Here, we firstly describe the context and development of PHM, and then the specific governance practices underpinning this policy are described and compared.
Background context to PHM
In 1949 the People’s Republic of China was established. China was economically undeveloped after a long period of war. Because the People’s Republic of China was established and the threat of war still existed, the development of national defenses was China’s priority. Poor health was the biggest challenge facing China in terms of strengthening the fighting capacity of the army. The life expectancy was 35 years old, with the greatest health challenges including a high prevalence of infectious diseases. Maternal mortality was 1500/100,000 and the infant mortality rate was 200/1000. In addition, health was regarded by the country’s leader as important to promote the country’s social and economic development. Consequently, in terms of public policies, public health was given the highest priority [21, 22]. In addition, the health system was poorly developed at that time: health facilities and human resources were scarce and unevenly distributed, mainly concentrated in the urban areas. There were only 1400 county hospitals in over 2200 counties nationwide. In rural areas, the density of hospital beds was 0.05 per 1000 population, with a few private facilities available (0.73 per 1000 population), and there was an acute shortage of medicines. There was less than one doctor (trained in western medicine) per 100,000 people, and these were largely concentrated in major coastal cities and provincial capitals [23,24,25].
Content and achievements of PHM
The aim of PHM was to control infectious diseases by improving environments, changing people’s health knowledge, and encouraging healthy behaviors by extensive social mobilization.
The content of this policy changed according to the public health problems in different periods. From 1952 to 1954, the policy was based on eradicating the media pests of infectious diseases, such as the plague, cholera, and typhoid; with compulsory immunization, water source protection; and encouraging the maintenance of a clean environment. From 1955 to 1967 the policy focused on eradicating the intermedium, changing those behaviors and social traditions that were detrimental to health, thereby improving the environment.
The Patriotic Health Movement was stopped during the Culture Revolution and restarted in 1979. The policy content since 1979 has been very comprehensive, covering nearly all public health management issues and health promotion actions, such as improving drinking water and toilets, upgrading the infrastructure and living facilities, environmental protection, health education, infectious disease control, etc.
In 1989, as a response to the WHO Healthy Cities Project, in big cities and regions, the China Health City (CHC) Project was started as an effort to strengthen the Patriotic Health Movement and to improve urban living conditions. The Patriotic Health Movement Committee is responsible for the daily management of the CHC project, and in order to win the CHC award, cities have to meet a list of environmental and health indicators .
No studies have used rigorous method to evaluate this comprehensive policy. However it has been broadly accepted that the Patriotic Health Movement has contributed greatly to quickly controlling rampant infectious diseases and effectively lowering morbidity. The statistics show that by the end of 1997, the water supply system had benefited 850 million people, 25.4% of excrement and urine was treated, which was double that of 1992. In the 1940s, schistosomiasis was widespread in 12 provinces, and more than 400 counties. With the efforts of PHM, schistosomiasis was eradicated in 1958 . It was reported that China eradicated smallpox 16 years ahead of other Asian and African countries.
One study evaluating the CHC project found that the CHC initiative was associated with increases in the proportion of treated urban domestic sewage (32%), and the proportion of treated urban domestic garbage (30%) . The health status of the population in China also improved although this was attributed to the comprehensive health system in addition to PHM: the mortality rate was 25 per 1000 in the 1950s which decreased to 6.57 per 1000 in the 1990s; the infant mortality rate decreased from 200 per 1000 to 31.4 per 1000 at the end of the last century; the average life expectancy increased from 35 in 1949 to 70 in 2000 .
Policy guidance and vision
Based on WHO’s framework of health system governance, the government should ensure that its policy aims are clear and of a high priority in terms of the country’s development, and it should also provide explicit guidance on how to plan and design the policy content .
The PHM was started in 1952 when China had just entered a period of peace after long-term war and devastation: the infrastructure had been destroyed and economic development was extremely slow. Deadly infectious and parasitic diseases were also very common. As discussed in the majority of studies, the PHM was regarded as a crucial policy for national security and development [21, 22].
