This study chose policy documents about the development of healthy cities since the launch of the “Healthy China 2020 Strategy,” introduced by the former Ministry of Health in 2008, as samples. The investigation was performed from January 1, 2008, to September 1, 2023, utilizing the terms “healthy cities” and “healthy towns.” The search duration extended from January 1, 2008, to September 1, 2023. The terms “healthy cities” and “healthy towns” were employed to examine the official websites of Chinese administrative entities at various levels, including the State Council, the Health Commission, provincial governments, and municipal governments with districts, as well as the Database of Laws and Regulations of China. This research develops inclusion and exclusion criteria to assure the accuracy and representativeness of the policy wording.

The classification of policy instruments developed by Zegveld and Rothwell served as the basis for the construction of a framework for the analysis of policy documents (14) and the two dimensions of healthy city construction. What are the reasons for selecting this specific type of policy classification and the five dimensions of healthy city construction? We contend that the construction of a healthy city should prioritize the enhancement of the natural and social-ecological environment, the improvement of public health, the overall health level of the city, the creation of an attractive and suitable environment for human settlements, and the enhancement of the comprehensive development quality and sustainable development capability of cities. This will facilitate the potential for healthy cities to develop further and become more conducive to entrepreneurship, as well as foster a more harmonious and dynamic economic, social, and ecological environment. Furthermore, this will lead to an improvement in the quality of health and quality of life, enabling the public to enjoy a better way of life as a result of improved health. Accordingly, the aforementioned classification of healthy urban construction policy is compatible with three distinct types of policy: demand-based, supply-based, and environmental-based. Additionally, Chinese scholars concur that the foundation of healthy city construction is comprised of five key elements: health services, a healthy environment, a healthy culture, a healthy society, and healthy people. Furthermore, the “Outline for the Implementation of the Construction of a Healthy China,” as issued by the Chinese government, also encompasses the aforementioned five areas. These form the theoretical basis and research framework of the subject.

There are three categories into which policy instruments can be classified: environmental, supply, and demand policy. The five main areas of healthy Chinese construction, which include health services, the health environment, the health culture, the health society, and the health population, define the field of healthy city construction. The y-axis represents the realm of healthy city construction, which establishes a two-dimensional analysis framework (see Figure 1).

NVivo is a software for text content analysis. The phrase “content analysis” refers to a methodological approach employed in the scientific community to investigate the fundamental nature of a phenomenon by analyzing it via its framework. The proposed method enables the reproduction of policy text content while extrapolating the outcomes. The thirteen policy documents about healthy cities in China were categorized by “policy number (Title 1–Title 2).” The idea of “non-disaggregation” establishes the minimal unit that characterizes the subject of measurement in the content analysis methodology. This concept guarantees the comprehensiveness of the meaning. A paragraph conveying a singular meaning serves as the analytical unit. In a text with several levels of meaning that may be segmented into several sentences, the sentence functions as the analytical unit (22, 23). The designation 13–4–5 indicates that the thirteenth policy document is titled “Circular of the General Office of the Shanghai Municipal People’s Government Transmitting the Opinions of the Municipal Health Commission and 14 Other Departments on Strengthening Community Health Services in the City to Promote the Development of Healthy Cities.” This chapter comprises 246 units of policy content analysis in the fifth paragraph under the fourth-level topic. We assess each analytical unit in the original text using contextual analysis to generate clear classifications for policy instruments and domains associated with the development of healthy cities. The units are thereafter categorized according to their distinct meanings. The application of policy instruments to foster the advancement of healthy cities is illustrated by quantitative data. To validate the coding’s reliability, two researchers independently coded the data, followed by a final consistency assessment of the coding outcomes. The test produced a kappa coefficient of 0.905, signifying a substantial level of consistency in the coding outcomes. Owing to spatial limitations, only a selection of coding results is presented (see Table 3).

The presentation rule of coding: Taking the title of the policy text itself as the reference basis, according to the progressive relations of the first-level heading, the second-level heading, and the third-level heading, the coding classification is made for searching. Taking the above-mentioned measure as an example, it is located in the second secondary title in the third level title in the first document and is coded as 1–3–2. When coding, as far as possible, one paragraph is a code, but if there are several equally important different policy tools in a paragraph, it is divided by sentence.

