureaus, city-level posts and provincial departments before reaching national leadership.

Every Chinese Health Minister over the past 30 years began as a practising clinician. The health minister at the time, Ma Xiongwei, had trained in medicine and epidemiology and spent decades in health governance. In comparison, the UK health secretaries we represented at that time, Matt Hancock and Sajid Javid, both had no health background, and were cycled through in succession.

After a decade working across both systems, I’ve seen how much this difference matters.

In the UK, leadership is often a fluid path to power.

In China, leadership is always built through domain expertise.

Neither system is perfect. But there are crucial consequences. Who gets to lead and what qualifies them to do so shapes everything from policy design to crisis response to public trust. It affects whether reforms survive political cycles, whether crises are improvised or planned, and whether institutions learn, or forget.

That’s why I’m writing this new deep dive series on China’s health institutions.

If we want to understand how China reforms its system, responses to emergencies and advances global health ambitions, we need to understand how its governance is structured, and who is in charge.

If you missed it, I recently published a foundational explainer on China’s health ministries and governance model (link below), including a comprehensive visual map of the key players.

This series builds on that foundation. I’ll be writing about regulators, insurers and others, but today, we begin at the centre of it all: the National Health Commission.

Subscribe now

Function

Today, China’s National Health Commission is a cabinet-level executive department under the State Council. Unlike many health ministries globally, the NHC does not operate at arm’s length from political leadership. It is both policy architect and system convenor, with explicit political alignment to the Party’s strategic objectives, including health security, resilient economic workforce and national rejuvenation.

Read more

While much of the world’s attention is currently on US–China tariffs and trade friction, last month’s 78^th World Health Assembly provided a subtler, health-focused stage for the same tensions.

The WHA takes place every May in Geneva. It is the World Health Organisation’s highest decision-making body, where 194 member states discuss and vote on resolutions, funding decisions and treaty endorsements to set out global health for years to come.

This year, however, for the first time since the founding of the WHO in 1948, the United States was both financially and diplomatically absent. In contrast, China arrived with a greater presence, a louder voice and significantly more funding: its 500 million USD pledge now makes it the biggest state donor to the WHO, and it brought the largest ever WHA delegation in history.

Most headlines about this year’s WHA did not focus on technical breakthroughs. Instead, predictably, they chose to highlight politics: namely, that “the US has stepped back from global health”, and that “China is stepping in to fill the vacuum”.

I’ve written before about why this binary is altogether misleading.

China’s engagement in global health has always followed a different logic. It has never sought to replicate the Western models of public goods and technical neutrality, instead favouring bilateral cooperation for its strategic control, pace of returns and political alignment. For China, health is folded into trade, infrastructure, diplomacy and power, delivered through a mix of public and private mechanisms.

This year, China used the WHA to intentionally articulate specific priorities, amplify preferred narratives and deliberately consolidate its position within key technical domains.

But these crucial points have received little attention in mainstream, English-language coverage. I’ve yet to see a comprehensive summary of China’s movements at WHA out there. And so, today’s post aims to address this gap.

Here at China Health Pulse, I combed through all available sources in English and Mandarin, and repeatedly quizzed colleagues who attended the event, to answer three key questions: what was China actually doing at the WHA this year? What messages did it want to send? And most importantly, has it succeeded?

Subscribe now

World Health Assembly 101

Formally, the WHA sets the global health agenda. It approves WHO’s work and budget, reviews technical progress, debates resolutions and endorses strategic plans that define how countries respond to shared health challenges. But its informal functions are just as significant. It is a performative, yet necessary stage, where countries test alliances, promote domestic models and signal how they believe global cooperation should work, and who they think should lead it. After all, showing and telling is just as (and sometimes even more) important as the doing.

This year marked the 78th Assembly (WHA78), and in his opening speech, UN Secretary-General António Guterres spoke of both the extraordinary progress made in global health since the WHO’s founding, and the fragility of those gains. He pointed to falling child mortality and rising life expectancy, but warned that war, climate disruption and pandemic aftershocks now risk reversing decades of development.

WHO Director-General Tedros Adhanom Ghebreyesus echoed in his own address: “The world’s expectations of WHO have increased,” he said, “but its resources have not.” He described the current landscape as one of growing need and diminishing stability: "The road is winding and rugged, but the goal is unwavering."

Member states reviewed over 75 agenda items across a marathon eight days of formal plenary sessions, technical committees and side events. Technical frameworks and priority actions covered mental health, rare diseases, access to controlled medicines, antimicrobial resistance and climate-related health risks. As in recent years, politically charged and persistent debates re-emerged: Russia’s war in Ukraine, Israel’s actions in Gaza and Taiwan’s contested observer status.

Two major milestones defined the WHO’s institutional response to the US retreat. First, member states agreed to raise assessed contributions by 20%, alongside a 5% increase in mandatory dues (measures aimed at stabilising WHO’s funding base after years of dependence on earmarked donations). Second, the long-negotiated Pandemic Agreement was formally adopted, although in diluted form, following three years of difficult negotiations.

WHA78 had the (perhaps overly) optimistic theme of “One World for Health”. I was told by colleagues who attended, that the atmosphere felt markedly less cohesive than previous rounds. While technical milestones were acknowledged and many thematic discussions moved forward, the sense of fragmentation was hard to ignore. Between retreating funds, scaled-back programming and geopolitical rivalries, this “One World” concept seemed to be very much under strain. Indeed, Richard Horton, Editor of The Lancet, has (jokingly) questioned whether this year’s WHA was actually a “funeral for what global health used to be”.

Share

A Misleading US v. China Narrative

No senior US official attended WHA78, following President Trump’s executive order to withdraw from the WHO. The legal exit takes effect in 2026, but its consequences are already being felt. The US has withheld 260 million USD in assessed dues for the 2024–2025 cycle, and no new funding commitments have been made. In turn, WHO has revised 2026–2027 base programme budget from 5.3 to 4.2 billion USD. This year, member states approved a 20% increase in assessed contributions (90 million USD annually) but the gap remains substantial.

Indeed, the only US presence this year was an ill-received video message from US DHHS Secretary Robert F. Kennedy Jr, recorded for Fox News and played to a mostly silent audience of WHA diplomats and ministers. In it, he urged countries to cooperate with the US “outside of the WHO”, which he slammed as "mired in bureaucratic bloat, entrenched paradigms, conflicts of interest and international power politics."

China, by contrast, arrived in stupendous force. This year, it sent the largest delegation in WHA history: over 180 representatives from the National Health Commission, Foreign Ministry, National Healthcare Security Administration, Chinese CDC, state-owned biotech firms and embassy teams, led by Vice Premier Liu Guozhong and Health Minister Lei Haichao.