Firstly, the explicit aim of this policy is to mitigate the risks of serious infectious disease outbreaks, which had led to a large number of deaths and loss of labor, thus holding back economic development . In addition, under the threat of the germ war (China government predicted the risk of other countries using germs attacking China at that time), the Chinese government regarded epidemic prevention and a clean environment as a strategy to combat this threat, which is commonly accepted among academics as the reason why China launched the PHM [21, 22, 28]. The planning and implementation of many actions highlighted the government’s commitment to this policy. At the national level, China’s Prime Minister took the role of director of the national patriotic health committee, and at the local level, the patriotic health committees were also directed by the top leader of the local government . PHM was also included in several national development plans, including “Twelve Years Health Work Plan” and “National Plan for Agricultural Development” in the 1950s [30, 31]. In addition, in order to identify the specific actions and provide a clear direction for local governments in the implementation of the policy, a series of documents were also issued by central government .
“The highest leader of the Communist Party in each area should directly lead the epidemic prevention campaign, and take actions against the germ war.” From “The Instructions on How to be a Strong Leader in the Epidemic Prevention Campaign” issued by Jiangxi Province Communist Party Committee .
In WHO governance framework, health policy with system design should build or adjust its delivery system of health services and organizational structure in order to respond to the implementation and aims of this policy. In addition, when the structure is built or adjusted, duplication and fragmentation should be avoided .
In order to implement the PHM, the first step of each government level was to establish the administration departments from the top to bottom levels. In mid-March 1952, the central government established a “central epidemic prevention committee” (changed to “patriotic health committee” in 1953) . At the end of March, local epidemic prevention committees were established in the level of provinces (the largest administrative geographical area in China) and municipality (the second largest). In the following months, each county, township and village (From the largest to smallest, the administrative levels in China are province, municipality, county, township and village in sequence.) all quickly established epidemic prevention administration departments. For example, In 1952, 433 administrative townships in Jinhua City, Zhejiang Province, all established epidemic prevention departments .
In order to mobilize all the population, different industries and organizations also established departments to organize this epidemic prevention work . Usually the committees at different levels were comprised of not only a health department, but also all the relevant departments based on the content of the PHM, which highlights how the management structure was designed in accordance with policy aims. For example, in 1952 in Hebei Province, the core PHM work included the prevention of epidemics, quarantine in ports, quarantine of entomophily, and epidemic status reports. Hebei province thus set up a committee, which included agriculture, health, education, transportation, and public security departments .
Regulation and management capacity
This governance function ensures the enforcement of the health policy, including the regulations and incentives used to guide the behaviors of different levels of government and the various actors involved .
The administrative system of China was very hierarchical at that time, and thus the highest administrative level usually forwarded the directives, regulations or work requirements to lower administrative levels [35, 36]. After the PHM directive in 1953  issued by the State Council, the first step was to establish an administrative and implementation system from the top down. The effectiveness of top-down directions or policy documents was stronger if the policy was endorsed by the highest level. For the PHM, the strong push from the highest leader, Mao Zedong, was an important driving force. Before the issue of the State Council’s directions, Mao Zedong even personally advocated “mobilizing all resources and populations, to pay attention to sanitation, to reduce the prevalence of infectious diseases and improve the health status, and to defeat the germ war”. (Literature Research Office of the CPC Central Committee 1989) .
Under this hierarchical administrative system, supervision and inspections from the top down, as a form of administration pressure, was the most common measure to ensure the enforcement of policies [39, 40]. For example, between April to September of 1952, Nanjing City established over 1000 inspection groups and conducted over 12,000 inspections, covering 2400 companies and 200,000 households. After inspections from the highest government level, the appraisals and ranking were usually based on performance: those performing well would be rewarded financially and recommended as representative successful cases [41,42,43].
Another kind of incentive to mobilize all the citizens and institutions to implement the PHM was to inspire their patriotic emotions. At first, the government simply explained the health situation, but without obtaining the desired results [14, 44,45,46]. From the beginning of 1952 the focus turned to inspiring patriotism and anti-war feeling by introducing the threat of a germ war and the importance of PHM in combating this threat . The incentive power of patriotism was effective since China had just experienced a long war, and because the population’s anti-war feeling was strong and this had inspired a high level of patriotism.
