Research on Innovative Practice and Improvement Strategies of Government Purchasing Services in the Patriotic Health Movement in the New Era ()
1. Introduction
To support the effective development of the Patriotic Health Campaign in the new era, the State Council of the People’s Republic of China issued the “Opinions on Deepening the Patriotic Health Campaign” (hereafter referred to as the “Opinions”) on November 27, 2020. Article 16 of the Opinions stipulates: “Strengthen social mobilization and support the active participation of social organizations, professional social workers, and volunteers through measures such as government procurement of services (i.e., the government contracts out certain public service tasks to qualified social organizations or enterprises based on performance and cost)”. This provision introduces, for the first time, government procurement of services into the social mobilization mechanism of the Patriotic Health Campaign. It indicates that, as China’s national governance system and capacity modernize, the new-era Patriotic Health Campaign will actively adopt more established tools and methods of modern public governance. However, this provision remains broad and preliminary, and it needs further clarification and elaboration. Accordingly, this paper analyzes the necessity of using government procurement of services to promote the Patriotic Health Campaign, examines the current challenges it faces, and proposes policy recommendations for applying government procurement of services from a broader perspective. Before proceeding, three concepts merit clarification. “Government procurement of services” refers to the government contracting out specific public service tasks to qualified non-governmental entities based on performance and cost. “System supply” means the institutional framework of laws, regulations, and implementation rules. “Exit mechanism” denotes procedures for terminating contracts when service providers fail to meet standards. This study focuses primarily on service procurement; goods and construction are included only descriptively.
2. The Necessity of Government Procurement of Services for the Patriotic Health Campaign
2.1. Better Meeting the Growing Health Needs of the People
As the new era unfolds, the public’s health needs have become increasingly multi-layered and diverse, encompassing both the demand for basic medical and health services and the desire for a high-quality lifestyle. This requires the Patriotic Health Campaign—which relies primarily on social mobilization—to be not only scientifically planned and centrally led but also vigorously implemented for greater effectiveness. If the existing model of centralized state oversight and management is maintained, it will be difficult to adapt organization, mobilization, and implementation to different times, places, and situations, and thus impossible to meet the people’s diverse health needs promptly. By procuring services, certain tasks within the Patriotic Health Campaign can be entrusted to more suitable or specialized organizations, thereby achieving broad mobilization and precise implementation to meet the people’s varied health needs.
2.2. Better Aligned with the Intrinsic Requirements of the Healthy China Initiative
From its early focus on countering biological warfare and eradicating the “four pests”, to the “Two Controls and Five Improvements” and the “Toilet Revolution”, and then to the “Five Emphases and Four Beauties” and the creation of National Sanitary Cities, every stage of the Patriotic Health Campaign has been closely integrated with China’s economic and social development context. In line with the requirements for building a Healthy China in the new era, the “Healthy China 2030” calls for further streamlining administrative procedures, delegating power while improving oversight, and optimizing services in health-related fields. It specifically cites government procurement of services as a method in areas such as “establishment of medical institutions” and “public sports services”. Promoting government procurement of services is a crucial means for China to accelerate the transformation of government functions, improve national governance capacity, advance supply-side structural reform, and better meet the public’s demand for services. This approach aligns more closely with the theoretical and practical logic of modern public health governance. In this vein, using government procurement of services to promote health initiatives within the Patriotic Health Campaign inherently aligns with the theme of the Healthy China strategy: “Joint Construction and Shared Benefits, Health for All”.
2.3. Further Promoting the Effective Implementation of the Patriotic Health Campaign
First, government procurement of services improves the effectiveness of the government’s efforts to promote the Patriotic Health Campaign. It can optimize the allocation of funds for the campaign, improve the efficiency of fund use, and, through competitive mechanisms, promote social mobilization, organization and implementation, as well as supervision and inspection. This significantly enhances the campaign’s effectiveness and the government’s responsiveness. Second, it raises the professionalism of the Patriotic Health Campaign. As the government’s responsible authority, the Patriotic Health Campaign Committee has limited staff and defined responsibilities; it cannot possibly possess all the specialized knowledge required for such a broad-based campaign. By procuring services from external providers, the government can delegate specialized tasks to professional organizations or individuals, thereby elevating the campaign’s professionalism. Relevant departments can then monitor the whole implementation process, solicit feedback, and be subject to public oversight [1], which in turn helps fulfill the campaign’s health promotion functions.
