2.1 Literature review

A structured search strategy was used across major databases pertaining to COVID-19 response and management (Appendix method). The search was guided by the 10 pillars proposed by the WHO for the evaluation of COVID-19 preparedness and response planning [5]. Specific domains were examined, such as theoretical frameworks in emergency management, national infrastructure, medical response, prevention and control strategies, information technology, socioeconomic factors, and global engagement. Within each domain, sub-categories were defined to aid logic development of the search process. Abstracts of the most relevant papers were thoroughly reviewed, and the additional concepts identified in these abstracts were used to refine and expand the search. We prioritized peer-reviewed articles, but also covered gray literature such as reports, white papers, and guidelines from trusted organizations and official government-issued documents or press releases.

2.2 Theoretical framework

Over the years, several key theories have been developed to guide emergency management, particularly during a pandemic. In the 1950s, Quarantelli introduced the Theory of Warning and Emergency Response, emphasizing the need for timely responses to emergencies [6]. Later, in the 1980s, Fink proposed the Crisis Management Theory, describing the different stages of crisis [7]. In 1997, Quarantelli proposed 10 criteria for evaluating the management of community disasters, focusing on the impact on social functioning [8]. In 2003, Robert Heath developed the 4R Crisis Management Theory, which covers four critical periods of reduction, readiness, response, and recovery. In 2007, McEntire put forth Strategies and Tactics for Resilience, suggesting the integration of sustainability and emergency management [9]. In 2012, Perry introduced the Protective Action Decision Model, highlighting that emergency management should be a continuous process [10]. In the 2020s, Botzen put forth the Emergency Situation Awareness Theory, highlighting information perception and decision-making processes during emergencies [11]. The development of these theories reflects the evolving understanding of emergencies over time, providing a theoretical foundation for improving emergency management.

Jung et al. proposed a comprehensive framework to understand the intricacies of national responses to the COVID-19 pandemic, emphasizing the interplay among drivers, complexities, and uncertainties in handling such health emergencies [12]. Within this framework, pre-existing and structural systems are viewed as the outer context, and disease prevention and control strategies are viewed as the inner context, thereby capturing the evolving nature of pandemic conditions and the critical nature of evidence-led responses. Building upon this foundation and contextualizing it for China, our research integrated insights from Wang, who emphasized a scientifically based, full-cycle crisis management model tailored for infectious diseases [13]. This theory primarily focuses on the response process, including prevention and preparation, investigation and analysis, crisis warning, and response and recovery. Notably, this model accentuates the pivotal role of knowledge-sharing and information exchange in shaping efficient and adaptable responses to infectious threats.

In our study, we adapt and extend these frameworks into two main realms (Figure 1). The outer context encompasses pre-existing and structural components like national infrastructure spanning from health systems, legal frameworks, political institutions, and governance, and the social context influenced by culture, history, geography, and demographics. The inner context, which is more pandemic-driven and dynamic, focuses on China's specific response to the disease, prevention and control measures, and global engagement strategies. Central to our framework is the balancing act between socioeconomic factors and prevention and control efforts, with information technology serving as a powerful catalyst bolstering all aspects of the inner context. Taken together, this review offers an in-depth examination of China's response strategy to COVID-19, which should be viewed as coexisting, complementary frameworks that are best used in concert.

3.1 Global epidemic prevention and control system models

Across the globe, the approach of different countries to pandemic prevention and control are largely shaped by their governance structures and community mobilization capacities. Based on these attributes, we can categorize global epidemic prevention and control systems into four primary models, outlined below and in Figure 2.

The Decentralized Command System with Limited Community-Level Cooperation model is represented by countries such as the United States (US), Germany, and Austria. As federal republics, these nations exhibit regional variations in preventive measures, even in the presence of national guidelines or suggestions [14-16].