“All citizens are required to participate in epidemic prevention work, including cleaning work, eliminating flies, mosquitoes, delousing and fleas etc.; and the epidemic prevention work should be more emphasized in cities and vital transportation areas.” From a Directive issued by the State Council of the Central Government and People's Revolutionary Military Committee .
“Every committee at the village or township level should organize appraisals once a year and reward the well-performing organizations/families/individuals once a year, and provincial committees should organize appraisals and reward the well-performing cities/counties every two years.” From the Handbook for the Patriotic Health Movement issued by Hunan Province Patriotic Health Movement .
Accountability and transparency
This governance function aims to ensure that all the relevant actors are held publicly accountable.
In the PHM, several procedures were designed to ensure that the local government would be accountable for how effectively the PHM was implemented. Firstly, frequent inspections from higher administration levels were combined with critical reports of those that performed poorly . In addition, in some areas the performance of different districts or institutions were ranked and reported to the public by different kinds of media [41, 51]. As one documented case shows, during one inspection of the food industry’s sanitation conditions in Shenyang City in April of 1952, some stores with poor sanitation were broadcast to the public [47, 52].
“This measure applies to all health institutions, factories, mining sites, schools, troops, state-owned businesses, the food industry; all individuals etc. … The institutions who did not conduct the required work were warned... People were fined 0.5 yuan for spitting, and those leaving cigarettes burning in the street were fined 0.5 yuan … ” (From a report on the reward and punishment measures of the Beijing Patriotic Health Movement) .
Intelligence and oversight
A supportive governance system defined by WHO framework uses intelligence and evidence in policy generation, implementation and impact evaluation .
In the 1950s, the academic research and intelligence resources in China were not very well developed, and the design of PHM was conducted by central government based on limited experience of epidemic prevention. Central government thus just established the policy direction and various principals regarding the policy content . For example the total content of the government’s “Instructions on carrying out the Patriotic Health Movement in 1953”  consisted of fewer than 1000 words. This document did not propose detailed operational plans or guidelines, but just emphasized that every province should put forward a concrete local plan of the PHM before January 1953. A review of various provincial policy plans on local patriotic health work revealed more specific goals, tasks and supporting measures [49, 55], however documentation on how the local governments used the evidence or other intelligent sources to design the specific policy is not available .
In view of the importance of monitoring in relation to epidemic prevention, policymakers started to build data collection and reporting systems for epidemic diseases. For example in Hebei Province, the data collection platform was built by epidemic prevention committees the first of which was set up in 1952. Telephones and telegrams were used to report epidemic information and had to be reported at the provincial level within 24 h for a area on the plains, and 48 h for a mountainous area. The policy documents issued after 1955 reveal that a three-tier health delivery system was in operation, which started to take the responsibility for collecting information on epidemics. However, there are few documents showing how the information system really worked .
This governance function requires cooperation between the government sectors and external actors, jointly support the generation and implementation of public policies .
The PHM was a typical policy involving the cooperation between different sectors in China’s health system. The PHM work involved many sectors, such as health, the environment, and food and agriculture . From its start, the highest level decision makers realized that without the cooperation of multiple sectors, the aims of PHM would never be achieved. When patriotic health committees started to be established at every level, central government required that they be led by the highest leader in local government, and be comprised of each relevant government department director along with representatives of trade unions and other youth and women’s groups . For example in Shanghai, the mayor acted as the director of Shanghai’s patriotic health committee; associate mayors acted as associate directors; and department leaders of public security, civil administration, public work, financing, culture, education, health, federations of trade unions, women’s unions, students’ unions, and the association of industry and commerce also participated as committee members .
“In 1957, Shanxi Province issued “Notification about Implementing the Sudden Eradication Campaign against the Four Pests (rats, flies, mosquitoes, and sparrows) in Spring”, all the relevant departments, including the department of agriculture, health department, food department, communist youth league of the provincial Party committee, provincial trade union, and the provincial women’s union, worked together to implement the eradication activities.”