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Improvement of China’s healthy city construction policies from the perspective of policy instruments

Abstract

Background

This study aims to examine the current policy documents on building healthy cities in China. This will provide ideas for improving these policies and fostering the growth of healthy cities.

Methods

The NVivo software was used to analyze policy tools and construction areas for healthy city development. Policy documents on healthy urban development issued by central government authorities from 2009 to 2023 were selected. Demand, supply, and environmental policy were the three categories of recognized policy instruments. Health services, health environment, health culture, health society, and healthy people are the five pillars of a healthy city.

Results

This paper analyzes policy documents on healthy urban development in China from two dimensions. The policy tool is on the X-axis, and the field of healthy city construction is on the Y-axis. Regarding the dimension of policy instruments, supply-based policies were used most frequently, at 62.9%. Environmental policies are implemented 26.5% of the time in conjunction with economic policies. Following this, demand-based policies have a frequency of 10.6%. From the perspective of two-dimensional shapes on policy instruments and healthy city building domains, each of the five fields of healthy city construction focuses on using three policy instruments. From the two-dimensional perspective of policy tools and healthy city building domains, each of the five fields of healthy city construction focuses on using three policy instruments.

Conclusion

The results show that China’s current healthy city policies use a mix of policies to manage supply, environment, and demand. Most of these policies are based on supply, with high levels of government involvement. However, more policies are needed. They encourage individuals, families, communities, and social groups to participate freely in the policy process. In the future, the combination of policy tools can be quickly adjusted to enhance the effectiveness of policy implementation. At the national level, a strong commitment is made to promote healthy urban development. However, the use of policy tools across different construction sectors needs to be evenly distributed. It must be acknowledged that the effectiveness of policy tools in enhancing efficiency requires further investigation. However, the current study needs to be revised. Differences in the understanding of policy instruments may lead to different results, thus affecting the effectiveness of policy recommendations.

Peer Review reports

Background

The concept of healthy cities has been in use since the 1980s and was born from a profound context. At that time, the global urbanization process was accelerating, the urban population was growing rapidly, and a series of urbanization problems ensued, such as environmental pollution, resource shortages, traffic congestion, and insufficient public health facilities, which presented many challenges to human health [1, 2]. Based on the New Public Health Movement [3, 4], the Ottawa Charter [5, 6], and the strategic idea of “Health for All” [7, 8], the concept of Healthy Cities has emerged as a global action strategy advocated by the World Health Organization (WHO) to address the impact of urbanization on human health in the 21st century. The strategy is advocated by the WHO to address the effects of urbanization on human health in the 21st century [9,10,11].

The idea of healthy cities was first discussed at a large meeting in Toronto, Canada, in 1984. In 1986, the WHO Regional Office for Europe decided to start a program to encourage cities to become healthier. This was called the “healthy cities project” (HCP) [12, 13]. The city of Toronto, Canada, was the first city to respond to the movement. It did very well by making plans to be a healthy city, introducing rules to manage health, taking steps to reduce pollution, and getting many people involved in making their city healthier [14, 15]. Since then, the Healthy Cities concept has spread rapidly from Canada to the United States and Europe, and then to Japan, Singapore, New Zealand, Australia, and other countries. It has gradually developed into a global effort to build better cities [16,17,18,19].

On April 2, 1996, the World Health Organization (WHO) chose the theme for World Health Day to be Cities and Health. This decision was made based on the experiences and achievements of countries around the world in implementing healthy urban activities [20, 21]. Therefore, the “10 Criteria for Healthy Cities” were created. These findings show the direction in which efforts should go and provide ways to measure how healthy cities are being built [22, 23].

In China, the Healthy Cities program is closely linked to the creation of national health cities. The first of these cities was created in 1989, and many more have since been built [24]. The concepts and methods of healthy city construction have not only helped consolidate and enhance the achievements of the creation of national health cities but also further enriched and deepened the connotation of the patriotic health movement [25, 26]. China’s Healthy Cities Program has gone through two stages. First, an exploratory and pilot testing stage was conducted. There was then a full-scale development stage [27]. Before 1993, it was still in the early stages of development. This included the idea of healthy cities and working with the WHO to provide training. In early 1994, after visiting China by WHO officials believed that China had the necessary conditions to perform the Healthy Cities Planning Campaign. In August of that year, the WHO and the Chinese Ministry of Health worked together to start a pilot project for the Healthy Cities Program in the Dongcheng district of Beijing and the Jiading district of Shanghai. This was an important moment for China, as it joined the global movement to plan healthy cities [28].

After the SARS epidemic in 2003, China began to develop healthy cities big. The former Ministry of Health encouraged and advocated the establishment of healthy cities, with many cities taking the initiative to create such a program to improve the urban environment and the health and quality of life of their citizens. Notable examples of this initiative include the cities of Suzhou and Shanghai. In particular, Suzhou has been a prominent proponent of the concept of a healthy city since the late 1990s [29]. On June 12, 2001, the Office of the National Patriotic Health Committee formally declared Suzhou the first pilot city of China’s “Healthy City” program to the WHO. In August of that year, Suzhou set itself the objective of becoming a healthy city in the next five to ten years. In September 2003, the city held a mobilization meeting and issued a series of documents to initiate the construction of a healthy city [30]. The Shanghai Municipal Government issued the Shanghai Three-Year Action Plan for Building Healthy Cities (2003–2005) at the end of 2003, identifying eight projects that cover 104 indicators and promoting them as key government tasks, with mid-term and final evaluations to be completed in 2004 and 2005, respectively. As the first megacity in China to develop a healthy city, Shanghai has provided valuable experience to other cities [31, 32].

