Mechanisms of the Chinese Government's Efforts to Fight COVID- 19 : Integration of Top-Down Interventions and Local Governance

Abstract

The experiences and lessons of China's response to COVID-19 have been described in several studies, but the mechanisms of the Chinese government's efforts to fight COVID-19 have not been well characterized. Despite strong policy directives and orders from the central government, the response and handling of the epidemic also reflected distinctive characteristics of local governments in terms of their governance systems and capacities. In this article, we analyze public health policies and mechanisms of the Chinese government's response to COVID-19 based on the integration of top-down and local governance. A compendium of key events and measures provides the foundation for our analysis. Mechanisms related to leadership, emergency response, centralized mobilization, and accountability fully reflect the decisive measures for top-down interventions in the face of emergencies. China's policies and mechanisms to address the COVID-19 pandemic are consistent with its party-state bureaucracy and socioeconomic context. However, lower levels of government have used “repeated increments” and “one-size-fits-all” practices in the implementation of antiepidemic policies. Conservative local officials are more averse to social innovation and favor strict controls to manage the pandemic. Moreover, even under a unified system, there are substantial differences in the capacity and level of crisis management among local governments, especially in the mobilization of nonprofit organizations and volunteers. In this case study, we aim to expand the existing understanding of the tension between top-down interventions and local governance innovations.

Introduction

In December 2019, the first case of COVID-19 infection was reported in Wuhan, China. Within a few weeks, widespread transmission occurred due to the massive population movement related to the Chinese Lunar New Year.¹ Many countries around the world have paid a high toll in this pandemic in terms of human lives lost, damage to health, economic repercussions, and increased poverty.² China, under the unified leadership and strategic deployment of the Chinese Communist Party Central Committee and the State Council, has implemented strong interventions, including comprehensive lockdown of cities and communities with serious outbreaks, proactive case surveillance, rapid investment to improve detection capacity, treatment of severe cases, isolation of infected cases and high-risk groups, and behavioral risk reduction strategies, such as mandatory masking of the general population and increased vaccination rates. China has also taken large-scale coordinated measures at all levels of government,³ mobilized professional institutions and social organizations to help fight COVID-19, and made efforts and important contributions to contain the spread of the epidemic to other countries.

Using strict and extensive protocols, China has been able to contain COVID-19 since the lockdown of Wuhan,⁴ with no large-scale cases of infection or persistent widespread transmission, except during the early stages of the outbreak. Some studies have explored the experiences and lessons learned from China's response to COVID-19.^5,6 For example, China established temporary hospitals, enforced strict isolation, recruited specialists with knowledge of COVID-19, and implemented measures to increase social distance.⁶ In addition, China enabled early identification of infected individuals, carriers, and contacts, and timely implementation of quarantine measures at the national level with an organized, proactive, and unified strategy.⁷ At the same time, there have been questions as to whether these actions were a reasonable and proportionate response to the outbreak.⁸ Some preventive measures, such as the application of the electronic health code and travel code, may have created new digital inequalities and infringed on individual freedoms.

In addition, despite strong policy directives and orders from the central government, not every province in China faces the same COVID-19 outcomes due to different levels of economic development and geographic location.⁹ Local governments have taken differentiated measures to manage the crisis, producing differentiated effects. The response to and handling of the outbreak also reflects the distinctive characteristics of local governments in terms of governance systems and capacities. In this regard, it is important to explore how China coordinates the relationship between relevant departments of the central government and corresponding departments of local governments, and fully mobilizes local governments in all regions to assist in efforts to contain the epidemic.

In this case study, we provide a comprehensive analysis of the Chinese government's efforts to fight COVID-19 from a combination of top-down and local governance perspectives. We argue that the governance practices of public health crises in China contain distinct top-down features, particularly central government directives, coercive interventions, and the exoneration of officials for negligence in prevention and control. Second, the hierarchical responsibility and local management system in China's emergency management fully reflect local governance in public health crisis response, which has clearly become the root cause of local differences. China's experience and practices in responding to the COVID-19 pandemic may also be a reference for other countries.^10-12

Context and Key Questions

China is widely perceived as an authoritarian regime by Western democracies.^13,14 This style of governance has been an important mechanism for developing the country's economy and addressing social problems.¹⁵ A fundamental feature of this model is the top-down operation of power, organization, and mobilization of social resources. The Chinese government under Xi Jinping has placed a strong emphasis on a top-down strategy in policy formulation, which is beneficial in correcting past distortions caused by uneven policy implementation and resource allocation.¹⁶ The top-down strategy gives more power to the central government and highlights the importance of central design and guidance. It vividly demonstrates how the government organizes command structures, directs bureaucracies, mobilizes resources, and carries out community-based law enforcement in response to crises.⁴