In addition, the headline news was of China’s pledge of 500 million USD to the WHO over five years. If fully realised, this would make it the largest state donor. According to official statements, this includes increased assessed dues under the new 20% hike, voluntary programme contributions, and South–South health development financing.

Some public health analysts have argued that this pledge remains modest, given China’s relative economic size and rising geopolitical ambition. It also falls short of past US contributions. They call for greater flexibility, urgency and discretionary support, but such critique misses China’s core strategy, which is about control, not volume, and intentionally designed to serve its own national interests.

This distinction is important. China’s is not a discretionary cash injection in the style of past US funding. So far, it appears to blend routine dues with earmarked project support and in-kind contributions. It remains unclear how much will be channelled through the WHO versus China’s own development platforms.

On the surface, China may now seem be more publicly aligned with multilateral mechanisms than previously, but in practice, its approach remains strategically hybrid and bilaterally focused. Nevertheless, there are several important motivations for signalling its expanding presence at the WHA this year. The next section explores what these are.

Subscribe now

What China Actually Signalled

China is not “funding the WHO” in the traditional Western sense, because it is funding its own version of the WHO. Beyond its headline cash pledge and record-sized delegation, it has made a series of deliberate moves this year, ranging from norm-setting and technical agenda influence to strategic engagement with the Pandemic Agreement and a more assertive play for institutional legitimacy within WHO systems.

Below, I analyse each of these domains of influence, in terms of China’s intent and positioning, and how they come together as a coordinated strategy to position China as a rule-shaper in the evolving architecture of global health.

Norm-setting and Legitimacy

This year, we saw the WHO signal strong institutional endorsement for China, repeatedly and publicly. This is a big deal: China’s relationship with the WHO has not always been so smooth (particularly during the pandemic). Director General Tedros Adhanom Ghebreyesus and other WHO leaders highlighted China’s leadership in key health areas, endorsed new cooperation agreements, and linked China’s actions to the WHO’s future direction. All of this helps China to reinforce its image as a responsible and central actor, and even standard-setter, in global health governance.

“China has made strong contributions to global public health and to the work of WHO. We are grateful for your support and look forward to deepening cooperation in key areas such as digital health and health system transformation.”
— WHO Director-General Tedros, meeting with Vice Premier Liu Guozhong, 22^nd May

“We welcome China’s continued role in promoting South–South cooperation and equitable access to health technologies.”
— DG Tedros, WHA78 plenary, WHO Secretariat briefing, 22^nd May

China was eager to accept all of this enthusiastic recognition from the WHA, but its responses were direct and strategic. Senior leaders welcomed and amplified WHO praise as international validation, but they also pushed for norm diffusion, promoting ideas around China’s own preferred concepts of sovereignty, equity and mutual respect.

In what was perhaps a subtle rebuke to the US, Vice Premier Liu urged countries to “resist unilateralism and power politics” and look to the WHO as a “professional, science-based authority”. Health Minister Lei linked China’s domestic successes to global legitimacy, including life expectancy and health access.

“At present, faced with the shock of unilateralism and power politics, global public health security faces serious challenges. Only through mutual support and solidarity can humanity create a healthier world. China has firmly fulfilled this commitment through concrete actions.”
— Vice Premier Liu Guozhong, WHA78 plenary address, 20th May

“China continuously contributes Chinese wisdom and strength to building a global community of health for all.”
— Lei Haichao, Minister of Health, WHA78 remarks, 21 May

Share

Leverage Through Side Events

WHA78 was an opportunity for China to showcase its technical prowess in health. Through side events, technical roundtables and bilateral meetings, it sought to promote models it believes to be globally exportable and systemically influential: including digital-first primary care and Traditional Chinese Medicine. In addition, it targeted specific under-addressed areas that the WHO has prioritised, like mental health and rare diseases, where it knows it can demonstrate both policy leadership and implementation strength.

1. Digital Health x Primary Care

This year, China’s forum on “Empowering Primary Health Care with Digital Intelligence” drew over 200 delegates, with many more attendees apparently queuing outside. Presentations described how China’s 1.4 billion residents are now covered by a unified digital infrastructure. Officials showcased smart hospitals, AI diagnosis, integrated payment systems, and public health surveillance. China has long pitched its own evolution from rural barefoot doctors to 5G-enabled tiered referral networks as a success story worth sharing. Chinese speakers framed these systems as adaptable mechanisms for LMICs through standard templates, shared digital norms and transferable infrastructure.

No wonder the forum was so popular: this was a very smart move. Digital health is a global topic with bipartisan excitement and minimal geopolitical baggage, and an area where China is now a global leader (I’ve written about this many times already, including here, here and here). Showcasing prowess in digital health governance at the WHA brought China significant credibility.

2. Mental Health, TB, Rare Diseases

These are disease areas with real unmet need across much of the world. Mental health and TB have long been WHO priorities, and China has recently moved fast on both: expanding community-based services, training its health workforce, and trialling digital triage tools. Rare diseases, meanwhile, sit at the intersection of China’s biotech ambitions and health equity goals. Officials highlighted alignment with WHO’s new 10-year roadmap, citing expanded orphan drug lists, fresh reimbursement policies and major state investment in genetic screening.

By co-hosting sessions in domains the WHO is actively advancing, China positioned itself as a practical partner. It showed it can engage with real substance, as a valuable technical contributor as well as a supportive financial donor.

3. Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) has long been a national priority under President Xi’s administration: enshrined in law, backed by budget and reinforced through political will. This first-ever TCM-focused WHA side event, co-hosted by countries from both Asia and African, was a strategic move to elevate TCM from soft-power branding to hard-power legitimacy. The forum spotlighted clinical research centres, IP showcases, standardised pharmacopoeia and export-ready wellness products, all designed to emphasise the scientific credentials of TCM.

This WHA78 event marked a notable step forward. China deliberately aligned its messaging with WHO language around “integration” and “pluralism,” carefully framing TCM as complementary rather than oppositional to biomedicine. I previously wrote about China’s ambitions to position TCM on equal footing with biomedical models. The very fact that this forum took place at the WHA, under the auspices of the WHO, represents a clear win for China in reshaping the global epistemology of health. It offered institutional validation for traditional knowledge systems that have often been hotly contested by some (particularly the Western) member states.

Subscribe now

Pandemic Treaty and Global Governance

After three years of intense negotiation, the WHA finally adopted the Pandemic Agreement, marking a symbolic milestone in reaffirming the WHO’s convening power. This is a non-binding framework to strengthen global preparedness through shared surveillance, rapid response and equitable access to treatments. However, the deal is still incomplete: the critical Pathogen Access and Benefit-Sharing (PABS) system ,implementation timelines and financing are all still under negotiation.