3. Current Status and Issues regarding Government Procurement of Services for the Patriotic Health Campaign
3.1. Forms of Government Procurement of Public Health Services in China
Government procurement of services in the health sector is not a new practice. Since 2002, many localities in China have piloted government procurement of public health services, giving rise to a variety of models.
1) Public Health Service Vouchers. In 2004, Chun’an County, Zhejiang Province, introduced a public health service voucher system to address rural public health needs, specifying five types of free services [2]. In 2005, Qianjiang District, Chongqing Municipality, implemented locally tailored rural maternal and child health care service vouchers [3].
2) Contract-Based Outsourcing. In early 2005, the Wuxi municipal government outsourced tuberculosis prevention and control—a public health initiative—to the privately run Anguo Hospital through a contract. Relevant government departments oversaw and evaluated the program, which was also subject to rigorous patient feedback [4].
3) Internal Contracts. The government has introduced market mechanisms within public community health service institutions, separating service provision from procurement and implementing performance-based payments [5]. All 12 community health service institutions in Hefei that are operated by private enterprises participate in the implementation of basic public health service projects on an equal footing with similar public medical institutions, creating a landscape of orderly competition. Shenzhen ensures the effective provision of health services through market access mechanisms and government procurement models, conducting open tenders to attract broad participation from all sectors and guarantee service effectiveness and efficiency [6].
These various forms of government procurement of public health services in China have been reported in the literature to have achieved certain results, such as improved service quality in specific pilot areas (e.g., Wuxi’s TB control program). However, these outcomes are context-specific and not directly generalizable; the present study focuses on the adoption patterns rather than causal effectiveness. Aspects such as the scope of procurement, procurement procedures, and procurement oversight also provide valuable lessons for government procurement within the Patriotic Health Campaign.
3.2. The Current Status of Government Procurement of Services in the Patriotic Health Campaign
Due to differences in confidentiality requirements and other factors, the disclosure levels, methods, and volume of publicly available data vary significantly across provinces and municipalities. Therefore, we used the China Government Procurement Network as the search benchmark and conducted a full-text search of procurement notices using the keyword “Patriotic Health Campaign”. From the issuance date of the Opinions to the present, a total of 203 relevant entries were initially identified from the China Government Procurement Network. After removing duplicates (multiple notices for the same project, such as bid announcements, correction notices, and contract awards, were counted only once; identical projects published in different provinces and municipalities directly under the central government. were counted as one), 86 unique procurement notices remained from 19 provinces and municipalities directly under the central government (Figure 1). These notices were manually classified into three types based on the “procurement category” field or project description: services (56 notices, including vector control, campaign planning, and health education), goods (24 notices, e.g., medicines and promotional materials), and construction (6 notices, e.g., restroom renovation and sewage station construction) (Figure 2). There were 6 procurement notices for construction projects, covering five categories: construction of fecal sewage treatment stations, renovation of rural public restrooms, elevator installation, road repair, and domestic sewage unblocking projects. However, these figures only indicate the adoption and geographic spread of government procurement in the Patriotic Health Campaign; they do not by themselves demonstrate improved service quality, efficiency, or public trust. Direct evidence of policy effectiveness must come from program evaluations. Existing studies on specific procurement programs have reported positive outcomes: for example, Wuxi’s contracted TB control program achieved higher patient satisfaction and treatment completion rates compared to traditional models; Shenzhen’s open tender process for community health services improved service responsiveness and cost-effectiveness. Nonetheless, systematic, large-scale effectiveness evaluations of procurement under the Patriotic Health Campaign remain limited, which is a gap this study aims to highlight.
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Figure 1. Procurement announcements by Chinese provinces and municipalities directly under the central government.
Figure 2. Purchases by project type.
The government has always had procurement needs for various goods. Against the backdrop of major disease prevention and control, goods procurement projects mainly focus on epidemic prevention drugs and medical devices, but also include the purchase of materials such as promotional display boards and advertising materials. Danfeng County leases bus shelters and bus stop signs to display public service advertisements about core socialist values, the Chinese Dream, and the Code of Civilized Conduct for Citizens. This initiative aims to encourage the general public to actively participate in consolidating and enhancing the county’s status as a provincial-level “Civilized County”, thereby continuously improving citizens’ civilized conduct and raising the city’s overall level of civilization. Service procurement projects primarily focus on vector control, outsourcing environmental disinfection services to specialized social institutions, and achieving new breakthroughs in environmental sanitation maintenance and the planning of public health campaigns. Baolong Subdistrict, Longgang District, Shenzhen, has issued a public tender for emergency disinfection services for the prevention and control of major diseases; Zhuhai Media New Media Operation Co., Ltd. is providing planning services for the “Ten Thousand People March” campaign under the New Era Patriotic Health Campaign in Zhuhai. This represents a new initiative by the government to procure conference and exhibition services within the Patriotic Health Campaign, enabling more professionals to participate in the movement.