Do top-down approaches exist in public health crisis management? The performance of different countries in response to the COVID-19 pandemic suggests they do. A growing number of studies have attempted to explain such phenomena using a top-down perspective.^17-19 For example, some researchers found that, through the establishment of a top-down leadership team or headquarters and complex horizontal/vertical and formal/informal institutional arrangements, the decisionmaking and coordination capacity for public health emergency governance in China has been strengthened.¹⁸ In another study, we suggested that the establishment of a top-down leadership mechanism was one reason for China's successful response to the COVID-19 pandemic.¹⁵

Moreover, the top-down approach to crisis management is inextricably linked to the political rhetoric of leaders. In some countries, the COVID-19 crisis was reconceptualized as a people's war to prompt idea sharing within the regime.²⁰ Places that managed to build a sense of “we-ness,” emphasizing national identity and collective solidarity discourse, found an effective response to COVID-19, which enabled them to unleash the power of the group and unite against the pandemic.²¹

Nevertheless, the response to COVID-19 shows that central authorities are by no means the only political or governance actors. Instead, fragmented responses among local authorities and nonstate actors played an important but often underrepresented role in the crisis.²² A well-known Chinese saying, shang you zheng ce, xia you dui ce (“from above there are imposed policies, and from below there are evading strategies”), vividly reflects the space for innovation and autonomy that local governments have in local governance.²³ Some researchers have focused on the territorial impact of the COVID-19 crisis. Subnational governments, especially regions and municipalities, are considered to be on the frontlines of crisis management and recovery, facing asymmetric health, economic, social, and financial impacts of COVID-19 within the country and between regions and localities.²⁴ When a crisis strikes, street-level organizations often form the first line of response, and their work becomes more important and visible.²⁵

To respond effectively to public health crises and optimize decisionmaking mechanisms, a balance needs to be achieved between centralization and the effectiveness of local governance.²⁶ Grassroots governance, as an important part of the national governance system, is the “last mile” connecting the state and social governance. Communities and volunteers in urban and rural areas have been quickly mobilized to serve as the frontline of outbreak prevention and control.^27,28 In recent outbreaks, community volunteers helped facilitate social distancing and minimize disease transmission.²⁹ Communities can also ensure effective advocacy, appropriate networking, and dissemination of information during a pandemic and subsequent translation into community-level action by empowering community members, mobilizing resources, and strengthening local community ownership.³⁰

In our review of the mechanisms and outcomes of the COVID-19 crisis, China appears to have been more efficient than many other countries in controlling the confirmed case growth and promoting economic recovery. China's approach represents a different model of crisis management compared with democratic countries such as the United States and countries in Europe. An analysis of the Chinese mechanisms in the context of its political system is noteworthy. We are hopeful that China's experience and lessons in overcoming the epidemic will help other countries end the ravages of the COVID-19 pandemic quickly and reduce the misconceptions about or accusations made against China.

Methods

We used a qualitative design to assess the mechanisms of the Chinese government's efforts to fight COVID-19 from a top-down and local governance perspective. A compendium of key events and measures laid the foundation for our analysis. Our research was reviewed by the Institutional Review Board Number 68.

Case Description

Reasonable and scientific emergency response should run through the entire process of emergency development. For public health emergencies, the central government and local governments should take targeted measures according to the characteristics and functions at different stages, forming an effective crisis response and management model that is aligned with the life cycle of the epidemic. The Chinese government places different emphases on the public health system depending on the stage of an epidemic; this was reflected in the early stages of pandemic prevention and pandemic response.³¹ In the early stages of pandemic prevention, local governments at the county level and above and their health administrative departments should have adequate early warning.³² The main task of local governments is to be well prepared before an epidemic occurs, including developing and improving emergency plans, establishing and improving emergency surveillance and early-warning systems, and reporting and disseminating timely and accurate information about the epidemic. To control the spread of a pandemic, however, strong interventions by the central and provincial governments—in addition to close collaborations among grassroots governments, local communities, and members of society—are needed during the concentrated response phase of an epidemic.³³

During the early stages of the COVID-19 pandemic, the massive mobility of people during Chinese New Year celebrations resulted in the spread of the virus from Wuhan to several Chinese provinces. The COVID-19 outbreak was then defined as a national public health crisis. Accordingly, the Chinese government quickly implemented special measures for the affected and hardest-hit areas, such as the activation of a Level 1 response, complete lockdown of Wuhan city, rapid establishment of square cabin hospitals (makeshift mobile units), and quarantine of confirmed cases. This phase was characterized by widespread transmission and swift response.

When the epidemic evolved into a pandemic, the Chinese government adopted top-down interventions to rapidly contain the spread of the virus. At the request and mobilization of the central government, local governments in several provinces across the country supported Hubei Province and Wuhan City to achieve information sharing and joint epidemic prevention. Domestic and international resources were also fully utilized and mobilized to minimize the economic and social losses caused by the epidemic.^34,35 This phase was characterized by comprehensive top-down interventions and rapid reduction of confirmed cases. The COVID-19 pandemic has been largely controlled in China.

