Strengthening the Frontline: A Qualitative Evaluation of Emergency Response Capacity at Grassroots CDCs in Post-Pandemic China

Public health emergencies refer to sudden occurrences of diseases or health events with large-scale and serious hazards that have a significant impact on public health and social stability¹. Such events may be caused by infectious diseases, natural disasters, environmental pollution, and other factors, such as influenza epidemics, earthquakes, chemical leaks, etc. Within the past two decades, acute infectious diseases have contributed significantly to the emergence of public health emergencies worldwide, posing severe threats to both global health and the economy^2,3. In recent years, China has also experienced several outbreaks of acute infectious diseases, including severe acute respiratory syndrome (SARS) in 2003, H1N1 influenza in 2009, H7N9 avian influenza in 2013, and the novel coronavirus pneumonia (COVID-19) in 2019². The frequent occurrences of acute infectious diseases in China, constitute a significant public health threat to population health and health system strengthening efforts^4,5,6.

Public health emergencies are characterized by their suddenness, unpredictability, widespreadness, and diverse causes⁷. In the face of public health emergencies, timely and effective measures to respond are very important, including the monitoring and early warning mechanism to detect and control the spread of the epidemic as early as possible and the improved ability to prepare for and respond to the health emergency⁸. Since the SARS outbreak in 2003, China has dedicated the necessary resources, including personnel, funding, and materials, to establish a robust and efficient public health system⁹. In China, the Centers for Disease Control and Prevention (CDCs) serve as the foundation of the public health system and play a central role in disease prevention and control^10,11. During the 12th meeting of the Central Committee for Comprehensive Deepening of Reform on February 14, 2020, the importance of improving the mechanisms for primary epidemic prevention and control, as well as strengthening the national public health emergency management system, was emphasized¹². China has established a comprehensive four-tier disease control system consisting of national, provincial, municipal, and county-level CDCs¹³.The most numerous county-level CDCs often act as the first responders to public health emergencies¹⁴. The grassroots CDCs in the study include the county-level CDCs and the economically backward municipal CDCs. These municipal CDCs are located in prefecture-level cities with relatively lower levels of economic development and limited financial support. As a result, their resource allocation, staffing structure, and emergency response capabilities differ from those in more developed areas and more closely resemble the operational reality of county-level CDCs. Therefore, including them in the grassroots category provides a more comprehensive reflection of the emergency response capacity within the disease control system of economically underdeveloped regions^2,15. During a public health emergency response, these grassroots CDCs are responsible for extensive daily monitoring and emergency warning tasks, and their emergency response capabilities significantly impact the effectiveness of managing public health emergencies¹⁶. The outbreak of COVID-19 further highlights the importance of enhancing these capabilities of grassroots CDCs¹⁷.

The development of emergency response capabilities in grassroots CDCs has recently gained significant attention both domestically and internationally^7,8,18,19. For instance, Lv et al. identified the inadequate health infrastructure and a paucity of technical expertise in the grassroots CDCs in Shenzhen¹⁴. Cao et al. analyzed significant public health emergencies in China over the past decade, revealing issues such as a shortage of highly qualified emergency personnel and insufficient investment in emergency funds². Previous studies have mainly focused on the emergency response capacity of CDC institutions in the developed region of China.

Located in the southeast central part of China, Jiangxi Province has a total area of 166900 square km and a population of 45.02 million people in 2024. The GDP of Jiangxi Province in 2024 is 3420.25 billion yuan, ranking moderately among 31 provinces and cities²⁰. Currently, there is limited research on the emergency response capability of grassroots CDCs in Jiangxi Province, which is located in central China. Therefore, we adopt qualitative research methods to comprehensively analyze the current status of the grassroots CDCs' capacity to respond to public health emergencies in Jiangxi Province. Additionally, this study aims to identify the influencing factors and provide targeted recommendations and data support for policymakers. The findings can provide a reference for the government and related health institutions in improving the construction of China's health emergency management system.

This study was approved by the Ethical Review Committee of Xinyu University (Approval Number: 2020076). Prior to any involvement, potential participants were comprehensively informed about the study's aims, significance, potential benefits, and risks, and were assured of their right to withdraw voluntarily at any time. Strict confidentiality was maintained by anonymizing all data and using secure storage. Written informed consent was obtained from each participant only after confirming their complete understanding of the study.