At the end of 2007, the Office of the National Patriotic Health Committee officially launched the construction of healthy cities and districts (towns) throughout the country and identified Shanghai, Hangzhou, Suzhou, Dalian, Karamayi, Zhangjiagang, Dongcheng District of Beijing, Xicheng District of Beijing, Qibao Town of Minhang District of Shanghai, and Zhangyan Town of Jinshan District of Shanghai as the first batch of pilot cities and towns for the construction of healthy cities in China. The initial cohort of cities (districts and towns) has been designated as the inaugural cohort of pilot cities in the initiative to build healthy cities in China. This initiative is poised to propel the development of healthy cities in China into a new phase of growth and development [33].

Since 2008, the People’s Republic of China has been promoting the development of healthy cities. The “Healthy China 2030” plan, which outlines the country’s strategic approach to achieving this objective, places a significant emphasis on the development of healthy cities as a crucial component in the broader effort to create a healthier China [34].

In 2016, the National Association for Love and Health initiated a comprehensive program for the development of healthy towns and cities, incorporating specific measures to achieve this goal, including: improving the policy system, successively issuing specifications for the construction of healthy enterprises, schools, communities, and other healthy cells, as well as healthy townships and counties, and building a whole chain construction system for healthy China, healthy cities, healthy counties, healthy townships, and healthy cells, forming a leadership pattern by the Party Committee and the government, cooperation among multiple departments, support by professional organizations, and joint participation by the whole society; and it has formed a working pattern led by the Party committee, led by the government, cooperated by multiple departments, supported by professional organizations, and jointly participated by the whole society [35];

Following extensive research and consideration of the relevant theoretical models, a proposal was made in favor of the “6 + X” construction model. The “6” in this model signifies the establishment of a functioning mechanism overseen by the Party Committee and the Government. This mechanism must be accompanied by a comprehensive city development plan, the cultivation of “healthy cells”, the promotion of crucial construction projects, the establishment of a universal health management system, and the evaluation of the efficacy of construction projects [36]. The letter ‘6’ encompasses some key elements related to the development of this initiative. First, it refers to the establishment of a working mechanism led by the Party Committee and the government. Second, it concerns the formulation of a healthy city development plan, the implementation of “healthy cell” construction, the promotion of key construction projects, and the establishment of a health management system for the entire population. Finally, it is also concerned with the evaluation of construction effects. In contrast, the “X” encourages localities to explore characteristic construction modes according to specific circumstances. For example, Chengdu City has established a model of upward linkage to raise health awareness and bring together healthy cells, and Maanshan City has adopted the “three micro” initiative as a means to mobilize citizens to participate in health governance [37]. The integration and promotion of relevant work on the subject should be prioritized. A selection of 15 cities should be undertaken to construct healthy cities while also advocating for the innovative model of the Healthy China Initiative. The promotion of healthy city construction should be coupled with initiatives to promote maternal and child health, as well as cancer prevention and treatment. Exploring various combined service models is also recommended [38].

Currently, efforts have been made to carry out a pilot health impact assessment to strengthen control of the source of risks and hazards while concomitantly promoting the integration of health into all policies [39]. A demonstrative role has been played by releasing a system of indicators to evaluate the construction of healthy cities, conducting regular evaluations, and launching model cities to lead and drive the work using a typical example [40]. Through these efforts, the overall index and subindexes of healthy cities around the world have steadily improved, the health of the population has continued to improve, the median life expectancy has increased, and infant and child mortality rates, under-five mortality rates, and maternal mortality rates have continued to fall, reaching or exceeding the average levels of high-income countries [41].

In recent years, China has made remarkable progress in the construction of healthy cities and has gradually constructed an urban public health service model in which everyone participates and benefits from the service [35]. In 2022, the 14th 5-year plan for national health requires summarizing and popularizing the pilot experience of healthy cities and creating several healthy city models. To promote the construction of healthy cities, the Chinese government and its various departments and organizations have issued relevant policies to provide policy guidelines and institutional safeguards for the construction of healthy cities [42].

This paper begins with a content analysis of China’s current policy documents on healthy city construction, examines the advantages and shortcomings of the current healthy city construction policy, and proposes optimization measures and suggestions for China’s health construction policy, to provide reference for China’s further improvement of its healthy city construction policy.

Methods

Materials sources

The present study selected policy documents related to the development of healthy cities since the initiation of the “Healthy China 2020 Strategy,” introduced by the former Ministry of Health in 2008, as samples for analysis. The search period was from January 1, 2008, to September 1, 2023. The search strategy involved the use of keywords, namely “healthy cities” and “healthy towns”, to systematically explore the official websites of Chinese administrative bodies at all levels. These levels included the State Council, the Health Commission, provincial governments, city governments with districts, and the Database of Laws and Regulations of China. To ensure the accuracy and representativeness of the policy text, this research also establishes inclusion and exclusion criteria.

(1) inclusion criteria: First, the phrase “Healthy City” must appear in the document title. Second, the departments that issue them include the Chinese State Council, the China National Health and Family Planning Commission, provincial governments, and municipal governments with districts. In other words, the document issuer must be a government department.