Since April 29, 2020, the COVID-19 pandemic in China has been in the ongoing prevention and control phase. The focus of prevention and control has shifted from prevention of new cases in the mainland to prevention of inbound cases. All provinces and municipalities have implemented a mandatory 14- or 21-day isolation and observation policy for persons returning from abroad and require multiple nucleic acid tests. During this phase, although confirmed cases have occurred regionally, small-scale outbreaks were often quickly contained. China did not experience multiple rounds of recurrent outbreaks as seen in Western countries.

Data Collection

We collected data from official government statistics, government documents on COVID-19, academic journals, and media reports. Official statistics were mainly collected from government websites related to the epidemiological and public health system, such as the National Health Commission of the People's Republic of China and the Chinese Center for Disease Control and Prevention. We also collected data from the websites of relevant Chinese government departments, including the State Council of the People's Republic of China, the Ministry of Transport, the Ministry of Human Resources and Social Security, the Ministry of Civil Affairs, and other ministries and commissions.

Government documents about COVID-19 are important sources for our data collection; these include work circulars, prevention and control plans, management norms and guidelines, and published official studies related to COVID-19. We also collected key academic articles and media coverage articles to make the data more comprehensive. They helped us to identify the Chinese government's discourse on top-down interventions, local governments' innovations, and self-governance measures.

Findings

Leadership and Working Mechanism: Establishment of Epidemic Prevention and Control Headquarters

A top-down leadership mechanism is one reason for China's successful experience in responding to COVID-19. As the COVID-19 pandemic spread from Wuhan to Hubei and other provinces, prevention and control of infectious diseases was treated as the most important task of the time. The Central Committee of the Chinese Communist Party decisively established a central leading group to respond to COVID-19 in January 2020 and set up 7 working groups according to the pertinent work arrangements. They are the Forward Working Group, the Grassroot Skilled Group for Community Prevention and Control, the Expert Group for Epidemic Response and Disposal Work, the Medical Treatment Group, the Inspection Group, the Military Forward Command and Coordination Group, and the Working Group to the Southwest Region. All ministries and commissions of State Council are required to implement the work arrangements of the Central Leading Group in Response to the COVID-19 Outbreak. Furthermore, the National Health Commission of the People's Republic of China took the lead in establishing a joint prevention and control working mechanism to respond to the COVID-19 outbreak, with 32 departments, including the National Health Commission, the National Development and Reform Commission, and the Ministry of Human Resources and Social Security as members. Several working groups were set up under the operational mechanism, with each working group headed by a full ministerial-level leader. Under the unified arrangement and deployment of the central government, local governments at all levels in China then quickly set up provincial COVID-19 pandemic prevention and control leading groups or working commands to be unified and responsible for the prevention and control of the epidemic in their administrative regions.

Emergency Response Mechanism: Activate Level I Response for COVID-19

In 2006, the Emergency Regulation for Public Health Emergencies was created and the National Emergency Plan for Public Emergencies was implemented. They stipulate that public health emergencies can be divided into 4 levels according to their nature, degree of harm, and scope of involvement: particularly significant (Level I), significant (Level II), major (Level III), and general (Level IV).³⁶ Among them, Level I represents the highest level of response. Due to the rapid growth of confirmed cases in early 2020, a total of 24 provinces, municipalities, and autonomous regions in China have activated Level I response for COVID-19 according to the principle of local management of public health emergencies, covering a total population of more than 1.2 billion.³⁷ Based on the decisionmaking and unified command of State Council, the provincial commands organized and coordinated the emergency response within their administrative regions. According to the needs of preventing COVID-19, after the initiation of Level 1 response, people's governments at all levels can mobilize all types of personnel, materials, transportation, related facilities, and equipment in the administrative region to participate in the emergency response. In terms of epidemic prevention and control measures, local people's governments can take measures to restrict or stop fairs, rallies, theater performances, and other activities where crowds gather within their administrative regions. In addition, work, business, and school suspensions may be declared. As far as the management of the mobile population is concerned, infectious disease patients and suspected patients will be subject to local quarantine, local observation, and local treatment measures, and close contacts will be placed under centralized or home medical observation, depending on the situation.

Support Mechanism: Pooling National Efforts to Support the Hardest-Hit Areas

The Chinese government's ability to mobilize quickly is strong, especially in the production of antiepidemic supplies and the deployment of medical personnel during public health emergencies. In the response to COVID-19, China made good use of its institutional advantage of “concentrating its efforts on major issues” and established a national system to manage the epidemic. In terms of resource deployment and material security, we witnessed the largest deployment of medical forces during the epidemic since the founding of New China, as reflected in the Dui kou zhi yuan, or “partner assistance” and “military assistance.”³⁸ Thirty provinces, autonomous regions and cities, and the People's Liberation Army dispatched medical teams and personnel to assist Hubei, in the form of “one province supporting one city,” to relieve the plight and pressure of depleted medical resources in the hardest-hit areas. The People's Liberation Army also dispatched more than 4,000 medical personnel to assist Wuhan. The People's Liberation Army Air Force dispatched aircraft to transport emergency support materials and assumed the medical treatment tasks of Wuhan Vulcan Mountain Hospital.³⁹ An additional 63 designated hospitals and more than 10,000 medical personnel from the army were involved in frontline treatment.³⁹