Nevertheless, after years of pandemic-related disputes between WHO and China, including on virus origins, this Agreement has now offered China the opportunity to shape multilateral rules on this topic, while asserting red lines. It backed the final text but did so on sovereignty-first terms, repeatedly framing its contributions as central to the final adoption, and through language of “fairness, equity and digital security.”

Thanks to China’s efforts, all parties agreed to focus monitoring on emerging infectious diseases, clarify responsibilities in data sharing, reduce burden on member states, and safeguard the interests of developing countries.”
— Hu Guang, Director, National Disease Control and Prevention Administration (NDCPA)

Funding for Institutional Influence

With greater WHO funding and participation, we are now seeing China use its growing institutional influence to advance sovereignty-sensitive agendas. This year, Taiwan’s long-running bid for WHA observer status was removed from the WHA agenda during a closed-door committee vote. Chinese state media has described this outcome as both a legal necessity and a diplomatic success. For China, multilateralism is a means to institutionalise its worldview, not to dilute it.

“Taiwan's participation in the WHA must be handled in strict accordance with the one-China principle, as established by the UN General Assembly. We firmly oppose any Taiwan-related proposals. Any technical exchanges involving Taiwan that comply with the one-China principle can proceed smoothly.”
— Chen Xu, Permanent Representative of China to the UN in Geneva, WHA

Share

China’s Selective Multilateralism is Redefining Global Health

WHA78 showed us the clearest signals yet, of what China plans to do, and how, in global health. Separate from Western models of global goods, it is building a development framework where health links directly with infrastructure, governance, cultural legitimacy and commercial ecosystems. Health becomes a channel to build trust in Chinese vaccines, AI tools and TCM systems. It finds a way to normalise sovereignty-first principles across data, drug regulation and digital platforms. It enables the kind of bilateral engagement that blurs diplomacy, development, and industrial strategy — selective multilateralism, where it pays off.

Alongside its public-facing pledges and formal statements, China promoted a series of bilateral objectives: holding diplomatic meetings with Brazil, Indonesia, South Africa, Tunisia and Morocco to advance joint CDC partnerships, surveillance systems and talent exchanges which were all framed within its own broader diplomacy: the Global Development Initiative, the Global Civilisation Initiative and others, which are all very much separate from the WHO.

In addition, today’s global health architecture is no longer shaped by governments alone. Biopharma and digital health industry actors have played increasingly visible roles at WHA. This year, many deployed so-called “commercial colonisation” to coordinate shiny side events, invite-only roundtables and champagne breakfasts. While some public health traditionalists still balk at brands and the very idea of public-private partnerships, others see the value of industry in injecting much-needed capital, energy and speed into global health. And China knows exactly how to operate smoothly in this integrated ecosystem, with its hybrid financing, industrial tech alliances, and vertically integrated delivery models already competing across political, financial as well as commercial fronts.

It’s understandable why many member states, particularly lower and middle income countries (LMICs), are turning toward China. They are navigating a world of shrinking Western aid and fractured alliances. Just this week, DHHS Secretary RFK Jr. dismantled and replaced the CDC’s main vaccine advisory group, ACIP, sparking public health outcry. Meanwhile, last month, China’s multilateral lender, the AIIB, partnered with GAVI to offer up to $1 billion in financing for vaccines in LMICs. China’s alternative offer to the once US-dominated vaccine space, is yet another representation of its expanding and distinctive grip on the future of global health writ large.

WHA78 may not have been a “funeral”, exactly. But it certainly marked the end of an era in global health, and the beginning of a new dawn. China is reinventing what power looks like, and showing up with hard cash, sophisticated strategy and selective ambition. And more importantly, as I’ve written before, the Global South seems to like this, very much.

🔬This is a Real Diagnosis post at China Health Pulse, where I dive deeper into key topics and current trends. Today’s post covered China’s central role at this year’s World Health Assembly, and was recently featured in Bill Bishop’s Sinocism newsletter:

Sinocism

China-Central Asia Summit; EU frustrations; China at the World Health Assembly

Yesterday’s newsletter had a very bad typo, one that I corrected online minutes after hitting send, but too late for people who read the newsletter in email. The corrected text is bolded…

Read more

a year ago · 12 likes · Bill Bishop

For more on this topic, please see my post detailing how China is reshaping development aid, infrastructure-first diplomacy and public health partnerships:

When I wrote Part 1 at the start of April, we were still in the fog of threats and lobbying. Trump had just invoked tariffs on China, including threats on pharmaceuticals, and China had retaliated. Biopharma stocks slid dramatically, and no one knew how far things would go.

Today in Part 2, I cover the latest, most important updates since the market panics, walk-backs, and Geneva negotiations.

The dreaded topic of tariffs has already been widely (and wearily) covered by media outlets and market commentators everywhere. These days, it seems to be all that we reluctantly read online and complain about offline.

Indeed, on the ground in China during my travels in Beijing and Shanghai these weeks, nearly every colleague and friend that I have spoken with — from Western embassies to chambers of commerce, policy analysts to journalists — all have told me, with mournful expressions and semi-glazed eyes, that they are “absolutely sick” of analysing it.

And yet, despite the wall-to-wall coverage, there’s a lack of targeted insight into what all of this means for health.

That’s where China Health Pulse comes in. In this timely tariff update, I highlight what has changed, what has stalled and what is still uncertain — all while focusing on the real implications for biopharma, investors, patients and providers.

Subscribe now

From Sweeping Threats to a “Sort-of” Truce

Since my last post, US-China tariffs have escalated aggressively through April to now reach an uneasy truce in mid-May. By 11th April, total US tariff burden on Chinese goods had reached 125%, and a day later, a 20% “fentanyl surcharge” was imposed on specific categories, pushing the maximum tariff rate on selected goods to 145%. In full retaliation, Chinese tariffs on US goods reached a peak of 125% by 12th April.

China formally filed for WTO consultations over US healthcare-related tariffs, citing violations of the 1994 WTO Pharma Agreement. I had discussed last time how this longstanding precedent had provided protective scaffolding to morally keep life-saving drugs affordable across borders, eliminating over 7,000 pharmaceutical products and derivatives from tariffs and duties.

The markets reacted quickly. $6 trillion was wiped out on Wall Street within 2 days. US biopharma stocks fell by up to 9%, and pharmaceutical lobbies rushed to seek exemptions. Executives warned of disruptions to API flows, clinical trials, and diagnostic imports: not just the finished drugs, but the containers they come in, the intermediates that go into them and even the diagnostic tests used to prescribe them. Companies began to nervously plan for contingencies, COVID-style: warehousing, dual sourcing, Southeast Asia pivots… US industry groups submitted over 500 healthcare-specific exemption requests, and analysts began tracking supply chain exposure across both countries.