Study design
We employed a qualitative research design and conducted semi-structured interviews with relevant stakeholders. Based on literature analysis²¹, interview outlines were designed using a thematic framework analysis method, which is suitable for policy research²². The study analyzed the emergency response capability of grassroots CDCs in Jiangxi Province during the COVID-19 pandemic and identified associated challenges. This investigation comprised three main aspects: (1) The current status of personnel allocation in grassroots CDCs. (2) The emergency response capability of grassroots CDCs and influencing factors, such as the emergency planning system, availability of emergency supplies, laboratory equipment, emergency training and drills, and forecasting and warning capabilities. (3) Measures and recommendations to enhance the emergency response capability for public health emergencies in disease control.

Participants
Research subjects were selected using purposive sampling and following the information saturation principle. To ensure sample representativeness, we chose prefecture-level cities in Jiangxi Province according to their economic level (average GDP per year) and geographical location. Specifically, within Ganzhou (high GDP), Yichun and Shangrao (moderate GDP), and Xinyu (low GDP), 1 or 2 institutions per city were included as our target. Our interview subjects included 1 or 2 individuals engaged in emergency management and 4-6 healthcare professionals actively involved in COVID-19 emergency prevention and control at selected grassroots CDCs. We interviewed 35 healthcare personnel from 7 grassroots CDCs, designated as IDentification(ID)-1-ID-35. The distribution was as follows: High GDP: 5 from Ganzhou City  Ganxian District CDC; Medium GDP: 4 from Yichun City Fengxin County CDC, 5 from Yichun City Zhangshu City CDC, and 4 from Shangrao City CDC; and Low GDP: 5 from Xinyu City CDC, 5 from Xinyu City Yushui District CDC, and 7 from Xinyu City Fenyi County CDC.

Data collection
To comply with the COVID-19 prevention and control measures in Jiangxi Province, our team conducted interviews between December 2020 and June 2021 using either Tencent meetings or face-to-face group interviews. All interviews were conducted by the same interviewer and note-taker to minimize bias²³. The interviewer and recorder have received training and extensive experience in qualitative interviewing. Before the interview, the purpose, content, and assurance of anonymity were explained by the interviewer, and consent was obtained from the participants. The recorder then assisted in documenting the entire process. During the interviews, the interviewer encouraged participants to share their opinions and adjusted the discussion based on real-time feedback, gathering more in-depth and authentic information²⁴. After the interviews, the interviewer cross-verified and provided feedback to the participants on the main points discussed. A total of seven group interviews and five in-depth interviews were conducted, with each group interview lasting 20-30 min per person and each in-depth interview lasting 60 min per group.

Statistical analyses
All audio or text materials were transcribed and processed by two researchers. We systematically analyzed the text using thematic analysis based on the grounded theory approach²⁵. The process involved the following steps: (1) Familiarizing with the original textual materials. (2) Identifying key themes or keywords. (3) Establishing a thematic catalog or analytical framework based on the identified themes. (4) Coding the original materials according to the thematic catalog. (5) Classifying the data according to the identified themes or subthemes. (6) Summarizing the data. (7) Interpreting the data. The NVivo 8.0 software was employed for text analysis, coding, and deduction for this qualitative research to derive the final themes. Researchers engaged in discussions and comparisons of the themes until reaching the point of information saturation, where no new themes emerged.

Demographic information of interviewees
A total of 28 frontline healthcare professionals and 7 emergency managers actively responding to the COVID-19 pandemic were interviewed for this study. Detailed demographic information is presented in Table 1.

Table 1: Demographic information of interviewees

Findings

Theme 1: Human Resource Allocation in Grassroots CDCs

Inadequate authorized strength in grassroots CDCs
Our interviewees from various CDC levels reported initial improvements in hardware facilities following the outbreak of the COVID-19 pandemic. Additionally, local governments have reinforced funding support for COVID-19 response measures.

ID-10 mentioned that since the onset of COVID-19, the government has shown significant commitment to investing in medical systems, such as the construction of office buildings and updating sampling and testing equipment, as well as developing laboratory testing systems and big data flow control systems. ID-4 added that they have established a PCR laboratory and acquired three emergency vehicles in response to the outbreak. However, some CDCs still find gaps in meeting national standards for specific emergency configurations, including in-car systems and emergency vehicles. ID-6 stated that some aspects of the emergency sanitary supplies required for unforeseen public health events have not fully met the national standards. Shortcomings in emergency vehicles, command systems, and onboard equipment require further attention and improvement.