Accountability Mechanism: Removal or Suspension of Officials for Ineffective Prevention and Control

The removal of leaders is a routine measure to stimulate the bureaucracy.⁴⁰ Any official who compromises the public interest in the work to control the epidemic and sets aside people-centered principles in their work will be held accountable. If government officials fail to serve the people, they will be replaced by competent counterparts. The term “removal from office,” which appeared frequently during the COVID-19 outbreak period, has drawn strong public attention in each case. From the cases that have occurred, those who have been held accountable include deputy mayors, deputy district governors, directors of health committees, and hospital directors, in addition to township grassroots cadres and heads of community health services. Some of them are even members of the COVID-19 pandemic response leadership team or the main leaders of departments in key areas of epidemic prevention and control. For example, in early 2020, the Chinese government removed 2 officials from the health system in Hubei Province and appointed a trusted official from the National Health Commission to replace them. According to relevant media reports, from August to September 2021, more than 100 public officials and party cadres were held accountable for epidemic prevention failures in many parts of the country.⁴¹ Officials were removed from their posts for a variety of reasons, including misreporting epidemic data, failure to implement prescribed measures, inaction and false action, lack of civic service awareness, failure to put people's lives and health first, and interference with epidemic prevention and control. In general, the different reasons for removing officials from office reflect the severity of their accountability. The main ways of accountability include organizational accountability, party disciplinary punishment, and political punishment. Organizational accountability is relatively lighter than the latter, party disciplinary sanctions are for party members, and political penalties are for all supervisory subjects who perform public duties.

Community Prevention and Control Mechanism: Strengthen the Role of Primary Healthcare Institutions

The prevention and control of epidemics in rural grassroots and urban communities is of great importance to effectively strengthen the role of primary healthcare institutions as “sentinel sites” and further enhance the ability to detect, report, and manage epidemics at an early stage. Nearly 4 million medical personnel in primary healthcare institutions have played an active role. They mainly carried out 5 areas of work. First, they did a good job of prescreening, triaging, isolating, and referring febrile patients and suspected patients in a timely manner. Second, rural medical and health institutions cooperated with village committees to implement health monitoring and protection guidance for those returning to their villages. Together with community workers, grassroots medical personnel implemented web-based management and carpet screening to manage suspected cases in home or centralized isolation.⁴² Third, China has enhanced the nucleic acid sampling capacity of primary healthcare institutions, requiring primary institutions with fever clinics to sample and test all fever patients for nucleic acid. Fourth, in areas where prevention and control forces are relatively weak, emphasis had been placed on resources such as personnel and protective materials at the county level and down to townships and villages. This approach has greatly enhanced regional capacity for epidemic prevention and control. In addition, grassroots medical and health institutions have joined hands with urban and rural community organizations to actively carry out vaccination against COVID-19. They also continue to strengthen publicity and health education on epidemic prevention and control measures to enhance residents' awareness of protection.⁴³ At the entrances and exits of airports, docks, and highways, grassroots medical personnel can often be found performing antiepidemic tasks.

Volunteer Participation Mechanism: Forming a Service Model of “Social Workers and Volunteers”

Volunteers and nonprofit organizations are essential and vital resources in crisis management. Under the coordination of local governments, social workers and volunteers in various regions have played an irreplaceable role in epidemic prevention and control. Not only have they provided diversified, personalized, and specialized services, they have also developed a service model of social workers and volunteers both online and offline to implement routine community prevention and control measures. Specifically, volunteer service organizations provide a variety of services such as psychological guidance, emotional support, spiritual comfort, protection, and other services for various groups—low-income groups, people with disabilities, orphans, vulnerable children, and others. They also provide psychological intervention and guidance, mental health assessment, and other services for frontline medical personnel. In the community, volunteers manage temperature measurement, personnel screening, mask registration and purchase, isolation and placement, epidemic prevention and promotion, and facility disinfection. At transportation hubs and important road junctions, volunteers participate in vehicle guidance, information registration, temperature testing, order maintenance, and foreign language translation.⁴⁴ On the internet, volunteers actively carry out epidemic prevention and disinformation education, science promotion, course counseling, and psychological guidance. For example, the Red Cross Society of China participated fully in epidemic prevention and control by mobilizing and organizing more than 390,000 volunteers to carry out health monitoring, door-to-door inspection, and volunteer services in the community to provide support during times of difficulty. A total of more than 7.5 million people were covered, with 71 million hours of service.⁴⁵ The orderly participation of local volunteers in epidemic prevention and control fully demonstrates the powerful positive energy contained in volunteerism.