The Centralized Command System with Limited Community-Level Cooperation model is prevalent in some parts of East Asia, Southeast Asia, the Middle East, and North Africa. Although many countries have a unified central command system, it is difficult for community-level governments to implement policies on time [17, 18]. Factors like resource constraints, organizational issues, and prolonged conflicts in some Middle Eastern and North African areas, have hampered community-level governance and health care provision [19].

The Decentralized Command System with Strong Community-Level Cooperation model is relatively rare, with Sweden as an example. This model relies on the cooperation of its citizens to effectively control the spread of an epidemic and flatten the curve, thereby alleviating the strains on medical resources [20].

The Centralized Command System with Strong Community-Level Cooperation model is represented by countries like China and Israel [21]. Israel and some Gulf countries have performed relatively well in early containment and preventive measures, followed by extensive vaccination programs [19]. With its centralized command structure, China formulated the “one plan, three systems” policy. This approach, encompassing emergency plans and management systems, has resulted in a successful responded to outbreaks like severe acute respiratory syndrome (SARS), pandemic influenza A (H1N1) pdm09, human infections with avian influenza A (H7N9) virus, and COVID-19, with the active cooperation of communities and individuals [22, 23].

3.2 China's command system for epidemic prevention and control

In terms of a vertical chain of command, China's national COVID-19 prevention and control efforts were led by the Central Committee of the Communist Party of China, with General Secretary Xi Jinping heading the working group. Central and local administrations formed a monitoring and reporting network [24], where provinces, cities, and counties implemented a graded emergency response system across all levels (Figure 3) [25, 26].

In terms of intersectoral coordination, China established a joint prevention and control mechanism in 2009 to combat the global pandemic of H1N1 [27]. Led by the National Health Commission, the mechanism is a platform for coordinating the work of multiple ministries at the central government level.

3.3 Public social governance

In prevention and control of the COVID-19 pandemic, deficiencies in human resources have been a challenging issue faced by many countries [28-30]. To address this, involving multiple stakeholders in epidemic prevention and control is paramount [31]. Community-based models globally have yielded important results. For instance, village health volunteers in Thailand, female health workers in Pakistan, and health extension workers in Ethiopia have all had pivotal roles in their respective regions [32]. In particular, China has the strengths of community-level social governance and has managed to harness the collective power of village committees, community committees, property companies, and volunteers [33]. This strategy combines vertical (top-down command) and horizontal (geographic grid management) systems to locate the main responsible bodies and establish protective networks for epidemic warning, investigation, monitoring, and surveillance [34], thereby fortifying the effectiveness of COVID-19 prevention and control efforts [35, 36].

3.4 Laws, regulations, and contingency plans

Over the years, China has established a public health legal system based on the Constitution [37, 38] (Appendix Table A1). China issued the “Opinions on Punishing Crimes of Obstructing the Prevention and Control of the Novel Coronavirus Infection Pneumonia,” to strengthen public security and market supervision to ensure social order [39].

In terms of contingency plans, China has established a system of health emergency plans at different administrative levels. Since 2003, timely assessments and evaluations have been carried out for each public health emergency response [40]. Special risk assessments have been routinely conducted for major public health emergencies, natural disasters, accidents, and other large-scale events [41].

4.1 Emergency response

In the face of COVID-19 and other outbreaks, as well as other sudden disasters, the US [42, 43], Israel [44, 45] and some European countries [46] have established relatively complete emergency medical systems and mechanisms. When disasters occur, medical personnel, materials and medical resources can be deployed at the first time. China's response to the COVID-19 outbreak in Wuhan City and Hubei Province was marked by a surge in patient cases and a shortage of medical resources. Over 42,000 medical personnel from 346 national medical teams were summoned and deployed; 16 cities and counties in Hubei Province were directly supported by 19 other provinces and the military system [47]. Over 9,100 critical care beds were converted to treat severe cases, and resources were centralized to provide the best quality of care [48, 49]. For mild cases, a hierarchical prevention and treatment network was established using fangcang shelter hospitals, newly built hospitals, renovated existing hospitals, and requisitioned hotels and sanatoriums, among other facilities, to expand bed capacity in a short period of time [50]. Sixteen fangcang hospitals with more than 14,000 beds were built in 10 days, offering treatment to one-quarter of Wuhan's COVID-19 patients [47]. In just over 10 days, two hospitals (Huoshenshan and Leishenshan) were built using modular design [51].