The results of the utilization of policy instruments were derived from the categorization and generalization data based on the Healthy Cities policy content analysis unit coding form (see Table 4). The existing planning policies for the Healthy China initiative predominantly employ supply-based, environment-based, and demand-based strategies, with utilization rates of 60.5, 29.1, and 10.4%, respectively. The three types of policy instruments demonstrate notable disparities in their utilization frequency, with supply-based policies being employed more frequently than demand-based ones.

Regarding specific content, alongside the “land support” policy instrument, the remaining five supply-based policy instruments—personnel training, information technology, public services, infrastructure, and capital investment—have all been executed. Among the 163 policy instruments analyzed, 115 (70.6%) are classified as public service instruments, while 25 (15.3%) are categorized as infrastructure instruments. Information technology and financial inputs accounted for 6 and 4%, respectively, while human resource development comprises 3.6%. This indicates that in the supply-oriented policy for healthy city growth, the government prioritizes public services and infrastructure enhancement. The oversight of policy tools like “land support” and “personnel training” in supply-oriented policies can considerably restrict the quality and extent of healthy city growth.

Of the five environmental policy instruments, financial support and tax incentives are underutilized, whereas regulatory control, goal programming, and strategic measures are effectively employed. Among the 68 units analyzed for policy content, strategic measures comprised 37 (54.4%), goal programming constituted 18 (26.5%), and Regulatory control represented 13 (19.1%). Current endeavors to promote healthy cities in China prioritize strategic strategies, targeted planning, and legal regulatory instruments while neglecting financial support and tax incentive policies.

Among the six distinct instrumental methods of demand-based strategies, government procurement, service outsourcing, overseas institutions, and encouraging consumption are not employed. Only two instruments have been executed: social participation and market incubation. Among the 27 units of policy content analysis, 21 (77.8%) pertained to social participation, whereas 6 (22.2%) were associated with market formation. Among the supply-based, environmental, and demand-based policy categories, demand-based policies employ fewer instruments, with only a limited percentage being implemented. Our healthy city policy does not prioritize a demand-driven policy framework.

The coding table for the content analysis unit of the Healthy City Policy facilitated the classification, summarization, and statistical analysis of the distribution of construction areas within China’s Healthy City Policy. Out of 253 policy content analysis units, 60 (23.7%) pertain to healthy environment construction, 31 (12.3%) to healthy society construction, 99 (39.1%) to health services construction, 33 (13%) to healthy population construction, and 30 (11.9%) to the culture of health construction, across the five principal domains of healthy city development. Our country has concentrated on five distinct domains of healthy city development. The establishment of a healthy environment constituted a marginally greater proportion than the other four specialized domains.

The results of the two-dimensional study of healthy city policies X-Y are generated from the examination of policy instruments in the X dimension and the incorporation of healthy city building areas in the Y dimension (see Table 5). Three policy tools concentrate on each of the five overarching domains of healthy city development. In health service construction, 99 units were utilized for policy content analysis: 57 supply-oriented policies (57.6%), 23 environmental policies (23.2%), and 19 demand-oriented policies (19.2%). In health care, policymakers have primarily supported supply-oriented approaches over those based on environmental and demand considerations. 60 units are offered for the analysis of policy content in the context of creating a healthy environment. Of them, 31 (51.7%) are supply-oriented policies, whereas 29 (48.3%) are environmental policies. 30 policy analysis units are available for the creation of health culture. Of these, 25 (83.3%) are supply-oriented policies, 3 (10%) are environmental policies, and 2 (6.7%) are demand-oriented policies. There are 31 policy analysis units dedicated to fostering a healthy society. Of them, 19 (61.3%) are supply-oriented policies, 12 (38.7%) are environmental policies, and there are no demand-oriented policies adopted. Within the domain of public health promotion, there exist 33 policy analysis units: 31 supply-oriented policies (94%), 1 environment-oriented policy (3%), and 1 demand-oriented policy (3%).

In total, three policy instruments were recognized throughout the five domains of healthy city development: supply-side policies, environmental policies, and demand-side policies. Nonetheless, supply-oriented policies are employed more frequently, while demand-oriented policies are somewhat less prevalent.