Discussion

First, we would like to discuss the drivers of crisis management decisions faced by local leaders in the context of China's authoritarian regime. Some scholars argue that there are 2 main drivers in social decisionmaking: top-down pressure from the regime and bottom-up motivation from local conditions.⁴⁶ The extraordinary mobilization capacity of the party-state enabled China to quickly commit substantial resources and, if necessary, to control the epidemic with an iron-fisted approach.⁴ The leadership mechanism, emergency response mechanism, centralized mobilization mechanism, and accountability mechanism fully reflect the decisive measures taken for top-down interventions in the face of emergency. The top-down approach to organizing and mobilizing the state for governance therefore constitutes a prominent feature of COVID-19 prevention. It tends to create a vertical management system that takes an executive directive regulatory approach to governing the crisis under the guidance of a core leadership council.⁴⁷

It is difficult for governments within a single administrative division to solve public governance problems in a risk society. To gain adequate support to resolve local issues, local governments need to work with relevant private-sector organizations such as nonprofits, healthcare providers, and community members.⁴⁸ Coordinated actions by local health departments, emergency management, and other government departments are equally needed to enhance joint responses to pandemics. China's emergency management approach has always emphasized hierarchical responsibility and local management. The Emergency Response Act states that county-level governments should be responsible for the response to emergencies within their administrative regions.⁴⁹ In the context of China, local governments at all levels are not allowed to go against the basic requirements of the central government. However, local governments also need to use innovate policy tools to maximize the involvement of other administrative departments and social forces in joint prevention and control efforts, taking into account regional characteristics and the severity of the COVID-19 pandemic.^50,51 The establishment of community prevention and control and volunteer participation mechanisms has given local governments room for innovation and freedom in crisis management.

What are the drawbacks of this mixed management or hybrid coordination model? Risk monitoring and early warning are important tools to improve the efficiency of disaster emergency response and preparedness.⁵² Risk monitoring and early warning are defined as “a set of capabilities to generate and disseminate timely and meaningful early-warning information to enable individuals, communities, and organizations threatened by a hazard to prepare and act in sufficient time to reduce the likelihood of harm or loss.”⁵³ It consists of 4 interrelated elements, namely risk knowledge, monitoring and early warning, communication and dissemination of early warning, and response capabilities.^54-56 In terms of information disclosure and information governance, China has long been perceived as a country with strong state control over not only the economy but also information.^57-59 With the use and popularity of new media technologies, the rise of civil society, and the increase in investigative reporting, it has become increasingly easy for citizens to access a variety of information through social media to monitor government actions. The actual amount of information disclosed to civil society organizations in China has progressed since the promulgation of the Regulations on Open Government Information in 2008.⁶⁰ The Regulations on Disclosure of Government Information (State Council Decree No. 711, 2019) stipulates in article 9, paragraphs 1 and 2, that administrative organs shall take the initiative to disclose information that concerns the vital interests of citizens, legal persons, or other organizations and needs to be widely known by the public.⁶¹

Nevertheless, we still found unscientific surveillance and early warning in the event of COVID-19. Rapidly sharing scientific information is an effective way to reduce public panic about COVID-19,⁶² and information disclosure is likely to be more effective in reducing panic when there is a high level of trust in the local government.⁶³ When facing pressure to assess the performance of local officials, some local government departments are reluctant to issue early warning information when a public health crisis occurs.^15,64 For example, the most severely affected province, Hubei, was relatively behind in activating emergency response mechanisms for COVID-19, which was met with strong public outcry. While some provinces, under the influence of national pressure, activated emergency response mechanisms that did not match the status of the epidemic when few cases were confirmed. For example, China's Tibet Autonomous Region activated a Level 1 response when there was only 1 confirmed case, which was clearly incompatible with its epidemic situation. Thus both insufficient and excessive early warning approaches to crisis management were used by local governments.¹⁵

In addition, lower levels of government have used “repeated increments” and one-size-fits-all practices in their implementation of antiepidemic policies.⁶⁵ In China, as in other countries with a multilevel government structure, there is a serious information asymmetry between different levels of government. Faced with this top-down information asymmetry, lower levels of government are forced to constantly speculate on the true intentions of their superiors when implementing their instructions.⁶⁶ The same is true when it comes to implementing policies to fight the epidemic. Higher governments often issue guidelines or regulatory documents, and local governments take for granted that higher governments have an intolerant attitude toward new confirmed cases. Severe penalties led to stricter enforcement by local officials in practice.

The case of China suggests that strict community lockdowns, resource mobilization across administrative regions, and sanctions by officials contributed to the ultimate effectiveness of China's response to the epidemic. Centralized leadership and strong bureaucratic mobilization were compatible with the country's own policy style, which proved efficient for pandemic containment.⁶⁷ While policy changes at the central level clearly affect the behavior of local policy officials, there are still notable regional differences. This partly depends on the personal character traits and dynamics of local leaders.⁶⁸ In addition, there are high and low levels of governance capacity and capability in cities. Conservative local officials are more averse to social innovation and favor strict control in managing the epidemic, which, ultimately, has led to chaos and boiling public discontent. The tension between administrative directives from higher levels of government and policy innovations from local governments remains a challenge in crisis management.