The above coordinated emergency response measures led to improvements in patient admission and recovery rates, as well as reductions in infection and mortality rates. The recovery rate for severely ill patients in Wuhan City treated at designated hospitals increased from 14% to 89% [47] (Figure 4).

4.2 Medical care

With ongoing changes in the COVID-19 situation globally, countries continue to adjust their diagnosis and treatment strategies, especially with the emergence and rapid spread of highly transmissive and immune-evasive Omicron variants, which further accelerated the pace of such adjustments [52-54]. During the epidemic, China's health system was actively engaged in patient testing [55], contact tracing [56], isolation [57], treatment [58], education, and community management. Treatment and management strategies were continuously adjusted based on virus mutations and development of the epidemic [59]. Patients with suspected COVID-19 infection were triaged at fever clinics, and severe cases were treated at designated hospitals [60]. Hospitals with respiratory disease treatment capacity were placed on standby [61]. Isolation and treatment capabilities were enhanced by building fangcang field hospitals [62], isolation centers [63], and health stations for high-risk individuals [64]. Classified treatment involved accurate patient classification, with high-risk patients treated in designated hospitals, and mild cases and asymptomatic patients admitted to fangcang field hospitals. Post-recovery, patients were transferred home for self-isolation [65].

From November 2022 to February 2023, China enacted a series of measures to cope with the peak of infection, including increasing the number of fever clinics in secondary and tertiary medical institutions [66]. expanding the number of beds for severe cases [66] and strengthening the capacity building of primary health-care institutions [67]. Public hospitals played a crucial role, effectively handling the daily increase of 10,000 patients with severe illness during the peak of the pandemic. During the transition period, nearly 800,000 severely ill patients received effective treatment, with a single-day peak of 128,000 hospitalized patients with severe illness. Despite these challenges, the COVID-19 mortality rate in China remained at the lowest level globally [48].

4.3 Evidence-based national guidelines

The National Health Commission of China has disseminated 10 versions of the “Diagnosis and Treatment Protocol for COVID-19 Patients” to direct clinical diagnosis, management, treatment, and care. Refinements and modifications to the protocol were supported by evidence-based medicine and progression of the pandemic in China [68]. For instance, the third version introduced nucleic acid testing for diagnosing suspected and confirmed cases [69]. Later, the eighth version established this as the “gold standard” for diagnosis [70]. Owing to the surge in cases during the Omicron outbreak and the constraints in nucleic acid testing capacity, the ninth [65] and tenth versions [71] of the protocol incorporated antigen testing as an auxiliary method. As scientific understanding of COVID-19 advanced and antiviral drugs became more available, the protocol underwent continual improvements in terms of general treatment and critical care. Traditional Chinese medicine (TCM) has also been incorporated into the treatment of COVID-19, known as the “China Solution.” In patient care, the signature “three medicines and three prescriptions” approach was recommended by experts alongside nonpharmacological therapies, such as acupuncture [72].

5.1 Overview of international prevention and control measures

The preventive and control measures adopted by different countries are usually related to their population distribution; geographic location; political, economic, and cultural factors, and their policy implementation capacity [73]. For example, countries with greater health-care resources tend to implement more preventive and control policies [74]. Countries with more neighboring countries tend to implement more border control policies, and countries with denser populations have adopted mask-wearing policies [20].

Among all countries, mandatory mask-wearing, testing and contact tracing, and travel restrictions are associated with more favorable health outcomes during the outbreak. Although these findings are consistent with COVID-19 mathematical models, the effectiveness of such policies depends on their implementation levels [75].