The development of healthy cities typically prioritizes supply-oriented policy instruments, while inadequately employing environment- and demand-oriented policy instruments. Categorical statistical analysis reveals that supply-oriented policy instruments with substantial government engagement are predominantly employed in initiatives focused on cultivating healthy cities. They offered several policies and actions across five distinct domains: a healthy environment, a healthy society, health services, healthy individuals, and a healthy culture. Nevertheless, demand-driven policy instruments that emphasize the independence of various social agents and amalgamate governmental power with market dynamics have not been completely utilized. Consequently, they are unable to stimulate the passion of varied participants and market dynamics (24). The implementation of this policy instrument is contingent upon compliance with a certain set of regulations. Advocating for the government’s perspective is essential when implementing a new policy. Moreover, if the policy garners community acceptance, it will transition from a supply-centric approach to one that prioritizes environmental and demand considerations. From a policy implementation standpoint, an optimal policy achieves equilibrium among several policy types. Consequently, each policy must be formulated to enhance the others to guarantee the attainment of the intended outcome (25).

The World Health Organization (WHO) and governmental proposals for developing healthier cities have led to considerable emphasis from both central and local governments on the establishment of healthy urban environments. Relevant policy documents and action plans have been issued. The initiative and creativity of local governments in formulating policies for healthy cities are comparatively limited. Many local healthy city policies appear to be derived from the frameworks established by the central government or higher-level state entities. Their efforts have not prioritized the establishment of policies and administrative programs suitable for fostering healthy cities, tailored to the specific realities of their local contexts. Numerous entities comply with the directives established by higher-level authorities and perceive policy formulation as a political achievement, frequently overlooking the implications of its execution (26, 27).

An optimal environment is essential for the protection of human health. A statistical examination of the utilization of policy tools indicates that, at the national level, there is an emphasis on developing and advocating for healthy environments as a priority topic. This also indicates that healthy cities embody an enhanced iteration of the concept of sanitary cities (28, 29). Nevertheless, the Healthy City Program’s development is not only reliant on establishing a healthy environment to attain the objective of being the city with the greatest health standards. It necessitates extensive advancement across multiple domains.

The development of healthy cities is a policy execution process that encompasses all tiers of governance. During the preliminary phase of building, owing to inadequate hardware infrastructure and the limited knowledge among all social stakeholders, it is essential to employ top-down, supply-oriented policy instruments. Nonetheless, the establishment of a healthy city necessitates a grassroots policy implementation process, and dependence simply on governmental authorities is inadequate. The establishment of a healthy city necessitates the collaborative engagement and advocacy of all individuals due to the existence of various social entities (33). Prolonged use of coercive programs by governments frequently results in diminished efficacy and exacerbated adverse consequences. Every policy instrument possesses distinct properties. Governments must consider all three categories of policy instruments and should not overlook the selection of demand-oriented policy instruments. Demand-driven policy instruments can act as a framework for fostering public engagement (1, 34, 35).

The Chinese government has consistently underscored the significance of environmental cleanliness and management. In 1953, China launched a comprehensive health campaign to effectively tackle public health issues and guarantee sufficient hygienic conditions. The government has spearheaded this patriotic initiative. Collaborated with all sectors and engaged the entire community. In the last 70 years, the patriotic health campaign has concentrated on enhancing environmental cleanliness, expanding sanitary toilet access, ensuring safe drinking water, and improving health literacy among the populace. The patriotic health campaign successfully mitigated the prevalence of infectious diseases and enhanced public health. The establishment of a healthy city is essential for fostering a healthy China, a vital component in promoting new urbanization, and an important foundation for the contemporary patriotic health campaign (36, 37). The creation of a healthy city encompasses diverse public policies across numerous sectors and is segmented into several construction phases. This approach necessitates the extensive and multidisciplinary application of policy instruments and the collaboration of diverse social stakeholders. The development of Healthy China is progressively transitioning from a focus on environmental health management to an emphasis on holistic health promotion. The focus has transitioned from the initial emphasis on constructing a singular, localized health environment to a model of integrated social health management including the full spectrum of a healthy environment, society, health services, individuals, and culture (38–40).

Multiple regions in China are advancing the initiative for a healthy China in alignment with the central government’s guidance. The foundation for constructing healthy cities differs based on location and environment. Local governments should customize their strategies to local situations to avoid duplicating policies. Nonetheless, the current foundations and settings for healthy cities differ from one location to another. Local governments should tailor their programs to specific conditions to prevent redundancy. Local governments must select among supply-oriented, environmental, and demand-oriented strategies to prioritize the five domains of healthy cities. While the national government prioritizes supply-side policies, it is crucial to stress environmental policies and formulate demand-side strategies at the local level. Simultaneously, it is vital to modify the application of particular policy instruments based on the type of policy. Support for talent development, land assistance, and information technology can be enhanced through supply-oriented policy instruments. The demand-driven policy instruments aggressively seek government procurement assistance, outsourcing services, forming offshore entities, offering consumption incentives, and encouraging social engagement. This fosters the development of synergies for creating healthy cities (41–43).