Conclusion

This case study explains why China controlled the outbreak quickly by reviewing its crisis response mechanisms and hybrid management model. Through this case study of COVID-19 crisis management, we aim to expand the existing understanding of the tension between top-down interventions and local governance. The Chinese government's efforts to fight COVID-19 revealed advantages of top-down interventions in an epidemic response, while also exposing regional differences in local governance of public health crises.

Our findings suggest that the mechanisms of the Chinese government's effort to fight COVID-19 exhibit salient top-down features, which are consistent with China's party-state bureaucracy and socioeconomic context. In particular, the establishment of epidemic prevention and control commands at all levels of government, the activation of a nationwide Level 1 response, the concentration of national efforts to support the hardest-hit areas, and the implementation of punitive accountability for local officials who were ineffective against the epidemic all reflect the unique advantages of top-down institutions. However, we cannot avoid the fact that even under a unified system, there are substantial differences in the capacity and level of crisis management among local governments, especially in the mobilization of nonprofit organizations and volunteers. We hope that the crisis governance mechanism appropriate to the Chinese context will be understood by other countries and provide helpful experience, but the extent to which the effectiveness of this model is accepted remains less certain.

References

Palacios Cruz

, Santos

, Velázquez Cervantes

, León Juárez

. COVID-19, a worldwide public health emergency. Rev Clín Esp (Barc). 2021; 221(1):55-61.

Ciotti

, Ciccozzi

, Terrinoni

, Jiang

W-C

, Wang

C-B

, Bernardini

. The COVID-19 pandemic. Crit Rev Clin Lab Sci. 2020; 57(6):365-388.

Lin

, Rocha

ICN

, Shen

, Ahmadi

, Lucero-Prisno

. Challenges and strategies in controlling COVID-19 in mainland China: lessons for future public health emergencies. J Soc Health. 2021; 4(2):57-61.

, Shi

, Liu

. Crisis governance, Chinese style: distinctive features of China's response to the Covid-19 pandemic. Policy Des Practe. 2020; 3(3):242-258.

Liu

, Yue

X-G

, Tchounwou

. Response to the COVID-19 epidemic: the Chinese experience and implications for other countries. Int J Environ Res Public Health. 2020; 17(7):2304.

Jin

, Lu

, Liu

, Cui

. COVID-19 emergencies around the globe: China's experience in controlling COVID-19 and lessons learned. Int J Qual Health Care. 2021; 33(1):mzaa143.

Peng

, Tu

, Yang

, et al. Management and treatment of COVID-19: the Chinese experience. Can J Cardiol. 2020; 36(6):915-930.

, McGoogan

. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020; 323(13):1239-1242.

Cheng

, Yu

, Shen

, Huang

. Coproducing responses to COVID-19 with community-based organizations: lessons from Zhejiang Province, China. Public Adm Rev. 2020; 80(5):866-873.

10.

Zhang

, Shi

, Zhong

, Guo

. COVID-19 prevention and control public health strategies in Shanghai, China. J Public Health Manag Pract. 2020; 26(4):334-344.

11.

Liu

, Saltman

. Policy lessons from early reactions to the COVID-19 virus in China. Am J Public Health. 2020; 110(8):1145-1148.

12.

Azman

, Luquero

. From China: hope and lessons for COVID-19 control. Lancet Infect Dis. 2020; 20(7):756-757.

13.

Wong

SH-w

, Peng

. Petition and repression in China's authoritarian regime: evidence from a natural experiment. J East Asian Stud. 2015; 15(1):27-67.

14.

Peřinová

Civil Society in Authoritarian Regime: The Analysis of China, Burma and Vietnam. Thesis. Lund University; 2005. Accessed May 10, 2022. https://lup.lub.lu.se/luur/download?func=downloadFile&recordOId=1330580&fileOId=1330581

15.

Gao

, Zhang

. China's public health policies in response to COVID-19: from an “authoritarian” perspective. Front Public Health. 2021; 9:756677.

16.

Stepan

, Ahlers

, Jianxing

, Teets

, Donaldson

, Xuelian

What does Xi Jinping's top-down leadership mean for innovation in China?. ChinaFile. October 27, 2016. Accessed May 10, 2022. https://www.chinafile.com/conversation/what-does-xi-jinpings-top-down-leadership-mean-innovation-china

17.

Luong

, Jardine

, Thomson

. Mobilizing the police from the top down as public health partners in combatting COVID-19: a perspective from Vietnam. J Community Saf Well Being. 2020; 5(2):57-59.

18.

Cai

, Jiang

, Tang

. Campaign-style crisis regime: how China responded to the shock of COVID-19. Policy Stud. 2021; 43(3):599-619.

19.

Boroumand

, Ghasemi

, Shirazi

The efficiency of governments' policies to COVID-19: a top-down approach based on DEA window analysis. Preprint. Preprints. Posted February 3, 2021. Accessed May 10, 2022. https://www.preprints.org/manuscript/202102.0101/v1

20.