At the same time, an internet search was conducted, with the search period limited from November 27, 2020, to February 25, 2022. Using Python web scraping technology, web pages containing the keywords “Patriotic Health Campaign” and “government procurement” were crawled. The obtained URLs were filtered using the “.cn.gov” keyword to identify government websites, resulting in 41 media reports and 57 government reports related to government procurement for the Patriotic Health Campaign (Figure 3). For example, the Nanyang Municipal Government has successively invested over 200 million yuan to vigorously advance inland river management, while the Municipal Patriotic Health Campaign Office allocated more than 2 million yuan to purchase vector control services, conducting large-scale disinfection and pest control operations in key areas such as inland rivers in the central urban area, the Bai River Scenic Area, squares, and parks [7]. Wangcheng District of Changsha invested 300,000 yuan to standardize vector control facilities in its subordinate subdistricts. It hired a third-party company to focus on private establishments such as restaurants, hotels, and hair salons, providing services including the standardization of “three-prevention” facilities, distribution of pesticides, and technical guidance. By targeting key units in public areas of the urban district, the district effectively reduced vector density and minimized the harm caused by vectors [8]. Shijiazhuang City has focused on vector control, smoke-free environment initiatives, and health literacy campaigns. By leveraging the media to spread its message, the city has widely organized online discussions and reward-based reporting programs to disseminate health knowledge to the public and promote a healthy, eco-friendly approach to public health [9].
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Figure 3. News releases by Chinese provinces and municipalities directly under the central government.
In summary, government procurement of services for the Patriotic Health Campaign mainly covers two aspects. First, purchasing service-oriented projects—such as environmental sanitation improvement and infectious disease prevention and control—from social organizations. In response to the requirements of different stages of major disease prevention and control, the National Patriotic Health Campaign Office has launched a series of special campaigns focusing on the market environment and living and working environments. Provinces, municipalities, and various organizations carry out targeted vector control efforts and issue procurement notices for vector control services and supplies. Second, the procurement of goods such as medical equipment, pharmaceuticals, and promotional materials. As part of the Patriotic Health Campaign, localities across the country conduct public education campaigns centered on themes such as promoting patriotism, personal protection, and eliminating poor hygiene habits. Through government procurement of Patriotic Health promotional items and services, they organize various health theme days and Patriotic Health awareness campaigns.
3.3. Challenges Faced in Government Procurement of Services for the Patriotic Health Campaign
3.3.1. Insufficient Institutional Framework for Service Procurement
The Central Committee of the Communist Party of China and the State Council attach great importance to government procurement of public services. They have issued policies and regulations such as the “Decision of the Central Committee of the Communist Party of China on Several Major Issues Concerning Comprehensively Deepening Reform” and the “Measures for the Administration of Government Procurement of Services”, which stipulate requirements regarding procuring entities, service providers, and performance evaluation. However, China’s legal framework for government procurement of services does not contain specific provisions regarding the Patriotic Health Campaign. Consequently, the procurement of services for the Patriotic Health Campaign has not yet established campaign-specific institutional guidance. This is manifested in: an ongoing development of supervision and management mechanisms for the procurement of Patriotic Health Campaign services; although local authorities have established certain regulations, these are established at the local level, leading to variations in regulatory approaches across regions; and varying interpretations across regions regarding the scope of services related to the Patriotic Health Campaign that are eligible for procurement.
3.3.2. The Scope of Services Covered Is Too Narrow
Whether based on the Opinions or local practices, procurement under the Patriotic Health Campaign has been largely limited to environmental services, primarily focusing on environmental remediation services, urban public health services, and biochemical products. This scope is far too narrow. Efforts could be made to integrate goods procurement into the service procurement framework, broadening the scope as much as possible and entrusting more procurement decisions to professional organizations. Public service projects such as cultural public services, public awareness campaigns, and exhibition services could also be developed for service procurement.