Uneven quality of emergency personnel
The research findings indicated differences in the quality of public health personnel at the grassroots level across various regions and levels. Regions with higher economic development have a higher quality of personnel than regions with lower economic development. Additionally, county-level CDCs often had personnel with lower educational qualifications, demonstrated by a scarcity of individuals holding master's degrees or higher qualifications and possessing advanced professional titles. Furthermore, a notable aging trend was found in some grassroots institutions.

ID-14 indicated that the proportion of personnel with master's degrees or higher at their CDCs in 2019 was approximately 13.3%, while those with advanced professional titles accounted for about 25%. Overall, the educational background of their personnel is relatively low. ID-24 pointed out that due to work requirements, a significant number of temporary workers without a background in public health, mainly involved in inspection and nursing, have been recruited, resulting in a lower proportion of public health professionals. ID-18 highlighted the significant aging of personnel, with many employees born in the 1960s and a scarcity of those born in the 1970s. This age distribution revealed a substantial age gap, as well as a shortage of suitable candidates for middle-level cadres after their retirement. ID-13 mentioned that the municipal leadership had emphasized talent recruitment in recent years, resulting in the hiring of about 30 young graduates with bachelor's degrees in preventive medicine. This measure has improved the overall talent pool and its composition, although it remains insufficient to meet the current need.

Low remuneration causing talent attrition and recruitment difficulties
All interviewees considered low salaries as the main factor leading to the brain drain and current shortage of personnel in the CDCs. The lack of recognition for their hard work diminished the enthusiasm and motivation of the workforce.

ID-22 mentioned that county-level CDCs are facing a severe shortage of personnel, resulting in heavy workloads and an overwhelming amount of tasks. However, attracting qualified talent has been challenging over the past decade, with only three new hires this year. ID-1 explained that the CDCs had become an entirely non-profit organization, and performance-based salaries were determined based on the local fiscal situation. Specifically, their income from testing, physical examinations, and surveillance was discontinued since 2016. Subsequently, the vaccination clinic was relocated to community and medical institutions since 2019. Hence, the CDCs lacks a source of income and offers lower salaries than institutions of a similar level, negatively impacting employee motivation and resulting in staff turnover.

Heavy workload and high psychological stress on grassroots CDCs personnel
The interview results indicated that frontline emergency personnel faced increased job demands and experienced higher levels of psychological stress after the outbreak of COVID-19.

ID-3 expounded on the substantial workload and the immense pressure during the epidemic prevention and control period. The reporting of infectious diseases via the network continued until midnight at the current Level 1 alert status; daily testing operations lasted until 10:00 PM, with follow-up inspections until midnight. Additionally, CDCs personnel can only take one day off per week, causing significant psychological pressure. ID-22 recognized the considerable exhaustion from the frequent overtime work during the epidemic.

Figure 1: Theme 1: Human Resource Allocation in Grassroots CDCs Please click here to view a larger version of this figure.

Theme 2: Emergency response capability at grassroots CDCs

Improvements in emergency infrastructure
Our interviewees from various CDC levels reported initial improvements in the hardware facilities of CDCs following the outbreak of the COVID-19 pandemic. Additionally, local governments have reinforced funding support for COVID-19 response measures.

Limited predictive and early warning capabilities in software
The COVID-19 pandemic led to some improvement in the emergency response capabilities of grassroots CDCs workers, particularly in sampling, disinfection, and epidemiological investigations. A significant limitation persists, however, in data analysis and the application of predictive models, attributable primarily to a lack of professionals skilled in advanced epidemiological investigation and statistical data analysis. Currently, the evaluation of prediction and early warning for grassroots CDCs primarily relies on early warning dynamics and seasons. However, this evaluation method suffers from excessive subjective judgments and lacks the capability to incorporate scientific and accurate prediction models in determining the outbreak of infectious diseases.

ID-30 highlighted the importance of statistical analysis capabilities in the Department of Infectious Disease Prevention and Control. Establishing a predictive warning model requires substantial data, but there are limitations due to human capacities. ID-17 mentioned the experience in their CDCs. Due to the pandemic, a young colleague with good data analysis skills resigned, as their family resided in another city. Consequently, they faced a shortage of skilled professionals for big data analysis, forecasting, and early warning.

Need for further refinement in emergency training
The provincial CDCs primarily conduct online training sessions focusing on epidemiological investigations. Nevertheless, most interviewees suggested the incorporation of small-group, case study-based training and on-site practical exercises within their respective units. Thus, it is recommended to adopt a blended training model that combines both online and offline methods.