(2) exclusion criteria: (1) Organizational arrangements and technical requirements at a specific operational level, such as the establishment of the Healthy City Construction Commission and the Evaluation Standard System. (2) Lower-level government departments forward documents from higher-level governments and departments. The design of such exclusion criteria is primarily concerned with the form and content of the basis for policy judgments [43, 44]. According to the aforementioned criteria, 13 policy texts were ultimately selected for inclusion in NVivo 14 to conduct a policy analysis. (see Table 1).

Table 1 Texts on policies for building healthy cities in China

The theoretical analysis framework

A framework for analyzing policy texts was constructed based on the Zegveld and Rothwell classification of policy instruments [45] and the two dimensions of the construction of healthy cities. Policy tools can be classified into three categories: environmental, supply, and demand policy. The field of healthy city construction is made up of five major areas of healthy Chinese construction. These include health services, the health environment, the health culture, the health society, and the healthy population. The y-axis represents the healthy city construction field, which creates a two-dimensional analysis framework (see Fig. 1).

Fig. 1
figure 1

Two-dimensional analysis framework of healthy city construction in China

X dimension — policy instrument dimension

A policy instrument is merely a way to achieve a particular goal that the government has set itself [46]. Currently, the classifications by Zegveld and Rothwell are the most commonly used. The categorization of the policy instruments was conducted into three distinct types: environmental, supply-based, and demand-based. The classification instrument has been rendered more clearly defined and operationalized [47]. Consequently, this instrument was selected as the X-axis in the two-dimensional analysis framework used in this research. Supply-based policy instruments primarily involve national support for developing healthy cities through funding, expertise, and technology. This constitutes the primary focus of policies that promote the development of healthy cities. In contrast, environmental policy instruments promote the development of healthy cities by establishing a conducive environment through focused planning, regulatory measures, financial assistance, and other means. In contrast, demand-driven policy tools are designed to promote the growth of healthy cities and expand opportunities for this progress through market stimulation, government procurement, and service outsourcing. Table 2 provides a detailed list of policy instruments and their definitions.

Table 2 Classification and meaning of policy tools for healthy city construction in China

Y dimension — healthy city building areas

The WHO has issued recommendations for healthy cities, calling for establishing supportive environments conducive to health. This involves improving the quality of life of the population. They ensure that the basic sanitary needs of the population are met. Improve access to sanitation services. Healthy city construction aims to gradually move toward a pattern of urban development that is economically prosperous, socially cohesive, environmentally clean and beautiful, culturally rich, safe, happy, and livable [36, 48]. The concept of “healthy city policies” is multifaceted, encompassing a wide array of social, economic, spatial, ecological, infrastructure, and other urban systems, each with its own intricate policy content. To understand the intricacies of healthy city policy instruments, it is imperative to examine primary evaluation indicators. These indicators were formally incorporated into the “National Healthy City Evaluation Indicator System” (NHCEIS) by the Patriotic Public Health Commission of China in 2018. This paper introduces a Y-dimensional healthy city construction field system. A systematic organization of healthy city policies into five distinct subsystems is imperative: a healthy environment, a healthy society, health services, healthy people, and a healthy culture.

According to previous research [49], unidimensional policy instruments can reflect primary methods and approaches; however, they must also fully demonstrate policy objectives and operational characteristics. This assertion is supported by research findings from experts and scholars on healthy cities, both domestically and internationally [22, 50, 51]. This paper establishes a two-dimensional analytical framework of “X dimension X (policy instruments) - dimension Y (healthy city construction field)” to examine policy documents related to healthy cities. The research and policy texts of the experts are combined to build this framework (see Fig. 1).

Research methodology and policy text coding

NVivo is a text content analysis software. The term “content analysis” is used in the scientific community to describe a method for examining the essence of a phenomenon through the lens of that phenomenon. The proposed method allows us to reproduce the content of a policy text while extrapolating the results. The 13 policy texts related to healthy cities in China were coded according to the “policy number (Title 1–Title 2). The principle of “non-disaggregation” determines the smallest unit that describes the object of measurement in the content analysis method. This principle ensures the completeness of the meaning. A paragraph that expresses one level of meaning is used as the unit of analysis. When a passage contains multiple layers of meaning that can be divided into multiple sentences, the sentence serves as the unit of analysis [52, 53]. For example, 13-4-5 denotes that the thirteenth policy document is a “Circular of the General Office of the Zibo Municipal People’s Government issuing implementation opinions on building healthy cities and healthy villages and towns.” This chapter contains 246 units of analysis of policy content in the fifth paragraph under the fourth-level heading. To establish distinct classifications for policy instruments and areas related to the creation of healthy cities, we evaluate each analytical unit in the original text using contextual analysis. The units are then sorted into categories based on their specific semantics. Finally, the use of policy instruments to promote the development of healthy cities is exemplified through quantitative data. To ensure the credibility of the coding, two researchers independently coded the data, and a final consistency test was performed on the coding results. The test yielded a kappa coefficient of 0.905, indicating high coding consistency. Due to space constraints, only some coding results are shown (see Table 3).

Table 3 Code table for Chinese healthy city construction policy

Results

X dimension: basic information on policy instruments

Based on the analysis of the content of the Healthy Cities policy, the unit coding form, categorization, and generalization statistics were used to derive the results with respect to the use of policy instruments (see Table 4). Current planning policies for the construction of Healthy China fully utilize supply-based, environment-based, and demand-based policies, with a frequency of use of 62.9%, 26.5%, and 10.6%, respectively. These three policy instruments exhibit significant differences in their frequency of use, with supply-based policies being used more frequently than demand-based policies.