3.3.3. The Operational Mechanisms for Purchasing Services Need to Be Improved
First, there is a lack of evaluation and oversight mechanisms. Because government procurement of services in China started late and relevant experience is limited, certain issues persist across the country regarding the evaluation and supervision of public health services. China mainly relies on government-led evaluations, but the entities responsible for these evaluations are not rationally designated, and there is a lack of professional evaluation systems and robust oversight mechanisms [10]. Second, there is a lack of effective communication and collaborative management mechanisms in the procurement process. The government lacks comprehensive communication mechanisms and effective communication channels. There is also a lack of robust collaborative management mechanisms between the government and service providers, leading to instances where information is lost, distorted, or delayed during transmission. This results in information asymmetry between the collaborating parties, causing unnecessary losses for both sides [11] [12].
It should be noted that the above findings are based on publicly available procurement notices, government reports, and media reports. Regional differences in information disclosure may underrepresent actual procurement practices, and the absence of internal performance evaluation data limits the ability to assess policy effectiveness directly.
4. Analysis of Forms of Government Procurement of Services in the Health Sector Abroad
To draw lessons for China, this section examines three distinct models of government-purchased health services: the contract-based US system, the purchaser-provider split in the UK’s NHS, and the community-led Total Sanitation Campaign in India, each representing market, institutional, and mobilization approaches, respectively.
4.1. The United States: Contract Outsourcing as the Primary Form
In the United States, the most common model for purchasing services is to outsource public services to private organizations. Government agencies enter into contractual relationships with private entities, stipulating that the private entities provide services to the public while the government agencies exercise oversight. The benefits of outsourcing health services include reducing the size of government agencies, promoting competition, improving service quality, reducing government spending on public health services, and encouraging service providers to take greater responsibility [13]. The drawbacks are that, if abused, this model may hinder other organizations from competing in this service sector, and long-term partnerships may lead government agencies to neglect oversight of service quality [14]. The US experience highlights the value of a robust legal framework (e.g., the Federal Acquisition Regulation) and performance-based contracting. However, its highly marketized health system differs fundamentally from China’s public-dominated model, so direct replication of its procurement scope is inappropriate.
4.2. The United Kingdom: Universal Public Healthcare
The United Kingdom is a well-known example of a country that has adopted the National Health Service (NHS) model. Its most distinctive feature is that it is primarily tax-funded, with the government providing free healthcare services to all citizens. Through measures such as corporate governance of healthcare institutions and decentralization reforms, the government has facilitated a shift in its functions and gradually established an internal market management system and operational mechanism that separates purchasers from providers [15]. The advantage of this model is that it clearly delineates the scope and domains of service procurement and defines the responsibilities of all parties [16]. However, as an aging population and socioeconomic development drive an increase in demand for health services, the growing demand for medical care coupled with constraints on fiscal budget expenditures has become the most significant challenge hindering the development of the National Health Service. The UK’s purchaser-provider separation mechanism offers a model for improving transparency and professionalism. But the NHS model relies on high tax revenues and a universal coverage system that China’s current fiscal structure cannot fully support, so selective adaptation is advised.
4.3. India: The Total Sanitation Campaign (TSC)
In 2004, the Indian government launched the Total Sanitation Campaign (TSC), a community-led, people-centered, incentive-based, and demand-driven initiative aimed at improving rural sanitation by constructing sanitation facilities to eliminate open defecation in rural areas. India’s Department of Drinking Water and Sanitation (DDWS) allocates 80% of TSC funds to the states. The TSC encourages rural communities to lead their own sanitation improvement efforts under the guidance of general practitioners and with the active participation of community groups. Government officials at the district and ward levels work with communities to ensure that the TSC remains a bottom-up movement. Research indicates that the TSC has improved the health and human capital of Indian children and encouraged villages to build and use toilets; however, sanitation coverage remains incomplete [17]. India’s incentive-based, community-led approach provides a reference for mobilizing grassroots participation in environmental health. However, the TSC has suffered from incomplete coverage and poor maintenance, and China already has a stronger community governance network (e.g., grid management), so cash-incentive models should not be imitated uncritically.
4.4. Summary
A review of experiences from other countries reveals the following characteristics:
1) Based on institutional frameworks. In the process of purchasing health services, policy formulation is one of the three core areas of focus for local governments in the United States [18]. The United States was one of the first countries to implement government procurement of public services and has a relatively well-developed legal framework governing such procurement. The US Congress has established the Federal Acquisition Act and the Federal Acquisition Regulation as the cornerstone of government procurement, strictly defining procurement policies and standards. In the United Kingdom, every stage of the NHS’s operations is underpinned by a legal framework, particularly the Health and Social Care Act of 2012. Under this Act, the NHS underwent large-scale restructuring and reforms to its funding allocation methods, aiming to provide patients with more choices and to improve services through competition [19].
