While China’s rigorous management of virus risks at home has received considerable attention, particularly as it hosts the 2022 winter Olympics, it’s massive vaccine effort abroad has been underreported. In fact, as of end 2021, Beijing had supplied more COVID vaccines to low- and middle-income countries than the WHO co-sponsored COVAX facility. 

Against the constant press scrutiny of global rollouts of vaccines from the big name western pharma companies, like Pfizer, Moderna and Oxford/BioNTech, China’s major role in increasing COVID-19 vaccine coverage globally has been largely overlooked – by the global health community  as well as donors. 

In fact, as of end 2021, Beijing had supplied nearly 1.3 billion doses to low- and middle-income countries – more than the WHO and Gavi co-sponsored COVAX global facility, which has so far relied mainly on vaccines licensed by Western countries. 

Moreover, manufacturing of Chinese vaccines has been further expanded through co-production partnerships with a number of middle-income countries. 

However, unlike COVAX, the overwhelming majority of  the Chinese vaccines have been sold, not donated. And while Chinese supplies have reached a total of its 98 countries, in terms of absolute volumes, most doses have been supplied to a smaller handful of, mostly upper-middle income, countries. 

At the same time, while COVAX has approved procurement of two Chinese vaccines, Sinopharm and Sinovac in 2021, China has generally preferred bilateral deals. In fact, Chinese doses supplied through COVAX accounted for only about 110 million of the 1.26 billion doses that it has sold or donated abroad in 2021.  

So while China’s role has been critical in filling the global vaccine supply gaps, it has operated largely outside of the multilateral architecture that WHO, GAVI and other global health agencies have sought to create during the pandemic. 

Recognizing this has important implications for the future of the established global health system, and how China may choose to engage, compete with or complement it.

Our analysis considered production and export patterns for the four Chinese vaccines, which have the most extensive international footprint, based on publicly available data up until October 2021. Additionally, we found that China’s COVID-19 vaccine landscape was characterized by: 

• Extensive Chinese partnerships in sales and manufacturing with LoMICs; 
• Prioritization of recipient countries that are part of China’s massive Belt and Road Initiative; 
• A nearly 50-50 split of investments by Chinese private and public sectors in the R&D initiatives that produced the vaccines. 

Two billion doses…. 

Vaccine inequality has been constantly highlighted as the culprit of prolonging the COVID-19 pandemic, costing more lives, slowing down the economic recovery, and leaving the world constantly ravaged by new variants. It has been a constant message of WHO Director General Dr Tedros Adhanom Ghebreyesus, including in his meetings this week with Chinese leaders at the start of the winter Olympics. 

Pleased to meet with 🇨🇳 Premier Li Keqiang. We discussed #COVID19 and the need for an aggressive effort on #VaccinEquity this year to vaccinate 70% of all populations. Solidarity is key to ensuring access and affordability of vaccines. pic.twitter.com/9aMgWR2j7R

— Tedros Adhanom Ghebreyesus (@DrTedros) February 5, 2022

In August 2021, China pledged to provide 2 billion vaccine doses for countries across the world by the end of this year. Our analysis found that, as of October 2021, China had either exported or donated 1.26 billion doses, surpassing the 1 billion dose distribution goal set by COVAX for 2021. But the vast majority of those were via sales, with a large proportion of the vaccines went to middle-income countries, with the upper-middle income Brazil and Indonesia in the top spots, followed by sales to COVAX.

UMICs as main purchasers of exports

Altogether, some 58.76% doses of Chinese vaccines were exported to 29 upper middle-income (UMIC) countries; 23.37% to 24 lower middle income (LoMIC) countries;  6.50% to 9 high-income countries (HICs); and 2.55% to 4 low-income countries (LICs). 

In terms of country-specific data, the top 10 biggest importers include Brazil, Indonesia, Turkey, Bangladesh, Mexico, Chile, Iran, Peru and Morocco.  

Notably, only 110 million doses were sold to COVAX, which accounts for merely 8.82% of the grand total.  In addition there were some 58.2 million donated doses to 93, mainly lower-income countries as well as UN peacekeepers.

Compared to its sales, donations of doses have been a small portion of China’s portfolio, totalling less than 60 million doses out of the total of the 1.26 billion doses exported abroad in 2021. 

Interestingly enough, some three quarters (74.2%) of those donations have gone to some 42 lower-middle income countries, as compared to only about 11.78% of donations to the world’s low income nations. 

In addition, some 12.30% of vaccine doses went to 26 upper middle income countries, and 1.21% of donations even went to 7 high income countries like Hungary.  

Targeted recipients, especially the Belt-and-Road Initiatives

While pledging to make Chinese vaccines a global public good, China has also taken the opportunity to use vaccines as part of its broader diplomatic initiatives. 

In particular, China’s ‘Health Silk Road (HSR)’ initiative has prioritized members of its economic Belt and Road initiative for donated vaccine doses. 