Table 4 Distribution of basic policy tools in Chinese healthy city construction policy texts

In terms of specific content, among the supply-based policy instruments, in addition to the “land support” policy instrument, the other five policy instruments, including H.R. development, ICT, public services, infrastructure, and capital investment, have all been implemented. Of the 155 policy instruments in the content analysis module, 110 (70.9%) are public service instruments and 27 (17.4%) are infrastructure instruments. Information technology and financial investments each account for 5% of the GDP, and human resource development represents 3%. This suggests that in its supply-based policy of healthy city construction, the government places great importance on public services and infrastructure development. To some extent, neglecting policy instruments such as “land support” and “human resource development” in supply-based policies can significantly limit the level and quality of healthy city construction.

Financial support and tax incentives are underutilized among the five environmental policy instruments, whereas legal management, target planning, and strategic measures are well used. Of the 65 policy content analysis units for this type of policy, strategic measures accounted for 34 (52.3%), targeted planning for 18 (27.7%), and legal control for 13 (20%). In the current initiatives that promote healthy cities in China, there is a greater emphasis on strategic measures, target planning, and legal control instruments. In contrast, financial support and tax incentive policy instruments are being overlooked.

Of the six specific instrumental approaches to demand-based policies, government procurement, outsourcing of services, offshore institutions, and consumption incentives are not used. Two instruments—social participation and market incubation—have yet to be implemented. Of the 26 units of analysis of the content of the policy for these policies, 18 (69.2%) were related to social participation and eight (30.8%) were related to market formation. Among the types of supply-based, environmental, and demand-based policies, demand-based policies use fewer policy instruments, with only a small proportion adopted. Our healthy city policy does not focus on a demand-based policy design.

Y dimension: basic information about the healthy city construction field

Based on the coding table for the content analysis unit of the Healthy City Policy, the distribution of construction areas in the Healthy City Policy in China was classified, summarized, and statistically analyzed. Of the 246 units of analysis of policy content, 77 (31.3%) are for the construction of healthy environments, 34 (13.8%) for the construction of healthy societies, 53 (21.5%) for the construction of health services, 34 (13.8%) for the construction of healthy populations, and 48 (19.5%) for the culture of health construction, among the five main areas of healthy city building. Our country has focused on five specific areas for healthy city construction. Among these, the construction of a healthy environment accounted for slightly more than the other four specific areas.

X-Y dimension: policy instruments for healthy city construction: two-dimensional basics

Based on the analysis of policy instruments in dimension X and the inclusion of healthy urban areas in dimension Y, the results of the two-dimensional analysis of healthy urban policies X-Y are derived (see Table 5). Three policy instruments focus on the five broad areas of healthy city building. In the field of health service construction, 53 units were used for the analysis of policy content: 42 supply-based policies (79.2%), seven environmental policies (13.2%), and four demand-based policies (7.5%). In health services, policies have predominantly favored supply-based policies over environment- and demand-based policies. Thus, 77 units are available for the analysis of policy content in constructing a healthy environment. Among these, 40 (51.9%) are supply-based policies, 33 (42.9%) are environmental policies, and only four (5.2%) are demand-based policies. In the development of health culture, 48 policy analysis units are available. Among them, 26 (54.2%) are supply-based policies, 7 (14.9%) are environmental policies, and 15 (31.3%) are demand-based policies. In building a healthy society, 34 policy analysis units are available. Among them, 20 (58.8%) are supply-based policies, 14 (41.2%) are environmental policies, and no demand-based policies have been implemented. In the realm of promoting a healthy population, there are 34 policy analysis units: 27 supply-based policies (79.4%), 4 environment-based policies (11.8%), and 3 demand-based policies (8.8%).

Table 5 Results of an XY two-dimensional analysis of the Chinese healthy city construction policy texts

In general, three policy instruments were identified in the five areas of healthy city building: supply-based policies, environmental policies, and demand-based policies. Supply-based policies are used more frequently, whereas demand-based policies are less common.

Discussion

The frequency of using policy instruments varies significantly, and their structure is unbalanced in different areas of healthy city construction

The construction of healthy cities tends to favor supply-based policy instruments while underutilizing environment- and demand-based policy instruments. Categorical statistical analysis indicates that supply-based policy instruments with significant government involvement are primarily used in policies aimed at developing healthy cities. They proposed several policies and measures in five specific areas: a healthy environment, healthy society, health services, healthy people, and healthy culture. However, demand-driven policy tools that prioritize the autonomy of diverse social actors and integrate government authority with market forces have not yet been fully used. As a result, they cannot catalyze the enthusiasm of diverse participants and market dynamics [54]. Adoption of this policy tool depends on adherence to a set of rules. Advocating for the government’s position is crucial when implementing a new policy.

Furthermore, if the community accepts the policy, it will shift from a supply-oriented policy to an environmental- and demand-oriented one. From a policy implementation perspective, an ideal policy balances different types of policy. Therefore, each policy should complement the others to achieve the desired effect [55].