Montiel

, Uyheng

, Dela Paz

. The language of pandemic leaderships: mapping political rhetoric during the COVID-19 outbreak. Polit Psychol. 2021; 42(5):747-766.

21.

Muldoon

, Liu

, McHugh

. The political psychology of COVID-19. Polit Psychol. 2021; 42(5):715-728.

22.

Song

, Liu

, Wang

, Guan

. Fragmented restrictions, fractured resonances: grassroots responses to Covid-19 in China. Crit Asian Stud. 2020; 52(4):494-511.

23.

Chen

A U-turn or just pendulum swing? Tides of bottom-up and top-down reforms in contemporary China. J Chin Polit Sci. 2017; 22(4):651-673.

24.

Allain-Dupré

, Chatry

, Michalun

, Moisio

The territorial impact of COVID-19: Managing the crisis across levels of government. Organisation for Economic Co-operation and Development. Published May 10, 2021. Accessed May 10, 2022. https://www.oecd.org/coronavirus/policy-responses/the-territorial-impact-of-covid-19-managing-the-crisis-and-recovery-across-levels-of-government-a2c6abaf/

25.

Brodkin

EZ.

Street-level organizations at the front lines of crises. J Comp Policy Anal Res Pract. 2021; 23(1):16-29.

26.

Zhang

, Zhang

. COVID-19 in China: power, transparency and governance in public health crisis. Healthcare (Basel). 2020; 8(3):288.

27.

South

, Stansfield

, Amlôt

, Weston

. Sustaining and strengthening community resilience throughout the COVID-19 pandemic and beyond. Perspect Public Health. 2020; 140(6):305-308.

28.

Mao

, Fernandes-Jesus

, Ntontis

, Drury

. What have we learned so far about COVID-19 volunteering in the UK? A rapid review of the literature. BMC Public Health. 2021; 21(1):1470.

29.

Kobokovich

, Hosangadi

, Rivers

. Supporting social distancing for COVID-19 mitigation through community-based volunteer networks. Am J Public Health. 2020; 110(8):1167-1168.

30.

Al Siyabi

, Al Mukhaini

, Kanaan

, et al. Community participation approaches for effective national covid-19 pandemic preparedness and response: an experience from Oman. Front Public Health. 2021; 8:616763.

31.

Zhang

, Gao

. Evaluation of China's public health system response to COVID-19. J Glob Health. 2021; 11:05004.

32.

Himmelstein

, Woolhandler

. The US health care system on the eve of the Covid-19 epidemic: a summary of recent evidence on its impaired performance. Int J Health Serv. 2020; 50(4):408-414.

33.

Lorion

RP.

Prevention and public health: psychology's response to the nation's health care crisis. Am Psychol. 1991; 46(5):516-519.

34.

Rodwin

VG.

The health care system under French national health insurance: lessons for health reform in the United States. Am J Public Health. 2003; 93(1):31-37.

35.

Rutten

, Van Busschbach

. How to define a basic package of health services for a tax funded or social insurance based health care system?. Eur J Health Econ. 2001; 2(2):45-46.

36.

State Council of People's Republic of China. National emergency response plan for public emergencies. Published August 7, 2005. Accessed August 15, 2021. http://www.gov.cn/yjgl/2005-08/07/content_21048.htm

37.

Central Disciplinary Committee of the Communist Party of China. What does it mean that many provinces, regions and municipalities have initiated a Level 1 response to a major public health emergency? Published January 25, 2020. Accessed June 28, 2022. https://www.ccdi.gov.cn/toutiao/202001/t20200124_210321.html

38.

Zhong

, Lu

. Exploring the administrative mechanism of China's Paired Assistance to Disaster Affected Areas programme. Disasters. 2018; 42(3):590-612.

39.

State Council Information Office of The People's Republic of China. Fighting Covid-19: China in Action. Beijing: State Council Information Office; 2020. Accessed May 10, 2022. https://english.www.gov.cn/atts/stream/files/5edc549dc6d0cc300eea778c

40.

Cai

, Zhu

. Disciplining local officials in China: the case of conflict management. China J. 2013;(70):98-119.

41.

China Discipline Inspection and Supervision News. Accurate accountability in the epidemic's big test—nearly 100 party leaders and cadres were held accountable in many places for failures to prevent and control the epidemic. Published August 19, 2021. Accessed June 28, 2022. https://www.moj.gov.cn/jgsz/gjjwzsfbjjz/zyzsfbjjzyw/202108/t20210819_435316.html

42.

Wang

, Zhang

. COVID-19 in rural China: features, challenges and implications for the healthcare system. J Multidiscip Healthc. 2021; 14:1045-1051.

43.

Notice of the General Office of the National Health and Health Commission on the classification and precise work of primary health care institutions in COVID-19 prevention and control. National Health Commission. Published March 1, 2020. Accessed May 11, 2022. http://www.gov.cn/zhengce/zhengceku/2020-03/03/content_5486258.htm

44.