Then came the surprising about-turn (a nice economic analysis of this by Robin J Brooks here, Brookings Institution Senior Fellow). Trump posted on Truth Social on 22nd April: “Tariffs are a tool, not a punishment. We won’t hurt American innovation.” The White House revised tariff lists. While several high-priority health inputs (reagents, diagnostic plastics, imaging components) remained, others including branded drugs and patented biologics, were spared.

US and Chinese trade officials began talks on 10th May in Geneva, overseen by WTO legal counsel. After two days of intense negotiations, a 90-day de-escalation agreement was announced on 12th May, to reduce tariffs and establish a bilateral mechanism for ongoing trade discussions. Trump tweeted ”GREAT PROGRESS MADE!!!”, in response to: US tariffs to drop from 145% to 40–70%, and China tariffs from 125% to 10%. However, most high-priority health products face partial exemptions, not full protection, and over 2,000 exemption requests remain under review, with hundreds from the health sector. The public comment period closes in late June, with policy finalisation expected by mid-July.

An uneasy truce continues for now, but biopharma and medtech companies remain exposed. The most recent Section 301 tariff revision still includes key health-related categories:

Active pharmaceutical ingredients (APIs), including precursors to antibiotics, statins and antivirals

Diagnostic components such as reagents, PCR consumables and sterile lab plastics

Selected medtech inputs, including parts for imaging, robotics and invasive devices

Some critical areas remain exempt: notably, finished branded pharmaceuticals, most consumer-facing digital health tools and patented biologics. However, the concern extends beyond the finished drug, raw materials or even any side-products. Tariffs also affect inputs further up the supply chain, including containers, intermediates and diagnostic materials used in prescribing and administration. These exposures have the potential to impact cost and availability across therapeutic and diagnostic pathways.

There are significant risks for both sides.

Share

Foreign Industry: Strategic Shifts Under Pressure

Foreign biopharma multinationals are choosing to execute a "US for US" strategy: bracing for fragmentation by localising domestic production, and shifting manufacturing out of China in order to sidestep levies and tariff-proof their supply chains. These substantial moves signal that they expect geopolitical volatility to persist long term, even if current tariffs ease:

AbbVie will invest $10 billion in the US over the next decade, adding four new manufacturing sites to its US network to prepare for potential scenarios. CEO Rob Michael said “in terms of po­ten­tial mit­i­ga­tion in the near term, we could take in­ven­to­ry man­age­ment ac­tions or se­cure al­ter­nate sources of API.”

Amgen is investing $900 million to expand its central Ohio manufacturing facility, adding 350 new jobs and increasing total US manufacturing investment to over $5 billion.

Eli Lilly has announced $50 billion to build four new US manufacturing sites, three of which will focus on active pharmaceutical ingredients (API), reshoring critical capabilities of small molecule chemical synthesis and further strengthening Lilly's supply chain.

Gilead is investing an additional $32 billion in US manufacturing and R&D through 2030 and create more than 3,000 direct and indirect jobs by 2028.

Merck is shifting manufacturing for its blockbuster drug Keytruda to a new $1 billion biologics factory in Delaware, reaffirming commitment to a strong US footprint. CEO Robert M Davis said “the Wilmington site represents our continued commitment to growing our investments in US manufacturing and has the potential to create thousands of high-paying American jobs while ensuring that we can produce and distribute products close to patients right here in the US”.

Moderna CFO Jamey Mock said “it’s an un­cer­tain en­vi­ron­ment, but no­body has lost faith”. They are expanding ef­forts to rein in costs, cutting from $5.9 bil­lion down to $5.4-5.7 bil­lion for 2026, and then further down to $4.7-5 bil­lion in 2027, aiming to break even in 2028.

Novartis has committed $23 billion over five years for seven US facilities and a $1.1 billion R&D hub in San Diego. CEO Vas Narasimhan said “Our goal is to have 100% of our prod­ucts pro­duced in the US for the US… we be­lieve this is man­age­able.”

Pfizer has already anticipated a $150 million financial impact in 2025 from the current slate of tariffs. CEO Al­bert Bourla expressed “cautious optimism” that potential Section 232 findings would focus on imports from countries considered actual national security risks, rather than allies, based on conversations with the White House, and is considering transferring overseas production to domestic sites.

GSK views its 2022 decoupling with its consumer health business Haleon, as “very in­ten­tion­al, de­lib­er­ate choic­es to re­set”, making it regionally resilient in its supply chains and mitigated for risk through double sourcing, in the face of biopharma tariffs. CEO Em­ma Walm­s­ley said “we're watch­ing it very care­ful­ly … we are well-pre­pared.”

AstraZeneca is planning to move some production from Europe to US plants.

Alongside their domestic manufacturing expansion efforts, foreign MNCs are actively reassessing their China strategies. For many companies, continued presence in the Chinese market is a critical non-negotiable: typically, it’s the second or third largest globally by revenue.

Several are choosing to split operations geographically, accepting the higher costs and complexity involved. Eli Lilly has announced a $212 million upgrade to its manufacturing site in Suzhou. AstraZeneca is investing $2.5 billion to build its sixth global R&D centre in Beijing.

Subscribe now

China’s Industry: Relative Calm, Strategic Positioning

Unlike global firms, Chinese biopharma players remain relatively insulated — at least for now. Approximately 70% of drugs in China are developed and manufactured domestically. This “closed-loop” system helps shield the sector from US tariffs and foreign supply chain disruptions, reinforced by state policies that prioritise local innovation and self-sufficiency.

A small but growing number of Chinese companies are pursuing outbound drug approvals and distribution, which brings greater exposure to tariff risks and regulatory complexity. This includes Beione (formerly BeiGene’s China operations), which has secured US approvals for drugs like Brukinsa and Tevimbra. Still, most Chinese biopharma firms continue to concentrate on the vast domestic market. The majority of their international collaborations are structured around in-licensing foreign products for local manufacture and distribution — arrangements that remain largely unaffected by tariffs for now.

Even so, the balance remains delicate. Chinese biopharma companies with global ambitions are accustomed to separating market volatility from day-to-day operations. The latest tariff tensions are just one more chapter in a long series of disruptions that have not slowed their pursuit of overseas regulatory approvals or clinical partnerships.

In recent Q1 earnings calls, WuXi AppTec, Zai Lab and Hengrui Biopharma, among others, have all projected continued confidence, reporting steady revenue growth to global investors. Their messaging strikes a tone of measured resilience, highlighting strong domestic manufacturing capabilities, diversified global operations and therefore limited direct exposure to US trade measures. For instance, Beone reported a 49% year-on-year revenue increase in Q1 to reach $1.32 billion, and WuXi Apptec reported a 21% increase to $1.32 billion, even as tariffs escalated.