The emphasis on healthy city construction varies among urban areas

In the context of the World Health Organization’s (WHO) proposal to develop healthier cities, central and local governments at all levels have emphasized establishing healthy cities. They have issued relevant policy documents and action plans. However, the initiative and creativity of local governments in establishing policies for healthy cities could be more robust. Most local healthy city policies are suspected of being copied from those of the central government or higher-level state bodies. They must focus on establishing policies and administrative programs that are appropriate for developing healthy cities in their localities and tailored to their specific local realities. Many places adhere to policies established by higher-state organizations and view the formulation of policies as a political achievement, often neglecting to consider the impact of their implementation [56, 57].

A healthy environment is a crucial safeguard for human health. A statistical analysis of the frequency of use of policy instruments reveals that, at the national level, there is a focus on the construction and promotion of healthy environments as a priority area. This also reflects the fact that healthy cities represent an improved version of the concept of sanitary cities [28, 58]. However, the implementation of the Healthy City Program only partially depends on creating a healthy environment to achieve the goal of becoming a city with the highest level of health. It also requires comprehensive development in various fields.

Conclusions and recommendations

The WHO Healthy Cities program is based on two fundamental principles [59]. First, we consider the state of the city. Urbanization is a prevalent trend in the global development of human society. It is an essential requirement and inevitable outcome of advancing social productive forces. The development of cities has brought great convenience to human life and work, contributing to the rapid advancement of the global economy. About half of the world’s population lives in urbanized, artificial spaces. However, the rapid development of urban construction, especially in industrialized cities, has caused numerous social, health, and ecological problems. Social problems such as high population density, traffic congestion, housing constraints, unsanitary drinking water and food supplies, increasingly polluted ecosystems, and violence are emerging as significant threats to human health. The second idea concerns a healthy city. Cities are not just economic entities that seek efficiency in economic growth; they should also be ideal environments that improve human health. Cities should be considered organisms that live, breathe, grow, and change. This is a new requirement for the existence and development of cities in today’s world.

“Health” in its narrow constructive meaning refers only to an individual’s physical well-being. Based on the two pillars of the Healthy City Program and the World Health Organization’s 1984 description of the 11 characteristics of a healthy city, as well as the requirements of the 10 criteria for a healthy city outlined in 1996, the concept of “health” of a healthy city is broad. A healthy city is an integrated whole that includes healthy people, the environment, and society [60, 61]. China emphasizes that the construction of a healthy China should uphold the concept of “big health,” implement the strategy of “integrating health into all policies,” adhere to the principle of “building and sharing”, and bring into play the responsibilities of the government, departments, society, and individuals to address health issues in urbanization jointly. Therefore, the construction of a healthy city can be categorized into five major areas: a healthy environment, a healthy population, a healthy society, a healthy culture, and health services.

A combination of supply-based, environment-based and demand-based policies should be integrated to promote the construction of healthy cities. Different policy instruments can be used to coordinate the promotion of healthy local cities while considering local circumstances. Therefore, the construction of healthy cities in China should be improved in the following ways:

Quickly adapt the proportion of policy instruments

The construction of healthy cities is a policy implementation process that involves all levels of governance. At the initial stage of construction, due to the limited hardware infrastructure and the low awareness of all social participants, it is necessary to implement top-down supply-based policy instruments. However, building a healthy city requires a bottom-up process of policy implementation, and more than relying on government agencies. The construction of a healthy city requires the collective participation and promotion of all individuals because of the presence of various social entities [62]. If governments adopt coercive policies over a long period, this often leads to a marginal decrease in effectiveness and more severe side effects. Each policy instrument has its characteristics. Governments should pay attention to all three types of policy instruments and should not neglect the selection of demand-based policy instruments. For the public, demand-based policy instruments can serve as a guide to mobilize public participation [63,64,65].

Apply policy instruments holistically and multidisciplinary

The Chinese government has always emphasized the importance of environmental sanitation and governance. To effectively address public health concerns and ensure adequate sanitary conditions, China introduced a comprehensive health campaign in 1953. The government has led this patriotic effort. Coordinated with all sectors and involved the entire society. During the past 70 years, the patriotic health campaign has focused on improving environmental sanitation, increasing sanitary latrine coverage, providing safe drinking water, and improving the population’s health literacy. The patriotic health campaign effectively controlled the prevalence of infectious diseases and improved public health. Building a healthy city is a crucial aspect of a healthy China, a key element in the promotion of the development of new urbanization, and a significant platform for the patriotic health campaign in the modern era [66, 67]. Developing a healthy city involves a range of public policies from various sectors and is divided into multiple phases. This process requires the comprehensive and interdisciplinary use of policy tools and the coordination of different social actors. The construction of Healthy China is gradually changing from emphasizing environmental health management to pursuing comprehensive health promotion. It has moved from the early days when the construction of a single place-based health environment was the main focus to a pattern of integrated social health management across the entire spectrum of a healthy environment, healthy society, health services, healthy people, and healthy culture [68,69,70].

Policies are localized and focused

Various regions of China are promoting the development of a healthy China in response to the leadership of the central government. However, the foundation for building healthy cities varies by location and environment. Local governments should tailor their approaches to local conditions to prevent redundant policies. However, the existing foundations and environments for healthy cities vary from one place to another. Local governments should customize their policies to local conditions to avoid duplicative policies. Local governments should choose between supply-based, environmental-based, and demand-based policies to prioritize the five areas of healthy cities. Although the central government emphasizes supply-based policies, it prioritizing environmental policies and developing demand-based policies at the local level. At the same time, it is appropriate to adjust the use of specific policy instruments depending on the policy type. For example, supply-based policy instruments should strengthen support for talent training, land assistance, and information technology. Demand-based policy instruments actively pursue government procurement support, outsourcing services, establishing offshore institutions, providing consumption incentives, and promoting social participation. This encourages the formation of synergies to build healthy cities [7172].