ID-24 mentioned that they primarily participated in video-based training courses, which offer great convenience due to eliminating the need for travel. Additionally, they can utilize training breaks to complete their daily tasks. However, this approach still challenges an individual's self-discipline, occasionally resulting in laziness and distractions like excessive smartphone usage. According to ID-13, the provincial CDCs primarily conducted training online during the pandemic. Typically, experienced employees mentored recruits within the organizations, familiarizing them with the operations through materials learning. Additionally, training courses focused on case studies and brainstorming activities were organized for all emergency responders, yielding positive learning outcomes.

Strengthening emergency drills
Before the COVID-19 pandemic, it was common to conduct prediction and early warning drills once or twice annually, focusing on various infectious diseases. These drills encompassed the entire process of infectious disease reporting, handling, sampling, and on-site disinfection. After the COVID-19 outbreak, more drills were carried out, including large-scale epidemiological investigations and nucleic acid testing exercises. The CDCs mainly emphasized drills for epidemiological investigations. ID-14 stated that they have conducted numerous exercises that cover sampling, disinfection, and epidemiological investigations, which were the primary focus in managing the epidemic. Furthermore, a recent drill for centralized isolation yielded positive results, demonstrating the importance of continuing these efforts.

Figure 2: Theme 2: Emergency Response Capability at Grassroots CDCs Please click here to view a larger version of this figure.

Theme 3: Opinions and Recommendations
Based on feedback from the interviewees, there is a significant salary gap between grassroots CDCs personnel and those employed in medical institutions. This disparity negatively impacts healthcare professionals' motivation and job stability and hinders the recruitment of highly qualified individuals in public health. Suggestions: (1) Ensure competitive incentive pay for disease control personnel to enhance their job enthusiasm; (2) Increase the authorized strength in CDCs; (3) Promote the development and widespread implementation of national-level predictive warning models among all disease control personnel. ID-8 proposed the development of a statistical model to predict the timing of epidemic peaks and turning points, aiming to provide reassurance to the public and achieve widespread dissemination among all disease control personnel nationwide. ID-6 suggested that funding and bonuses for personnel should align with local fiscal policies to ensure timely disbursement. Additionally, it is vital to increase the number of positions according to workload gradually.

Figure 3: Theme 3: Opinions and Recommendations Please click here to view a larger version of this figure.

Data availability
All data relevant to this study are included within the article and its supplementary materials. The datasets from the current study are not publicly available due to privacy and ethical restrictions. Public sharing of the data was not included in the ethical approval obtained for this study or the informed consent provided by the participants.

Supplement 1: Interview outlines Please click here to download this File.

Our findings indicated that grassroots CDCs face shortages in both the quantity and quality of public health personnel, consistent with previous studies³. Liu et al. found that most grassroots CDCs suffer from limited authorized strength and lack emergency personnel⁴. A survey conducted at grassroots CDCs in Shenzhen revealed that emergency personnel accounted for less than 50% of their workforce, and there was a lack of a dedicated emergency management department⁵. The healthcare technician staffing of China's CDCs exhibited a declining trend from 2014 to 2018, with a majority holding a three-year college degree or lower (55.9%) and junior or intermediate professional titles (87.6%)⁶. These issues, to some extent, have impeded the improvement of emergency response capabilities among healthcare technicians and may hinder the long-term development of China's disease control and prevention. While staff downsizing following institutional mergers has hampered recruitment in some provinces, this was not the case in Jiangxi²⁶, where human resource constraints stemmed primarily from fiscal limitations and non-competitive remuneration.

Hence, it is crucial to increase the financial allocation to grassroots CDCs and improve the performance evaluation mechanisms⁷. According to Guo Yufen, a National People's Congress deputy and Gansu Provincial Health Commission director, a "first-class guarantee, second-class management" system should be implemented for CDCs. This approach involves ensuring competitive personnel salaries and reinstating administrative fees to improve the compensation of disease control personnel and narrow the salary gap with medical institutions, thereby encouraging talent retention and recruitment. In response to COVID-19, the government has introduced policies to expand the enrollment scale for public health masters. Many public health professionals are anticipated to join CDCs over the next three years, addressing the issue of inadequate personnel quality²⁷.