For instance, in terms of total number of doses donated, the top 10 biggest recipients in 2021 were Cambodia, Bangladesh, Sri Lanka, Pakistan, Myanmar, Nepal, Laos, El Salvador, the Philippines, and the West Bank and Gaza. Of those, all but the West Bank and Gaza are members of the BRI. 

Scaling up manufacturing partnerships overseas 

Extensive cooperation has been carried out to scale up manufacture of Chinese vaccines overseas. A total of 17 manufacturing agreements with 15 countries were identified, with the sum of anticipated production per year amounting to nearly 2 billion doses. 

Manufacturing partners are mainly concentrated in lower-middle-income (LoMICs) and upper-middle-income countries (UMIC), and several countries have established partnerships with more than one Chinese vaccine developer: Egypt is in the lead in projected production capacity, followed by Indonesia, the UAE, Russia and Brazil. Notably, among the top five largest foreign manufacturers, four are part of the Belt and Road Initiative (BRI).

Significant Chinese private sector vaccine R&D investment

Overall, our database identified over US$ 1 billion of investments into Chinese vaccine R&D. Strikingly nearly half of the financial R&D contributions came from the private sector, while slightly more than half was public sector funding. 

This is in contrast to other global research by the Graduate Institute’s Global Health Centre suggesting that globally, public sector funding for COVID vaccine R&D accounted for more than 90% of the total vaccine R&D investment that could be tracked publicly, as of July 2021.

Chinese private R&D investors included companies such as Advantech Capital, Vivo Capital and China Evergrande Group. Apart from that, China National Pharmaceutical Group (CNPG) spent 145 million USD in developing its Sinopharm vaccines. Philanthropic organizations account for only 3.85% of the total.

 However, given the relatively limited data on research and development (R&D) investments into Chinese vaccines so far, it is difficult to draw a comprehensive picture.

In addition, given the close relations between the public and private sectors in China, such a funding distribution pattern should be interpreted with caution, and the proportion of the investment made by the public sector may well be severely underestimated.

China and COVAX

To better understand China’s role in increasing global vaccine coverage, it is interesting to  compare and contrast with COVAX, the global collaboration of WHO, Gavi the Vaccine Alliance and other partners to advance equitable access to COVID-19 vaccines. 

COVAX first set its initial goal as 2 billion vaccine doses available by the end of 2021, but cut its supply forecast by around 25% to 1.4 billion in September, and then again in December down to 800 million to 1 billion doses. The latest data from the UNICEF COVID-19 Vaccine Market Dashboard is that around 1.1 billion doses have been shipped so far by late January, 2022. 

Nevertheless, COVAX has supplied 144 countries with a mix of donations and sales, while China has provided doses to 115 countries with around 95% of doses via sales. Moreover, despite the wide coverage of LoMICs destinations with donated doses, the major chunk of Chinese vaccines are, in effect, supplied to upper middle income countries, which differs from COVAX’s focus on low income and lower-middle income nations in particular. Along with that, however, China sold 110 million doses to COVAX, which presumably reached a broader range of COVAX target recipients. 

New Chinese Pledge to Africa in 2022 

In 2021, in conclusion, the massive role played by China in expanding developing countries’ access to vaccine doses and technology, met the needs of middle income countries in particular. 

China’s active engagement with countries of the Belt and Road Initiative with regards to vaccine manufacturing, donations, and purchases, reinforced other economic and strategic initiatives underway.  

However, there are signs that China is also now looking at the broader picture of unmet needs in the lowest income countries – albeit again through mostly bilateral deals. 

In late November, amid growing concern over the spread of the Omicron variant, China pledged to deliver another 1 billion doses of COVID-19 vaccines to Africa   in 2022, which will mostly be through bilateral deals, with two thirds as donations and another third likely through joint production agreements. 

This would further enhance China’s large-scale role in increasing COVID vaccine coverage in Africa, the least covered region of the world.

However, African nations now have many other vaccines to choose from. 

And there are growing concerns among professionals about the relatively high COVID mortality rates seen among people vaccinated with Sinovac and Sinopharm – recently reported in Singapore. This has cast further doubts on the vaccines’ overall efficacy, which was always rated lower than most of its western competitors. 

Even so, China’s massive vaccine and manufacturing export can be expected to continue.  Understanding the global COVID-19 vaccine landscape requires taking that into account. 

In 2022 it will be important to continue tracking not only of Western vaccine manufacturers and suppliers, but also China’s massive role – in terms of supply, distribution as well as  efficacy data in light of the continually evolving SARS-CoV2 virus variants. Doing so also sheds light on potential future directions in global health diplomacy China will play in the next phase of pandemic recovery.  

With thanks to Suerie Moon, co-director of the IHEID Global Health Centre, for her comments and contributions to the analysis. 

Image Credits: Contraloría Perú, Xiaoyi Wang, Xiaoyi Wang , Council of Foreign Relations, Twitter – Chinese Ambassador to Zimbabwe.