This study has shortcomings that require further investigation. First, the policy tools were categorized according to the software requirements of the coding units to ensure accuracy and objectivity. However, the content and comprehension of the coding must be corrected, which may lead to inaccuracies. Whether perfectly described policy suggestions necessarily enhance policy efficiency remains to be seen. This requires further verification, which should have been included in this topic.

Data availability

Data is provided within the manuscript or supplementary information files.

Abbreviations

CCCPC:

Central Committee of the Communist Party of China

HCC:

Healthy City Project

HCCCN:

Healthy Cities Collaborating Center Network

HCCP:

Healthy Cities Construction Program

HCS:

Healthy China Strategy

NHCEIS:

National Healthy City Evaluation Indicator System

NHFPCC:

National Health and Family Planning Commission of China

PHC:

Patriotic Health Campaign

PPHC:

Patriotic Public Health Commission of China

SARS:

Severe Acute Respiratory Syndrome

WHO:

World Health Organization

References

  1. Sepe M. Contemporary approaches to healthy and livable public spaces: proximity, flexibility, and diversification. Urban Des Int. 2025.

  2. Borges J, Gallo E, Teixeira S. Transforming cities into sustainable and healthy territories starts with the culture of water: learning from traditional peoples and communities of the Carapitanga river basin. Front Env Sci-Switz. 2024;12.

  3. James J. Smoking, information, and education: the Royal College of Physicians and the new public health movement. J Policy Anal Manag. 2024;43(2):446–71.

    Article  Google Scholar 

  4. Young QD. Health-care reform - a new public-health movement. Am J Public Health. 1993;83(7):945–6.

    Article  Google Scholar 

  5. Watson M, Neil K. Positive health promotion: the Ottawa charter approach. Perspect Public Heal. 2025;145(1):11–3.

    Article  CAS  Google Scholar 

  6. Wang YL, Hsieh HM. Using the Ottawa charter for implement healthy eating programs in Taiwan’s hospital. Ann Nutr Metab. 2023;79:807.

    Google Scholar 

  7. Fenton K. Better health for all: public health and general practice working together. Brit J Gen Pract. 2025;75(751):55–6.

    Article  Google Scholar 

  8. Gore MN, Mallya SD. Health for all in India: a vision made possible through integrated public health and community medicine. Clin Epidemiol Glob. 2024:30.

  9. Abbasi K. Better health for vulnerable groups, better health for all. J Roy Soc Med. 2024;117(10):327.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Huntington MK. Global health for all. Fam Med. 2024;56(7):399–400.

    Article  PubMed Central  Google Scholar 

  11. Sibille K, Mickle A, Garvan C, Mohamed B, Hill C, Keil A. Advancing health disparities research and improving health for all. BMJ-British Medical Journal. 2024:385.

  12. Ritsatakis A, Ostergren P, Webster P. Tackling the social determinants of inequalities in health during phase V of the healthy cities project in Europe. Health Promot Int. 2015;30:i45–53.

    Article  PubMed  Google Scholar 

  13. Werna E, Harpham T. The implementation of the healthy cities project in developing countries: lessons from Chittagong. Habitat Int. 1996;20(2):221–8.

    Article  CAS  PubMed  Google Scholar 

  14. Barton H. Healthy urban planning: the anatomy of a WHO healthy cities project. Incentives, regulations and plans: the role of states and nation-states in smart growth planning. 2007:193–208.

  15. Stark W. Empowerment and social-change - health promotion within, the healthy cities project of WHO - steps toward a participative prevention program. Improving Children’s Lives. 1992;14:167–76.

    Google Scholar 

  16. Green G, Price C, Lipp A, Priestley R. Partnership structures in the WHO European healthy cities project. Health Promot Int. 2009;24:37–44.

    Article  Google Scholar 

  17. Kegler MC, Twiss JM, Look V. Assessing community change at multiple levels: the genesis of an evaluation framework for the California healthy cities project. Health Educ Behav. 2000;27(6):760–79.

    Article  CAS  PubMed  Google Scholar 

  18. Tsouros AD. The who healthy cities project - state-of-the-art and future-plans. Health Promot Int. 1995;10(2):133–41.

    Article  Google Scholar 

  19. Ashton J. The healthy cities project - a challenge for health-education. Health Educ Q. 1991;18(1):39–48.

    Article  Google Scholar 

  20. Vardoulakis S, Kinney P. Grand challenges in sustainable cities and health. Front Sustain Cities. 2019:1.

  21. Aliyu AA, Amadu L. Urbanization, cities, and health: the challenges to Nigeria - a review. Ann Afr Med. 2017;16(4):149–58.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Chakraborty B, Dey P. Assessing the role of urban reform policy in fostering healthy cities: a discourse on Jawaharlal Nehru National urban renewal mission of India. Discover Public Health. 2025;22(1).

  23. Boujari P, Ghamar S, Nasirian M, Ghapanchian F, Khajavi M, Qasemi A, Bahari M, Delavar Y, Garrousi H. A scoping review of urban design and planning studies on the Covid-19 pandemic and elements of the built environment. Tema. 2024;17(2).