Xinhua News Agency. “Dedication, friendship, mutual help and progress”—more than 200,000 epidemic prevention and control volunteers in Shanghai strive to practice the spirit of volunteerism. Published March 4, 2020. Accessed June 28, 2022. http://www.xinhuanet.com/politics/2020-03/04/c_1125662136.htm

45.

Xinhua News Agency. More than 390,000 Red Cross volunteers participate in epidemic prevention and control. Published February 12, 2021. Accessed June 28, 2022. http://www.gov.cn/xinwen/2021-02/12/content_5586914.htm

46.

Huang

, Kim

. When top-down meets bottom-up: local adoption of social policy reform in China. Governance. 2020; 33(2):343-364.

47.

Zhu

Mandate versus championship: vertical government intervention and diffusion of innovation in public services in authoritarian China. Public Manag Rev. 2014; 16(1):117-139.

48.

Gao

, Yu

. Public governance mechanism in the prevention and control of the COVID-19: information, decision-making and execution. J Chin Gov. 2020; 5(2):178-197.

49.

State Council of People's Republic of China. Emergency Response Law of People's Republic of China (Order of the President of the People's Republic of China No. 69). Published August 30, 2007. Accessed August 15, 2021. http://www.npc.gov.cn/zgrdw/englishnpc/Law/2009-02/20/content_1471589.htm

50.

Parchman

, Noël

, Lee

. Primary care attributes, health care system hassles, and chronic illness. Med Care. 2005; 43(11):1123-1129.

51.

Ewers

, Schaeffer

. Dying in Germany – consequences of societal changes for palliative care and the health care system. J Pub Health. 2007; 15(6):457-465.

52.

Horita

, de Albuquerque

, Marchezini

. Understanding the decision-making process in disaster risk monitoring and early-warning: a case study within a control room in Brazil. Int J Disaster Risk Reduct. 2018; 28:22-31.

53.

United Nations International Strategy for Disaster Reduction (UNISDR). 2009 UNISDR Terminology on Disaster Risk Reduction. Geneva: UNISDR; 2009. Accessed May 11, 2022. https://www.undrr.org/publication/2009-unisdr-terminology-disaster-risk-reduction

54.

de León

JCV

, Bogardi

, Dannenmann

, Basher

. Early warning systems in the context of disaster risk management. Entwicklung Ländlicher Raum. 2006; 40(2):23-25.

55.

Basher

Global early warning systems for natural hazards: systematic and people-centred. Philos Trans A Math Phys Eng Sci. 2006; 364(1845):2167-2182.

56.

Wisner

, Gaillard

, Kelman

, eds. Handbook of Hazards and Disaster Risk Reduction. London: Routledge; 2011.

57.

Mol

AP.

Environmental Reform in the Information Age: The Contours of Informational Governance. Cambridge, UK: Cambridge University Press; 2008.

58.

Wang

, Greer

, Lin

. Practice and inspiration of environmental information disclosure. World Environ. 2008; 5(5):24-26.

59.

Mol

AP.

Environmental governance through information: China and Vietnam. Singap J Trop Geogr. 2009; 30(1):114-129.

60.

Zhang

, Mol

, He

. Transparency and information disclosure in China's environmental governance. Curr Opin Environ Sustain. 2016; 18:17-24.

61.

State Council of People's Republic of China. Government information disclosure regulations of the People's Republic of China (Decree of the State Council of the People's Republic of China No. 711). Published April 15, 2019. Accessed June 28, 2022. http://www.gov.cn/zhengce/content/2019-04/15/content_5382991.htm

62.

Song

, Karako

. COVID-19: Real-time dissemination of scientific information to fight a public health emergency of international concern. Biosci Trends. 2020; 14(1):1-2.

63.

Liu

, Lin

, Wang

, Chen

, Zhang

. Can local governments' disclosure of pandemic information decrease residents' panic when facing COVID-19 in China?. Int Public Manag J. 2020; 24(2):203-221.

64.

, Li

. Crippled community governance and suppressed scientific/professional communities: a critical assessment of failed early warning for the COVID-19 outbreak in China. J Chin Gov. 2020; 5(2):160-177.

65.

Zheng

Y-J

, Yu

S-L

, Yang

J-C

, et al. Intelligent optimization of diversified community prevention of COVID-19 using traditional Chinese medicine. IEEE Comput Intell Mag. 2020; 15(4):62-73.

66.

Zhan

, Qin

. The art of political ambiguity: top-down intergovernmental information asymmetry in China. J Chin Gov. 2017; 2(2):149-168.

67.

Mei

Policy style, consistency and the effectiveness of the policy mix in China's fight against COVID-19. Policy Soc. 2020; 39(3):309-325.

68.

Teets

, Hasmath

, Lewis

. The incentive to innovate? The behavior of local policymakers in China. J Chin Political Sci. 2017; 22(4):505-517.