The Chinese patriotic health movement originated in the 1980s and has demonstrated a favorable response to the World Health Organization’s Healthy City construction program since the beginning of this century. To illustrate, the city of Shanghai has augmented its investment in urban environmental construction, completed the construction of the urban park system, completed the tertiary hospital system, gradually popularized the family doctor system, and achieved a high degree of satisfaction with health services (44, 45). Furthermore, it has actively popularized health education, thereby realizing the Trinity of a Healthy City, healthy community, and healthy town (46). This provides an exemplar of healthy city construction activities. It is important to note that the efficacy of healthy city construction activities varies depending on the context. A comprehensive evaluation is essential to identify areas for improvement and to develop strategies to address these shortcomings (47, 48). Promoting the dissemination of health education, enhancing food safety supervision, strengthening public health emergency warning and prevention mechanisms, and improving the medical classification system are key areas for consideration (49). It is essential to advocate a problem-oriented approach and actively improve the policy tools and content of healthy cities, thereby further promoting the level and quality of our healthy city construction (50). This approach should be based on the local reality.

Building a healthy city, setting up a healthy city indicator system, and carrying out an evaluation of its effectiveness are important paths to promote the construction of a healthy city (51, 52). Since the promotion of the Healthy Cities Project, some scholars have begun to research the Healthy Cities Indicator System (53–55). In 2018, the National Office of the Patriotic Health Movement in China conducted research and developed the National Healthy Cities Evaluation Indicator System. This system was designed to align closely with the objectives and tasks outlined in China’s Healthy City construction initiative. It aims to guide cities in improving the natural environment, social environment, and health services, promoting the comprehensive popularization of healthy lifestyles, meeting the health needs of residents, and facilitating the coordinated development of city construction and people’s health. The indicator system consists of 5 first-level indicators, 20 s-level indicators, and 42 third-level indicators, which can objectively reflect the overall progress of the construction of healthy cities in different regions. The indicator system also gives the definition, calculation method, caliber range, source department, and other information of each indicator to ensure that the data collection of healthy city evaluation can be carried out by uniform standards. Level 1 indicators correspond to the five areas of “Healthy Environment,” “Healthy Society,” “Healthy Services,” “Healthy People” and “Healthy Culture,” “Healthy Environment,” “Healthy Society,” “Healthy Services,” “Healthy Population” and “Healthy Culture,” while the secondary and tertiary indicators focus on the main health problems and their influencing factors in the development of Chinese cities (52, 56). Since 2018, the National Patriotic Health Campaign Office has engaged the services of a third-party professional institution to conduct annual evaluations of all national health cities across the country. The evaluations entail the analysis and assessment of the progress of healthy city construction in each city, the identification of areas for improvement, the promotion of continuous quality improvement in the work of healthy city construction, and the advancement of the positive development of healthy city construction (50, 57).

At the same time, it is important to pay attention to policy synergies in the process of formulating and implementing public policies for the development of healthy cities that are constantly being followed up. Firstly, it is important to note that local Healthy City construction is based on the Healthy China 2030 Planning Outline and the central Healthy City policy, and is aligned with the central policy (58). Secondly, it is essential to recognize the potential for synergy among local healthy cities, which may face different specific situations, factors affecting healthy cities, and progress in the construction of healthy cities. The model cannot be replicated, but there is an opportunity to learn from each other’s advanced experiences, based on the local construction of healthy cities (59). Thirdly, there is a synergy between policy tools and policy content. The deployment of different policy instruments is associated with varying degrees of efficacy, and the timing of their utilization is crucial for optimizing the overall impact of policy implementation (8). Fourthly, the process of policy formulation should be aligned with the practical implementation of policies. Policies must evolve by the requirements of practice, while practice also informs the necessity for policy (60). The formulation of policy and the practice of policy should be developed in a coordinated manner to facilitate the comprehensive advancement of all areas and aspects of healthy city construction.

Of course, this study possesses limitations that necessitate additional inquiry. The classification of policy tool kinds was performed according to the software specifications of the coding unit to guarantee precision and impartiality. Nonetheless, the understanding of the content and coding may be erroneous. This could result in code mistakes. The impact of precisely articulated policy recommendations on policy efficiency remains ambiguous. This necessitates more verification, which was omitted from this subject.