  24. Tan X. The study of the travelers’ ecological appeal in the innovation of folk tourism product. Proceedings of the 2015 International Conference on Education Technology, Management and Humanities Science (ETMHS 2015). 2015;27:788–792.

  25. Gu X, Zhu L, Liu X. Examining the impact of urban environment on healthy vitality of outdoor running based on street view imagery and urban big data. J Geogr Sci. 2025;35(3):641–63.

    Article  Google Scholar 

  26. Yang Y, Wu Y, Jiao H. Assessing urban park equity in China through supply and demand balance: a case study of Wuhan City. China Sustainability-Basel. 2025;17(5).

  27. Hao Y, Shen Z, Ma J, Li J, Yang M. Research on the spatial network connection characteristics and influencing factors of Chengdu-Chongqing urban agglomeration from the perspective of flow space. Land-Basel. 2025;14(1).

  28. Liu N, Wang Z, Li Z. The impact of the healthy cities pilot policy on mental health and its inequalities among urban middle-aged and older adults. Cities. 2025;158.

  29. Chen Z, Li S, Liu C. Challenges and potentials: environmental assessment of particulate matter in spaces under highway viaducts. Atmosphere-Basel. 2024;15(11).

  30. Yang M, Gong S. Geographical characteristics and influencing factors of the health level of older adults in the Yangtze river economic belt, China, from 2010 to 2020. PLoS One. 2024;19(9).

  31. Li Y, Tang H. Health-oriented evaluation and optimization of urban square space elderly suitability: a case study of Yiyang City center. Buildings-Basel. 2024;14(8).

  32. Huang H, Huang S, He S, Lu Y, Deng S. Healthy city evaluation based on factor analysis- taking cities in the Guangxi Zhuang autonomous region as an example. PLoS One. 2024;19(7).

  33. Chu J, Zhong A, Zhang W. Characteristics and problems of smart city construction above the prefecture level in China: an exploratory study. J Urban Plan Dev. 2024;150(2).

  34. Xie Y, Xie E. Intergenerational transmission of opportunity inequality in the context of the healthy China initiative. Soc Indic Res. 2025.

  35. Zhu X, Zhang Y, Zhu Y, Guo Y, Zhang Y, Wen B. Realization path and connotation of the healthy China strategy: macroscopic perspective of dietary structure and the entry of individual health consciousness. BMC Public Health. 2024;24(1).

  36. Ning C, Pei H, Huang Y, Li S, Shao Y. Does the healthy China 2030 policy improve People’s health?? Empirical evidence based on the difference-in-differences approach. Risk Manag Healthc P. 2024;17:65–77.

    Google Scholar 

  37. Wang H, Ye Q, Zhang H, Sun X, Li T. Prevention and treatment of pneumoconiosis in the context of healthy China 2030. CHINA CDC Wkly. 2023;5(41):927–32.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Vogeler CSS, van den Dool A, Chen M. Programmatic action in Chinese health policy-the making and design of healthy China 2030. Rev Policy Res. 2023;40(4):534–52.

    Article  Google Scholar 

  39. Lin X, Burnett RT, Xi J, Bai J, Xiang Y, Tian T, Li Z, Chen S, Jiang J, Hu W et al. Health impact assessment on life expectancy gains ascribed to particulate matter reduction. NPJ Clim Atmos Sci. 2025;8(1).

  40. Wu J, Dai Q, Song S. Optimizing benmap health impact assessment with meteorological factor-driven machine learning models. Sci Total Environ. 2024;949.

  41. Chen L, Zhang L, Xu X. Health behavior and medical insurance under the healthy China strategy: a moral hazard perspective. Front Public Health. 2024;12.

  42. Zhang NN. Overview of the development of China’s sports fitness and leisure industry from the perspective of. Healthy China VOP ISTORII. 2023;2(2):280–7.

    Google Scholar 

  43. Yan X, Han Z, Ye P, Yeh AG, Xu X, Lee AWM, Cheung KMC, Gong P, He S. Governing cross-border healthcare in Mainland China: a scoping review of national policies from 2002 to 2022. Lancet Reg Health-W. 2024;45:13.

  44. Zhao R, Huo M, Tan M, Wang L, Liu Q, Li J, Wang R, Li H. Enhancing older care services: a comprehensive internet plus community home indicator system. BMC Public Health. 2024;24(1).

  45. Rothwell R, Zegveld W. Possibilities for innovation in small and medium-sized manufacturing firms (SMFS). IEE Proceedings-A-Science Measurement and Technology. 1980;127(4):267–271.

  46. Huan X, Shan J, Han L, Song H. Research on the efficacy and effect assessment of deep-sea aquaculture policies in China: quantitative analysis of policy texts based on the period 2004–2022. Mar Policy. 2024;160:9.

    Article  Google Scholar 

  47. Hong J, Wang L, Gu J, Li Y. Green recovery in the wake of public health emergencies: policy instruments and their effects in China. J Environ Manage. 2024;354:11.

    Article  Google Scholar 

  48. Wang Z, Tan B, Yi B. A Study on the optimization and improvement of the construction of the campus football development model by a factor analysis method under the background of healthy China. J Environ Public Hea. 2022;2022:3260571.

  49. Han Z, Xia T, Xi Y, Li Y. Healthy cities, a comprehensive dataset for environmental determinants of health in England cities. Sci Data. 2023;10(1):13.

    Article  Google Scholar 

  50. Yin S, Chen WY, Liu C. Urban forests as a strategy for transforming towards healthy cities. Urban for Urban Gree. 2023;81:5.