Impact on Patients and Providers

In past trade disputes, healthcare was usually spared. As I had said in Part 1, the 1994 WTO Pharma Agreement had reflected a shared principle: life-saving goods shouldn’t be bargaining chips, and patients shouldn’t bear the cost of geopolitics.

This time, it’s different. Healthcare has been explicitly included in tariff proposals, raising alarm across the industry. But patients and providers don’t need to panic yet, either in the US or China.

Whether implemented fully or only in part, the current tariff schedule would phase in gradually. Supply chains are unlikely to feel direct disruption for at least 12 to 24 months. Major hospitals aren’t importing APIs, reagents or diagnostic plastics themselves. Instead, the impact will be felt first by their upstream suppliers. And when it comes to potential out-of-pocket costs for patients, other policy forces, from reimbursement regimes to price negotiations, are still the dominant forces affecting drug affordability.

In China, the most significant factor remains the National Reimbursement Drug List (NRDL - more to come in a future post). Both foreign and domestic drugs on the NRDL are reimbursed under China’s public health insurance, with prices negotiated between manufacturers and government through volume-based procurement to maintain affordability for China’s insured population, in order to promote China’s advancements towards Universal Health Coverage. If and when tariffs raise the import costs of foreign drugs on the NDRL list, the financial burden will have to be absorbed by pharmaceutical companies, impacting their profit margins rather than patient costs. But for non-NRDL drugs, where patients pay out-of-pocket, it’s true that tariffs could indeed push prices higher, especially in the private market or for imported specialty products.

In the US, the more immediate drug pricing concern isn’t tariffs, either. Biopharma companies have already been busy worrying about the 2022, Biden-initiated Inflation Reduction Act (IRA). Unlike other developed countries like Canada and the UK, where governments negotiate fair prices and restrict annual price hikes, US drugmakers have long enjoyed near-total pricing power, protected by long patent windows (12-14 years) and a fragmented regulatory system. It’s no wonder that the US pays far more per patient than almost anywhere else.

The IRA aims to change this, allowing US Medicare to negotiate prices for a small set of high-cost, top-selling drugs in order to make them more affordable for patients. These drugs have already made big pharma billions of dollars, and they have been fighting back in courts to protect future revenue, and so far, they have been losing. The IRA also aims to limit annual out-of-pocket costs for seniors to $2,000, and to penalise companies for price increases above inflation.

It’s true that tariffs may add a layer of pressure in certain instances. For Medicare-covered seniors, the IRA’s price caps will shield them from most increases. But for younger Americans, or for drugs not yet included in IRA-negotiated lists, tariff-driven price increases may still be passed through to patients.

Interestingly enough, the IRAs have been coming up as a frequent topic during my on-the-ground conversations in China these past weeks. Several Chinese gov officials and academics have gleefully pointed out to me (in off-the-record conversations) that this US mechanism for drug affordability, is in fact a “reverse-NRDL” that directly follows China’s footsteps. They believe that US is now copying China’s approach to drug price control and public purchasing: and see this as one of many signs that China is now switching positions to lead the West, including in technically complex regulatory and reimbursement frameworks where it had traditionally always followed. They see this symbolic shift as evidence that China is now setting global norms and standards, cementing its position as a world leader. I’m fascinated by these perspectives, and keen to review them more closely, in a future post.

Share

And What about Fentanyl?

One of the most politically charged moves in the recent tariff package was the White House’s decision to impose a 20% penalty on “fentanyl-related imports” from China. This thorny issue has once again become a focal point in US–China tensions, with both sides trading accusations that leave little room for nuance.

The US administration is blaming China for the continued flow of precursor chemicals, allegedly used by Latin American cartels to produce illicit fentanyl. Trump recently declared: “We’re doing what Biden never did. China is the root of this poison — and they’re going to pay.”

China has hit back. Its Ministry of Foreign Affairs called the measure “a politicised distraction from America’s internal public health crisis,” warning that “tariffing your way out of addiction will not work.” Their message is clear: the fentanyl crisis was made in America, not China.

This isn’t the first time fentanyl has featured in bilateral relations. In 2019, China banned all fentanyl analogues following negotiations with the U.S. That move was seen as a rare example of effective collaboration. But today, the tone is far more confrontational.

A 2023 Brookings Institution report provides context often missing from the current US narrative. It identified China as a principal (though indirect) source of fentanyl precursors, but emphasised that “while supply-side measures, even with limited effectiveness, can save lives, domestic prevention, treatment, harm reduction, and law enforcement remain fundamental.”

In truth, the crisis is driven less by international supply chains than by US domestic failures. Precursor chemicals are globally traded, and it is demand, not just supply, that fuels the fentanyl market. That demand is deeply rooted in the US health system.

In 2022, the US recorded 22.2 fentanyl deaths per 100,000 people. To compare, England and Wales had just 0.1 per 100,000 — a rate 222 times lower. The UK’s stricter prescribing rules, centralized NHS infrastructure, and robust harm reduction policies have contained the spread. Canada, despite facing its own opioid challenges, also maintains a significantly lower per capita mortality rate, attributed to broader access to addiction treatment and public health support.

In contrast, the US has failed to control the upstream forces driving demand. Its fragmented, underfunded healthcare system, legacy of unchecked opioid overprescription, and minimal investment in harm reduction have created the perfect storm. For decades, the US pharmaceutical industry, enabled by aggressive marketing and inadequate regulations, have flooded American communities with over-prescriptions of high-dose opioids at a scale that no other countries have seen. Treatment remains inaccessible to many, and efforts to build coordinated, evidence-based drug policy have lagged far behind.

Addressing this crisis requires deep structural reform: expanding access to care, regulating pharmaceutical marketing with foresight, and treating addiction not as crime, but as chronic illness. Without that, tariffs on fentanyl precursors will do little, and risk becoming just another political barb in trade dramas that have little to do with patient lives.

Beyond Drug Tariffs: Health Data and R&D Delays

The potential decoupling impacts between US and China go far beyond tariffs on physical goods – whether biopharma and medtech, fentanyl or otherwise. The wider context and even higher stakes are the free flow of health and genomic data. Restrictions from both governments are beginning to reshape how, where, and with whom global R&D happens. This has severe implications on cross-border collaboration in biotech and drug development.

US side:

Recently, the US Department of Justice’s Executive Order in April, restricted transfers of "bulk sensitive personal data," including large-scale datasets on health, genomics and biometrics. It was designed to prevent adversarial access to data categories now seen as national security assets, especially in the context of AI training and surveillance. The policy targets countries of concern, including China. While framed as a general data protection measure, it has specific implications for CROs, diagnostics firms, and life sciences companies working across borders. Many are now reassessing where they store, process, and transfer research data.