5.2 Adapting prevention and control measures

China has continuously adjusted its prevention and control measures based on virus mutations, epidemic changes and vaccination coverage [76]. China's policies has evolved through three phases: emergency prevention and control, normalized emergency prevention and control, and the transition from normalized emergency prevention and control to regular prevention and control. To ensure a stable transition as the pandemic progressed, the “20-point measures” and “Additional 10-point measures” were introduced [77, 78]. These efforts have resulted in the successful management of cluster outbreaks and have ensured a stable transition between phases [79]. By adopting situation-appropriate prevention and control measures at different stages, China has been able to withstand the impact of multiple global pandemic waves with minimal cost.

5.3 Timely control of infection sources

In China, a robust network of nucleic acid and antigen testing capabilities has been established [80, 81]. Innovative methods, such as stratified, block-based, grid-based, and rolling nucleic acid screening, have been explored to increase efficiency while minimizing the impact on daily life [82].

A multi-triggered monitoring system has also been developed, which includes medical institutions [83], fever clinics, pharmacies, and private clinics as “sentry posts” [84].

A large-scale infectious disease network reporting system has been established. Following the 2003 SARS epidemic, China built a national system in 2004, covering nearly all secondary and higher medical institutions and including 350,000 staff members [85].

Rapid isolation of infection sources and high-risk individuals has been prioritized. These facilities have implemented centralized and home isolation measures for individuals with COVID-19 infection or at high risk of infection [86].

Continuous monitoring of variant strains has been conducted. This has enabled a dynamic understanding of genetic variations of SARS-CoV-2 and their potential impact on vaccines, drugs, and the overall risk of pandemic prevention and control [87].

5.4 Disruption of transmission routes

A closed-loop management system was established in China to oversee pandemic prevention and control from the perspective of international to domestic scenarios, encompassing departments such as border control and customs, diplomacy, health, transportation, civil aviation, and disease control [88].

Efficient epidemiological investigations have been carried out via individual case investigations and cluster outbreak investigations, which are promptly reported through a network reporting system [89].

Scientific management of mobility has been enacted at both individual and regional levels (Table 1) [90]. And extensive education and promotion have been conducted to encourage individuals to take responsibility for their own health [91].

5.5 Building population herd immunity

Since December 2020, vaccinations have been strategically administered in phases to those groups that are most susceptible to infection [92]. To continuously monitor the gap between establishing an immunity barrier and addressing vaccine hesitancy among key groups [93], China has implemented incentives, improved the multi-level adverse reaction reporting system, and instituted a compensation plan in case of adverse events [94] (Figure 5).

Postvaccination safety and efficacy tracking surveys have taken place to evaluate the immunity barrier in the Chinese population. Statistics on SARS-CoV-2 immunoglobulin (Ig) M and IgG antibody levels among the population have been routinely collected [95].

China has implemented measures to protect vulnerable groups. Local governments have implemented tiered health management based on the level of health risk, utilizing color codes [94].

Efforts have also been made to expedite the development of broad-spectrum vaccines, multi-valent vaccines, and new vaccines targeting current and potential epidemic strains (Table 2) [95].

5.6 Information technology empowerment

5.6.2 Practical experience in China

China has effectively applied information technologies to manage the COVID-19 pandemic, with a focus on clinical medical services (online hospitals and telemedicine) [105], public health responses (digital health codes, travel cards, drones, thermal imaging devices, and facial recognition) [106], and emergency preparedness planning (e-commerce and logistics) [107]. Advanced technologies including mobile networks, big data, cloud computing, the Internet of Things, AI, and 5th generation mobile communication technology (5G) have provided crucial technical support in China's COVID-19 response efforts [108].

