Advancing universal health coverage through non-medical interventions: the evolution and equity of China’s National Fitness policy system

Background: Physical inactivity is a primary driver of non-communicable diseases (NCDs), posing a significant threat to the fiscal and operational sustainability of Universal Health Coverage (UHC). In China, the National Fitness initiative serves as a critical preventive health framework within the "Healthy China 2030" strategy. This study evaluates China's 70-year evolution of physical activity policies as a large-scale, non-medical public health intervention, aiming to provide governance lessons for global health systems seeking sustainable UHC solutions. Methods: We analyzed 145 central-level policy documents issued between 1949 and 2021 using a mixed-methods approach. Specifically, We employed quantitative attribute assessment for temporal mapping, Social Network Analysis (SNA) to identify interdepartmental governance structures, Latent Dirichlet Allocation (LDA) for thematic priority modeling, and qualitative coding based on Ramesh's framework to evaluate the distribution of policy instruments for health promotion. Results: Policy activity has surged since 2012 (74% of current policies), reflecting a strategic shift toward preventive healthcare. The governance network exhibits a centralized structure where the General Administration of Sport collaborates with a "Golden Triangle" of the Ministries of Education, Health, and Finance, though broader multisectoral integration remains nascent. Thematic analysis reveals a focus on "hardware" foundations (facilities, funding) and vulnerable populations (youth and older adults), aligning with UHC's equity goals. However, gaps persist in "sports-health integration" and digital health adoption. Policy instruments are heavily skewed toward command-and-control measures (68.4%), with market-based and voluntary incentives significantly underutilized. Conclusion: China's model demonstrates how state-led, non-medical interventions can rapidly expand preventive service coverage. To ensure long-term UHC sustainability, the governance model must transition from an infrastructure-centric, state-led approach to a multi-stakeholder, integrated governance framework. Enhancing interdepartmental coordination ("Fitness in All Policies") and rebalancing policy instruments are essential for building a resilient, equity-oriented public health system that reduces the long-term burden on curative medical services.