In parallel, the brewing BIOSECURE Act (still under congressional review) proposes banning US federal agencies from contracting with named firms like WuXi AppTec and BGI, which are viewed as national security risks. If passed, it would effectively firewall US biomedical procurement from any Chinese-linked entity, with ripple effects likely across the entire biopharma ecosystem.

China side:

Meanwhile, China has been expanding its own comprehensive data control regime, increasingly tightening cross-border research involving health and life sciences. This began with the 2017 Cybersecurity Law, but has since been layered with the 2021 Data Security Law and Personal Information Protection Law, which is China’s own GDPR-style framework. These require government approvals and security assessments for any transfer of personal or health data abroad, including for multinational clinical trials.

From 2023 onward, new sector-specific rules have further raised the bar. The Cross-Border Genetic Data Transfer Guidelines require formal approvals for any export of genomic data (even those anonymised). The Health and Medical Data Security Guidelines now classify patient records, bio-specimens and clinical trial data as strategic resources. Hospitals, trial sponsors and data processors must comply with national oversight protocols, including periodic reviews and disclosures.

Data once seen as a shared scientific asset is now increasingly viewed as a strategic commodity, with profound implications for multinational R&D, trial coordination and AI-driven drug discovery. The uncertainties are already impacting companies, particularly those traversing both US and China markets.

What Next?

For industry: decision-making should not be accelerated simply by panic, but now is definitely the time to start cooly thinking about the long term. Decoupling is becoming operational reality, and while the 90-day pause may buy time, strategic groundwork for reconfiguring manufacturing, data infrastructure and clinical trial geographies needs to begin now (if it hasn’t already). It will be important to build optionality across regulatory zones without assuming continued interoperability between them.

For investors: Sentiment and signal are diverging, so aim to look beneath the volatilities to prevent from being pulled by hype. Indiscriminate pricing may obscure real pockets of value. Chinese biopharma stocks have already been battered by delisting fears, tightening capital and persistent geopolitical risk, but those serving “closed loop” China’s markets may be better insulated from the cross-border pricing impacts of tariffs — unlike US and EU-facing peers.

For patients: while little may change tomorrow, tariffs on APIs, reagents and device components could slowly erode the long-term affordability of generics, diagnostics and tech-enabled care. Most health systems around the world are already under strain, and patients living in middle-income settings or outside of public insurance coverage (in both US and China) would be the ones to be impacted first.

As “health x tariffs” continues as an evolving conversation, I will keep tracking how the landscape shifts over the next 90 days, updating this post as needed with new developments in order to provide you with sector-specific focus.

Last week in Beijing, I attended an EU–China conference marking 50 years of bilateral relations, as well as a closed-door briefing with my former team at the British Embassy on the recent, 7th UK–China Ministerial Health Dialogue (the 6th was held in 2021). In both settings, tariffs were notably absent from public discussion. In side conversations, however, several EU and UK colleagues voiced quiet relief that their governments had remained outside the crosshairs of Washington’s latest trade measures. It reflects a growing undercurrent: non-US Western actors are increasingly seeking to define and separate their own commercial and diplomatic lanes with China.

I’m now in Shanghai, catching up with investors and industry leaders to get a closer read on how they’re responding to everything on the ground here in China. Later this week, I’ll be at the JP Morgan China Summit, where I’ll be watching closely for the gap between what’s broadcasted onstage, versus what’s shared in confidence in the coffee breaks in between.

I’ll be back in London on 25th May, where I look forward to speaking at the London Business School’s 2025 China Business Forum, on the “Global Healthcare: Innovation & Access” Panel. Hope to see some of you there.

As always, thanks for reading, and if you’re seeing relevant shifts from your vantage point, I’d love to hear from you.

🔬This was Part 2 of health x tariff coverage in CHP’s Real Diagnosis series. Read Part 1 here:

Here, in Part 1: I cover my visit to Alibaba HQ this week in Hangzhou, reflecting on how the company’s history, mission and vision has changed since I last worked at Alihealth.
Next time, in Part 2: A deeper look at Alibaba’s healthtech ambition, breaking down the good and the bad in its structure and scope — as well as the implications for patients, providers, competitors and industry partners.

Alibaba needs no introduction. It is one of China’s biggest tech and internet giants, born in Hangzhou (the city now also known as the origin of DeepSeek) in 1999, and well known around the globe.

The last time I was here on “campus” (as employees call it) in 2019 at HQ, I wore a badge and owned a desk in Building 9, working as a Medical Advisor at AliHealth, its health subsidiary. This week, I returned as a guest.

Alibaba’s story of transformation has become the stuff of tech legend. In 26 years, the company has grown from a B2B marketplace into much more than an e-commerce powerhouse, pushing founder and former English teacher Jack Ma, to global prominence as a shining symbol of the China dream: hundreds of biographies and self-help books have been written about his life story and the endless possibilities inspired by hard work and ambition.

Unlike Amazon, which has maintained an arguably tighter focus on e-commerce, Alibaba has built a broad, horizontal infrastructure, in order to become a holistic operating system for digital China. Today, it is a sprawling tech conglomerate with multiple IPO’s, which already has and continues to transform the way people interact with technology in their everyday, from digital wallets, logistics and deliveries, to cloud computing, as well as healthtech.

When I was working here six years ago (which, equates to several past lifetimes in China’s ever-accelerating tech landscape), Alibaba’s health strategy was still tentatively building from its natural strengths in e-commerce, with primary focus on drug deliveries and digital pharmacies.

Things look quite different now.

In this 2-part series, I want to share some highlight snapshots and reflections from my recent visit. I believe that understanding the structure and history of the company provides essential context in order to better analyse its wider incentives, mission and vision, and to predict how these influence health and care in turn.

Subscribe now

My Alibaba Journey

In 2019, I joined AliHealth for a stint as a Medical Advisor, working from Alibaba’s headquarters in Hangzhou, and occasionally its high-rise offices in the Northeast of Beijing.

The experience was fascinating, and at times, dystopian, in the way that only big tech can be — particularly as I had spent the majority of my career thus far as a doctor on UK hospital wards. This was my first time working and speaking at length in professional Mandarin for a Chinese company, let alone the biggest name around in tech. From extended screen-time to back-to-back meetings, each day felt fresh and novel for me, even the most seemingly monotonous routines.

Alibaba had absorbed elements of Silicon Valley culture: a vast, beautiful campus built around a landscaped lake, glass towers encircling manicured gardens, and employees doing laps around the water on their breaks. Nested within each very tall, very square building, canteens served everything from regional Chinese dishes to burgers and pizza, and convenience stores sold branded Ali-notebooks and pens that employees could buy as gifts for outside friends and family. There were often company festivals on-site, with themed gifts and interactive games, and regular pop-ups where staff queued for prizes and snacks.