2) Expand procurement across multiple sectors. As the economy grows and government finances improve, the government should appropriately expand the scope of its procurement. In the United Kingdom, in addition to procuring standard services such as maternal and child health care, health education, mental health care, and chronic disease management, the government also procures health care services for people with disabilities. At the same time, the government uses various channels and methods to assess public needs, which in turn inform its decisions regarding the health services to be procured.
3) Enhance effectiveness through multiple mechanisms. India encourages villages to actively build public toilets by offering post-construction rewards in the form of goods, monetary incentives, and other forms of support. In the 1980s, the UK’s NHS began separating the planning of healthcare services from the procurement and delivery of those services. The government established regulations, procured services through contracts, treated all healthcare providers equally, introduced a competitive mechanism, and assumed responsibility for oversight.
5. Strategies for Improving Government Procurement of Services in the Patriotic Health Campaign
Based on the challenges identified above, this section proposes corresponding strategies. Drawing on international experiences with government procurement of health services and incorporating China’s practical experience in procuring public health services, the following improvements should be made to enhance the effectiveness of government procurement in the Patriotic Health Campaign and to fulfill its health promotion functions.
5.1. Improving the Institutional Framework for Service Procurement
To address the insufficient institutional framework, improving the legal and policy basis for service procurement is essential. The “Implementing Regulations of the People's Republic of China Government Procurement Law”, issued in 2015, clearly state that “the term ‘services’ as referred to in Article 2 of the Government Procurement Law includes services required by the government itself and public services provided by the government to the general public”. In the detailed “Guiding Catalogue for Government Purchase of Services at the Central Government Level”, public service items such as education, social security, and public health are all included. However, for the Patriotic Health Campaign—which places greater emphasis on the concept of “comprehensive health”, integrated governance, and broad social mobilization—there are currently no specific laws, administrative regulations, or local rules defining its scope. Until the national legislation is amended to include specific provisions regarding the procurement of services for the Patriotic Health Campaign, provincial-level people’s governments may issue local regulations or policies that implement government procurement for the Patriotic Health Campaign. This would help avoid arbitrariness in practice and enhance consistency within a specific geographical area.
5.2. Expand and Formally Define the Scope of the Purchased Services
In response to the overly narrow scope of procurement identified, the range of purchasable services should be reasonably expanded and formally defined. The Patriotic Health Campaign encompasses multiple areas, including health education, urban sanitation, infectious disease prevention and control, and environmental protection. However, given the varying levels of economic and social development across different regions, the scope and catalog of services procured may differ. In standardizing the scope of procurement, it is necessary to adhere to the principle of combining uniformity with flexibility: while basic services related to the Patriotic Health Campaign can be uniformly defined, development-oriented services tied to local conditions should be determined autonomously by each region based on actual circumstances. In the realm of cultural public services, services related to cultural and artistic creation, performance, and exchange for the Patriotic Health Campaign can be expanded to support mass cultural activities. In public information and publicity services, public service announcements and exhibition services specifically dedicated to the Patriotic Health Campaign should be developed.
5.3. Establish an Exit Mechanism
Given the lack of exit mechanisms as part of the weak operational framework discussed, it is necessary to establish clear procedures for contract termination and service transition. In the process of government procurement of services for the Patriotic Health Campaign, governments at all levels have emphasized that the procurement guidance catalog should be binding. Services not included in the health service guidance catalog must continue to be provided directly by the government; those unsuitable for delivery by social entities must not be procured from them. This further clarifies the functional boundaries between the government and the market, which not only helps curb “overstepping” by the government in the procurement of Patriotic Health services but also enhances government efficiency and credibility [20] [21].
5.4. Establish a Monitoring and Evaluation System
To remedy the weak supervision and evaluation systems mentioned, a comprehensive monitoring and evaluation system involving the government, the public, and third parties should be established [22] [23]. To strengthen the regulatory mechanism for government procurement of services related to the Patriotic Health Campaign, it is necessary to establish a comprehensive supervision and evaluation system comprising the procuring entity (the government), the service recipients (the public), and third parties (entities outside the government and social organizations), thereby making third parties key participants in the regulatory process [24]. When introducing independent, professional third-party evaluation agencies, governments should formulate reasonable funding budgets based on the specific content and methods of the evaluation work, and provide effective oversight of fund usage. This ensures that procurement is conducted in a standardized and efficient manner, eliminates the practice of indiscriminate, campaign-style purchasing, and achieves the goal of procuring services to enhance the quality of government public health initiatives.
NOTES
*First author.
#Corresponding author.