  51. Zheng J, Lv W, Shen J, Sun M. Study on the impact of the healthy cities pilot policy on industrial structure upgrading: Quasi-experimental evidence from China. Sustainability-Basel. 2022;14(20):18.

    Google Scholar 

  52. Su B, Wu Y, Yihao Z, Chen C, Panliang Z, Zheng X. The effect of equalization of public health services on the health China’s migrant population: evidence from 2018 China migrants dynamic survey. Front Public Health. 2022;10:1043072.

    Article  PubMed  Google Scholar 

  53. Guo Y, Huang Y. Realising equity in maternal health: China’s successes and challenges. Lancet. 2019;393(10168):202–4.

    Article  PubMed  Google Scholar 

  54. Yan D, Wu S, Zhou S, Li F, Wang Y. Healthy city development for Chinese cities under dramatic imbalance: evidence from 258 cities. Sustain Cities Soc. 2021;74:11.

    Article  Google Scholar 

  55. Guo Z, Zhang X. Has the healthy city pilot policy improved urban air quality in China? Evidence from a quasi-natural experiment. Energ Econ. 2024;129:107260.

    Article  Google Scholar 

  56. Yang T, Shu Y, Zhang S, Wang H, Zhu J, Wang F. Impacts of end-use electrification on air quality and CO2 emissions in China’s northern cities in 2030. Energy. 2023;278:13.

  57. Feng Z, Lin Y, Wu B, Zhuang X, Glinskaya E. China’s ambitious policy experiment with social long-term care insurance: promises, challenges, and prospects. J Aging Soc Policy. 2023;35(5):705–21.

    Article  PubMed  Google Scholar 

  58. Arefi M, Nasser N. Health, city, and urban design. Urban Des Int. 2021;26(2):115–6.

    Article  Google Scholar 

  59. Aparicio-Martinez P, Martinez-Jimenez MP, Perea-Moreno A. Health environment and sustainable development. Int J Environ Res Public Health. 2022;19(13):5.

  60. Ziegler CS, Roegner AF, Aura CM, Fiorella KJ. Social constructions of health-environment risks: a comparison of fishing community and expert perceptions of cyanobacterial blooms. Soc Natur Resour. 2023;36(2):127–48.

    Google Scholar 

  61. Ngangue P, Robert K, Apho LB, Traore F, Philibert L, Vezina M, Bationo N. Evaluating the effects of an intervention to improve the health environment for mothers and children in health centres (BECEYA) in Mali: a qualitative study. Pan Afr Med J. 2023;44:138.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Zhu C. Demand for direct-to-consumer genetic testing services in China and its implications for precision public health - China, 2021. CHINA CDC Wkly. 2022;4(32):715–9.

    PubMed  PubMed Central  Google Scholar 

  63. Mao W, Zhong Y. The influence of demand-based policy instruments on urban innovation quality-evidence from 269 cities in China. Sustainability-Basel. 2024;16(7):16.

    Google Scholar 

  64. Mao W, Zhong Y. The influence of demand-based policy instruments on urban innovation quality-evidence from 269 cities in China. Sustainability-Basel. 2024;16(7).

  65. Tian X, Liu J, Mai Q. Exploring the impact mechanisms of the green innovation policy instruments system: a system dynamics approach. Int J Environ Sci Te. 2024.

  66. Wang Y, Liu M, Wang S, Cui X, Hao L, Gen H. Assessing the impact of governance and health expenditures on carbon emissions in China: role of environmental regulation. Front Public Health. 2022;10:16.

    CAS  Google Scholar 

  67. Huang Y, Li S. Can marketization of environmental governance improve public Health?-Empirical analysis based on the emission trading system. Int J Environ Res Public Health. 2022;19(23):15.

  68. Suman AB. The role of information in multilateral governance of environmental health risk: lessons from the Equatorial Asian haze case. J Risk Res. 2022;25(8):959–75.

    Article  Google Scholar 

  69. Fan W, Yang M, Shao Y, Shen D, Ao L, Chen Z. Integrated social development on analyzing the distribution, risk and source apportionment of antibiotics pollution in mountainous rivers. Water Res X. 2025;28.

  70. Elrahman OA. Governance of environmental health and transportation decisions: the case of new York City. Case Stud Transp Pol. 2019;7(2):463–9.

  71. Liu L, Huang G, Baetz B, Zhang K. Environmentally-extended input-output simulation for analyzing production-based and consumption-based industrial greenhouse gas mitigation policies. Appl Energ. 2018;232:69–78.

    Article  Google Scholar 

  72. Wang K, Wang J, Hubacek K, Mi Z, Wei Y. A cost-benefit analysis of the environmental taxation policy in China: a frontier analysis-based environmentally extended input-output optimization method. J Ind Ecol. 2020;24(3):564–76.

    Article  Google Scholar 

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Acknowledgements

The paper was written due to focused discussions among team members at the Shandong University Weihai Legislative Research Center.

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This work was supported by the Shandong Provincial Philosophy and Social Science Planning Office (24CFXJ06).

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Q.W. and Z.Z. wrote the main manuscript text and L.H. prepared all tables and figures. All authors reviewed the manuscript.

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Wang, Q., Zhou, Z. & Huang, L. Improvement of China’s healthy city construction policies from the perspective of policy instruments. BMC Public Health 25, 1958 (2025). https://doi.org/10.1186/s12889-025-23111-6

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