Alibaba also proudly maintained its own culturally Chinese imprint. When I joined, I had been bemused to discover that employee is asked to choose a 花名 (huaming, or nickname), by which they are exclusively known by. This meant that colleagues rarely knew of each other’s real names, even after years of working together. The names were often whimsical, sometimes aspirational, and I wasted days picking out pretentiously obscure Chinese characters from Tang Dynasty poetry in order to impress colleagues with my sophisticated taste.

I was also fascinated by the long-service awards: stamped gold rings, jade pendants and carved seals given at 1, 3, 5, and 10-year marks. These emblems were proudly displayed in security-monitored cases at the centre of the lobby entrance where my colleagues and I beeped in and out everyday, glowing and calling out to us as the symbolic rewards of long term loyalty.

Read more

On 8 April, Trump has confirmed incoming tariffs on pharmaceuticals. The details are pending, but the direction is set. I'll continue to update this post as the story develops.

What’s Going On?

The US-China tariff announcements this week have certainly shaken up the world. These measures have set the stage for a trade war, and the consequences, particularly in the health sector, are global.

Here’s the latest timeline:

2nd April: US President Donald Trump announced a 10% tariff on all imports and an additional 34% tariff specifically on Chinese goods, effective on 9th April. Pharmaceuticals were initially exempted.

4th April: China retaliated with a 34% tariff on all US imports, including pharma, effective on 10th April.​

9th April: US increased tariffs on Chinese goods to 104% after China failed to lift its retaliatory tariffs. Pharmaceuticals remained exempt, but Trump threatened more to come. At a state dinner in DC, he said "We're going to tariff our pharmaceuticals. They're going to come rushing back into our country".

9th April: China escalated again, announcing 84% tariffs on all US goods, including pharma.

13th April: on ABC News’ “This Week”, US Commerce Secretary Howard Lutnick said that US tariffs on pharmaceuticals (and semiconductors) will come “in the next month or two”, and “we need to make medicine in this country.” i.e. pharma tariffs are inevitably coming, but not as soon as Trump had said.

Global pharma has already felt the sting. AstraZeneca shares have fallen by 5.4%, GSK by 4.8%, and European giants like Sanofi, Roche, and Novartis have also posted sharp losses. Medical device stocks, including Boston Scientific, Medtronic and Siemens Healthineers, have also declined.

If the US is to impose tariffs on pharmaceuticals, this would shatter a longstanding precedent in the health sector. Pharmaceuticals have long been spared from trade wars, out of shared moral conviction: that saving lives is not just a market function, but a human right.

Since 1994, the WTO Pharma Agreement has provided protective scaffolding to keep life-saving drugs affordable across borders. It eliminated tariffs and other duties on over 7,000 pharmaceutical products and their derivatives.

Undoing that principle, even partially, risks far more than higher costs. It signals the US’s shift away from a global consensus that medicines should move freely, even when politics do not.

Subscribe now

The health implications are massive

Yesterday, on 8th April, European Commission President Ursula von der Leyen convened an emergency meeting with pharmaceutical executives. When heads of state and CEOs gather without pre-scheduled agendas, it signals more than routine concern.

Countries including India (whose Nifty Pharma Index fell 3% on 9th April) and Australia (which exports $2 billion of pharma to the US per year) are extremely concerned, as they import and export huge amounts of pharmaceuticals with the US, but here, I want to focus on the US-China health relationship.

I have been drafting analysis for my clients, and here are the four major implications on my mind:

1. Innovation will slow

2. Supply chains will strain

3. International pharma at risk

4. China’s health industry will harden

1. Innovation will slow

Cross-border scientific research depends on the free flow of technology, equipment and people. Tariffs introduce friction at every point, adding cost and delays. Innovation becomes collateral damage, and to everyone’s detriment.

US’s: Illumina Inc: Blacklisted under China's "Unreliable Entity List," since 4th February 2025, i.e. blocked from exporting its gene sequencers to China. This cuts off a major market for next-generation sequencing and disrupts collaborative international research in genomics.

US’s Eli Lilly: Heavily relies on overseas production, particularly in Ireland. Stock declined over 9% following the tariff announcements. Relocating production back to the US will be tough, and these increased costs and logistical hurdles are diverting resources away from research and development, delaying the introduction of new therapies.

2. Supply chains will strain

These tariffs are expected to disrupt global supply chains, leading to drug shortages and increased prices for consumers. The pharmaceutical industry is particularly vulnerable because it relies heavily on international manufacturing. Arguably, the US is more at risk for supply chain bottlenecks. In 2023, only 4% of US’s Active Pharmaceutical Ingredients (APIs) for life-saving drugs, including asthma and diabetes medications, were produced domestically.

US’s Belluscura plc: medical device maker (portable oxygen concentrators), withdrew its 2025 financial outlook due to the latest U.S. tariffs on Chinese imports. Its Chinese-sourced components became up to 54% more expensive overnight.

EU Pharma: European pharma trade lobby EFPIA has warned that broader U.S. tariffs could expedite a shift of operations to the U.S., potentially weakening the sector in Europe.

Share

3. International pharma at risk

The Chinese market remains a critical source of revenue for foreign pharma, especially in vaccines, oncology and rare diseases. The goal behind Trump’s tariffs is to promote domestic manufacturing. But in reality, the global pharmaceutical supply chain is too complex and interdependent to fully shift production back to the US. The more immediate outcome is likely financial harm, especially for US pharma companies that rely heavily on international sourcing, sales and research collaborations.

But for me, the bigger, long-term, risk isn’t tariffs alone. It’s how China could retaliate inside its borders at foreign pharma companies, whether through slower drug approvals, surprise audits or and bureaucratic roadblocks. I’ve written before about China’s preference for domestic brands over imports, and although Xi Jinping’s recent meeting with global pharma CEOs sent a strong public message of welcome and collaboration, those handshakes could fade quickly as trade tensions escalate. If relations keep souring, operational risks for foreign drugmakers inside China could rise even more, in ways that are harder to predict and overcome.

UK’s AstraZeneca: 12% of its global annual revenues came from China in 2024, the company's third-largest market. Tariffs threaten operational costs and complicate supply chains, potentially eroding profit margins.

France’s Sanofi: Opened multiple China R&D centres over the past five years, including in Suzhou, Chengdu and Beijing and now faces tougher import tariffs and slower approvals. Returns will become more uncertain.

Broader foreign industry: The European Federation of Pharmaceutical Industries and Associations (EFPIA) has warned that U.S. tariffs could expedite the relocation of pharmaceutical manufacturing from Europe to the United States.

4. China’s health industry will harden

China is not retreating. In fact, these new tariffs will likely help to accelerate and supercharge its domestic health ambitions further.