At the outset of the COVID-19 outbreak, to enhance contact tracing, isolation, and clinical management efficiency, technology companies such as Tencent and Alibaba partnered with the Chinese government to launch health codes on WeChat and Alipay platforms. Initially implemented in Shenzhen and Hangzhou in February 2020 [109], the health code system was adopted by all 31 provincial administrative regions within 39 days, becoming an indispensable tool for Chinese citizens during the pandemic [110]. The system comprises five categories of information: basic information, health risks, nucleic acid testing, vaccine information, and travel information [111, 112] (Figure 6a). Furthermore, user-friendly features (“health codes for family” and “health codes of others”) were designed for vulnerable groups such as older people and children.

From April 8, 2020, overseas travelers were required to declare the international version of the health code and present a negative nucleic acid test result before entering China [113]. To detect and intervene in the pandemic, the health code was required in public places or while using public transport. Medical institutions had stricter regulations, requiring patients to report their information and obtain a green flow control code before seeking treatment [114]. For cross-regional travel, individuals had to self-declare on the destination city application platform, obtain the local health code, and be assessed for risk level, which determined their entry status and potential isolation management measures [115] (Figure 6b).

6.1 Macroeconomics

The concern that the pandemic would lead to economic recession is indisputable [122, 123], but researchers differed on the correlation between the stringency of COVID-19 measures and losses in gross domestic product (GDP) [124]. Some studies based on production or equilibrium models have estimated the direct effects of COVID-19 shutdowns on macroeconomics, suggesting that tougher COVID-19 measures and lockdown would cause greater GDP losses [125-127]. However, by comparing the macroeconomic outcomes of countries that adopted different COVID-19 policies, no significant trade-off was found between restrictive policies and GDP [128]. Furthermore, when including the costs of infection in cost–benefit analyses, countries adopting stricter containment strategies have shown a less severe effect on GDP growth [129, 130].

China prioritized economic recovery while implementing pandemic prevention and control measures. Early in the COVID-19 epidemic, enterprises producing critical pandemic-related materials were encouraged to resume production [86, 131]. Since April 2020, virus-specific guidelines for various industries and public settings were issued, facilitating the safe resumption of normal activities [132]. Support was also provided to small and medium-sized enterprises to stimulate consumption [133] through tax reductions, financial credit, and insurance schemes [134-136]. As a result, China's economy grew by 2.3% in 2020, making it the only major economy to maintain positive growth [137]. In 2021, China's GDP grew by 8.4% [138], with its import and export scale reaching a record USD 6.05 trillion, a year-on-year increase of 21.4% [139]. In this way, the experience of China offered a new perspective on the interaction between public health measures and macroeconomics.

6.2 Supply of essential goods

The availability of crucial medical supplies and daily necessities received widespread attention. The outbreak caused a sudden increase in the need for masks, ventilators, and other medical products [140, 141]. Many countries encountered extreme shortages of personal protective equipment (PPE), even in developed countries such as the US [142], the UK [143], and Japan [144]. Disruptions in the PPE supply chain and the uncontrolled distribution of inventories were the main reasons behind these shortages [145, 146]. Beyond PPE, the food supply also raised concerns about food insecurity caused by unemployment, poverty, and the breakdown of food production and distribution chains during the pandemic [147-150].

By organizing the resumption of production in industries that manufactured critical medical supplies and taking full control over production and distribution [131, 134], a national distribution platform was established by the Chinese government to ensure the rapid, orderly use of these supplies, prioritizing key regions, key operations, and key patients, especially those with severe illness [151]. On a social level, many state-owned and private enterprises offered to shift their focus to produce medical supplies and protective equipment [152-154]. Through these efforts, China was able to produce 3.4 million medical N95 masks and 1.5 million sets of disposable protective suits daily [4]. To ensure the availability of daily necessities such as grain, vegetables, and meat during lockdowns, governments set up “Green Channel” and e-commerce platforms to secure these supplies [155-159]. For individuals under at-home quarantine, community-appointed personnel regularly delivered daily necessities [160].

6.3 Vulnerable populations

The working and living conditions of frontline health workers and other vulnerable groups in society have also been widely discussed. Great challenges such as adapting to changes in disease progression, facing a high risk of infection with limited protective equipment, and burnout owing to extended working hours made frontline health workers a particularly vulnerable group during the pandemic [161-163]. Similarly, elderly adults, children, disabled people, and other disadvantaged subgroups also faced higher risks of infection and struggled to survive during the pandemic, with their health and livelihood negatively affected [164-166].

China enacted a set of measures to address the above issues [167]. Except for the priority allocation of PPE, the government requested all units to fully support daily services for medical personnel, such as providing good conditions for adequate rest, essential drugs, and nutritious dining services. Civil affairs departments and communities arranged temporary or long-term living care for elderly and disabled people as well as minors lacking guardianship owing to the pandemic [168]. Timely assistance, such as temporary accommodation and food, was provided to those stranded as a result of traffic and mobility controls [169].

6.4 Mental health

As a global health emergency, COVID-19 also led to a mental health crisis. The adverse psychological impacts related to COVID-19, such as anxiety and depression disorders, sleep disorders, increased suicide risk, and posttraumatic stress disorder (PTSD), which are likely to be associated with physical symptoms, became more prevalent in the general population [170-173]. Social distancing, economic hardship, health risks, discrimination, and stigmatization are considered the main factors contributing to these adverse psychological effects [174, 175]. Many intervention measures have been proposed, such as providing resources for psychological support, timely updating of evidence-based information, and reducing loneliness using online platforms [174, 175].

In comparison with other countries, good acceptance of mask-wearing and hand hygiene, experiencing fewer physical symptoms, and greater access to health information in China led to lower levels of anxiety and depression [176-178]. To alleviate post-traumatic stress disorder (PTSD) among the general population, all provinces in China offered a 24-h psychological assistance hotline that could provide free psychological counseling, especially for health workers. Additionally, timely and effective provision of health information online [179], including webcasts showing the construction of makeshift hospitals, helped many Chinese people overcome the quarantine period and feel positive about the actions of the government, greatly alleviating psychological pressure among all residents of China.

7.1 Knowledge-sharing and information exchange

The Chinese government places great emphasis on international dialogue [186] and is highly committed to global pandemic prevention efforts [187]. As summarized in the Timeline on COVID-19 Information Sharing and International Cooperation [188], China quickly informed the WHO about the COVID-19 outbreak, identified the causative pathogen [189], released autopsy results of infected individuals, and shared the virus's genome sequence [190]. Diagnostic and treatment guidelines were subsequently published, translated, and commended by the WHO [191].

An academic sharing platform facilitated nationwide research into the origin of SARS-CoV-2, clinical treatments, and testing methods [192]. China's comprehensive reporting of drug screening results and essential treatment techniques fostered global information sharing [193]. Universities, hospitals, Chinese citizens overseas, and international students actively disseminated preventive measures [159], encouraging many countries to adopt stricter public health strategies [194, 195] (Table 3).

7.2 Bilateral assistance and multilateral supply

Initially receiving international support, China later became a crucial global supplier of pandemic prevention materials [185], demonstrating a generous and selfless spirit of international cooperation [196]. Policies, management manuals related to the construction of fangcang hospitals, and clinical guidelines were translated, and medical expert teams were dispatched to 34 countries [197, 198]. By learning from the experience in China, other countries could identify appropriate methods to control the pandemic [199, 200].

In May 2021, China's COVID-19 vaccine was included in the Emergency Use Listing. The Chinese government pledged to make the COVID-19 vaccine available on the basis of the global public good and to cooperate with developing countries in vaccine production and supply [201]. China has also promoted TCM via more than 100 live online events, introducing prevention and treatment solutions to more than 150 countries and regions.

China supports international organizations such as the United Nations, WHO, African Union, and World Food Program, assisting in fundraising, procurement, and stockpiling [202]. Public–private partnerships are encouraged, mobilizing domestic and international organizations to provide material supplies, online forums, and volunteer support (Table 3).