Beijing had already been promoting models for self-sufficiency (see my post on China’s rapidly maturing biotech capabilities). Since 2020, "Internal Circulation" (内循环) policies have encouraged Chinese firms to prioritise domestic R&D, manufacturing, and consumption, in order to minimise reliance on foreign imports.

In health, this meant: Pushing state-backed funding into biotech startups, fast-tracking drug and medtech approvals for domestic firms, strengthening IP protections for Chinese innovations, redirecting procurement toward "national champions" over foreign brands. These trade tensions may serve as further fuel for China to minimise and replace the vulnerabilities of external supply chains.

Short term, these tariffs might hurt Chinese firms trying to operate globally, but in the long term, they will likely deepen China's political and financial commitment to growing an independent, and globally competitive health ecosystem that thrives without US technology, capital or partnerships.

China’s GenScript Biotech: one of China's largest life sciences suppliers (especially in cell and gene therapy tools). US lawmakers launched an inquiry in early 2025, causing GenScript’s US operations stock prices to decline >30% in just two weeks. It is now restructuring its US presence to minimise new federal restrictions, by splitting its labs into separately incorporated entities.

Subscribe now

Where is this all going?

No matter how the next days and weeks play out, the consequences will be long term.

Biotech IPOs could shift East: China is likely to accelerate listings on domestic stock exchanges like Shanghai’s STAR Market, deepening its own biotech capital base to reduce reliance on US capital markets.

Pharma manufacturing could reroute: Pharma manufacturing for APIs and med-tech could flow toward lower-cost, lower-tariff hubs outside China and the US, including across Asia and Latin America. This could redraw supply chains in ways that will outlast this trade war.

Splintered regulatory systems could emerge: As US and China decouple, parallel regulatory ecosystems for drug approvals, clinical trials, and market standards are likely to develop. This could slow down international drug development and complicate global launches.

Permanent price increases in health products: Even if tariffs fall back later, higher baseline costs for medicines, diagnostics and medical supplies are likely to persist.

But, ultimately, the frontline casualties of these tariff wars will not be the corporations.

Patients will pay

Many essential U.S. health supplies, including medicines, gloves, gowns, IV equipment, are imported from China. Tariffs will drive up costs and tighten supply. Patients will face higher prices and real risks of shortages.

In China, retaliatory tariffs and export controls could restrict access to imported cancer therapies, immunotherapies and diagnostic tools. Treatment delays and limited options will follow.

These disruptions won’t be evenly felt. They will cluster where patients rely most on innovation and international supply chains. The disease areas most exposed are the ones that rely on complex global supply chains: cancer, rare diseases and chronic illness. As trade tensions escalate, vulnerable patients around the world will be the ones forced to pay the price.

🔬 This Real Diagnosis post breaks down the US-China tariffs, and what they mean for the health sector.

As of today (9th April), Trump has confirmed incoming tariffs on pharmaceuticals. The details are pending, but the direction is set. I'll continue to update this post as the story develops.

In Part 1, I unpacked the ten key health trends from this year’s Two Sessions.

Here, in Part 2, my deep dive continues: I look at the crucial forces driving those trends, and provide my predictions for what they mean for the future of China’s public and private heath services, domestic and foreign actors—as well as the very relevant context of Xi’s recent groundbreaking meeting with global pharma CEOs.

Last time, I reviewed this year’s 2025 Two Sessions and highlighted ten key health trends (see table below for a refresher). Some of these trends reinforced long-standing goals such as hospital reform, insurance restructuring, and signal China’s sustained policy commitment in these areas. Other trends consolidated newer or previously scattered priorities, such as the reframing of ageing under the “silver economy”, and the rising visibility of mental health.

The overall direction is clear: more decentralisation, greater pressure on local systems, and a growing reliance on industry and technology to fill in the gaps.

This time, I want to unpack the driving forces behind those shifts—to explore how China now sees health: what it protects, what it enables, and what it costs. Because in China’s current and uncertain economic landscape, health is now being positioned not just as a public service, but as a tool of governance, productivity and political legitimacy.

Here’s a table summarising the top 10 Health Trends from the 2025 Two Sessions:

Read more

Today: What was (and wasn’t) said about health at the Two Sessions—and what it signals for China’s policies, patients and ambitions.
Next time: Why these trends matter—and how they’ll shape the next months and years of living, working and doing business in China’s health system.

Subscribe now

Every spring, Beijing’s political calendar kicks into high gear. It’s not just fashion week that has reporters and analysts glued to their screens—the Two Sessions (两会, Lianghui) dominates headlines, social feeds and policy memos.

It’s China’s biggest political event of the year. This is when the country’s top leadership unveils national priorities, economic targets and policies that will shape the year ahead.

Thousands of delegates, identical in their black suits and dyed dark hair, pack into the Great Hall of the People in Beijing. Announcements roll out via tightly scripted schedules. Journalists, analysts and industry insiders analyse every line for clues about China’s next move.

If you’re deep in policy circles, you’ve likely been drowning in Lianghui analysis for weeks. But if you’re not? You might have only skimmed a headline—or missed it entirely.

Big mistake.

If you want to understand where China’s health system is headed, how it’s evolving, and what that means globally—you need to understand the Two Sessions. Because it’s the only political event where health gets this much public airtime—alongside economics, industry and national strategy.

What is said (and not said) during the Two Sessions will go on to shape the health of one in five people on the planet. And that affects all of us—whether you work in policy, tech or just care about how health systems are adapting to ageing, AI and other global shifts.

At LINTRIS Health, we’ve been covering this closely for our clients. Now, here at China Health Pulse, I’m breaking it down for you too—in a direct and digestible way.

Let’s dive right in.

Share

What are the Two Sessions?

The “Two Sessions” refers to two meetings which make up a choreographed double act of power and pageantry:

1. National People’s Congress (NPC): China's top legislative body (like Parliament or Congress), which reviews and rubber-stamps policies, budgets and laws

2. Chinese People’s Political Consultative Conference (CPPCC): a political stage for elite advisors—academics, business execs and Party loyalists. They don’t pass laws, but they do signal what sectors are in favour.

It happens every year, and it’s highly public. (By contrast: China’s Party Congress, held every five years, is more about leadership reshuffles and ideology, and the Central Committee Plenums are closed-door, elite-only affairs.)

The closest Western equivalents:

US: it’s like combining the State of the Union, the federal budget rollout and a legislative strategy speech all into one—with no public debate.

UK: imagine the Budget and the King’s Speech fused together — with announcements that directly shape national strategy across health, tech energy and more.

But unlike in Westminster or Washington, this isn’t about debate or drama. It’s about alignment. And signalling. Everything is pre-agreed, but everything is on purpose.

Read more