A vast majority of the interviewees reported increased workloads and significant psychological and physical stress following the outbreak of COVID-19, which aligned with the research regarding the emotional state of the personnel at the Beijing CDCs^28,29,30,31. The current workload involves extensive epidemiological investigations and disinfection tasks, leading to high-intensity work hours and increased risk of infection, consequently posing anxiety and depression among disease control personnel. Qiu et al. revealed that 44.7% of personnel at the CDCs experienced occupational burnout³². It is recommended to alleviate their workload and enhance organizational support, improving their sense of professional value and recognition. Several studies have demonstrated that disease control personnel typically experience notable levels of anxiety and depression during the COVID-19 pandemic³². Thus, it is essential to implement proactive psychological intervention measures and provide compassionate care for these individuals. Maintaining a positive and healthy mental state is critical in enhancing the emergency response capabilities of disease control personnel³². Therefore, close attention should be paid to the psychological well-being of the personnel at grassroots CDCs, offering guidance and practical support to alleviate their anxiety and stress effectively^29,33. At the same time, training programs to promote healthcare workers' mental health were suggested in many studies^29,31.

Sufficient and appropriate epidemic prevention and control materials are essential for medical institutions to respond effectively to public health emergencies. The eradication of COVID-19 revealed severe imbalances and deficiencies in emergency supplies across various levels of CDCs in China³⁴. Our study indicated that there have been initial improvements in hardware facilities at the grassroots CDCs throughout the epidemic's progression, such as experimental testing equipment and emergency vehicles. Nevertheless, the configuration of some grassroots institutions still falls short of meeting national standards. Securing specialized funds from local governments for emergency material reserves is crucial to ensure the availability and supply of sanitary materials for effective epidemic prevention and response.

Emergency training and drills are essential for strengthening the emergency capabilities of the CDCs³⁵. However, the inadequate training frequency and content for healthcare personnel in grassroots CDCs in China resulted in uneven training outcomes, highlighting the necessity and importance of improving the training model and adopting diverse scenario-based emergency training formats. A study conducted in Shenzhen revealed that trained emergency personnel still scored relatively low in emergency identification and on-site disposal¹⁴. Government departments should establish clear guidelines for emergency drills and implement a scientific and quantitative evaluation system to optimize the effectiveness of emergency training.

Disease surveillance and early warning involve continuous data collection, analysis, interpretation, dissemination, and feedback forecasting³⁶. The improved early monitoring and warning system is a critical source of early alerts. The online reporting system was established by the end of 2011, facilitating the real-time online reporting of statutory infectious diseases through automated infectious disease early warning³⁷. However, the COVID-19 pandemic exposed limitations in the network-based reporting system, leading to delays in detecting emerging infectious diseases and issuing early warnings. Our results indicated that grassroots CDCs have poor prediction and warning capabilities, consistent with prior studies^14,38. Furthermore, there is a low level of adoption of monitoring systems in grassroots prevention and control institutions. Moreover, there is a lack of information sharing and the implementation of joint early warning and response mechanisms between medical institutions and the CDCs³⁹. Huang Jianping and his team from Lanzhou University have developed the Global Pandemic Prediction System (GPCP)⁴⁰, the world's first comprehensive global prediction system for the COVID-19 pandemic. This system enables scientific forecasting of the epidemic's development and provides a basis for strategic analysis and effective prevention and control measures. The GPCP has demonstrated relatively accurate predictions and assessments of the epidemic situation in multiple locations within our country. It is recommended to organize relevant personnel from grassroots CDCs for training on the latest epidemic prediction system, focusing on practical implementation and considering regional differences to ensure its effective utilization.

This qualitative approach not only provides deep insights into grassroots CDC operations but also offers a methodological framework applicable to broader public health contexts. The methodology can be effectively employed to evaluate emergency preparedness in similar resource-constrained environments, assess capacity across different health system levels, and inform the development of targeted policies addressing workforce, infrastructure, and surveillance gaps. By highlighting the critical interactions among human resources, funding, and technical capabilities, this research provides valuable insights for building more resilient and responsive public health systems worldwide.

This study provides an initial exploration of the emergency response mechanisms of local CDCs in public health emergencies. However, strengthening grassroots CDC capacity is a long-term and systematic undertaking⁴¹. To advance this line of research, we outline the following planned steps: First, we intend to develop a standardized capacity assessment toolkit tailored for local CDCs in China. This toolkit would encompass key dimensions such as infrastructure, staffing, technical capabilities, and emergency management, enabling quantitative comparisons across different regions. Subsequently, we will employ this toolkit to conduct large-scale quantitative surveys, aiming to systematically evaluate the current status, regional disparities, and primary gaps in grassroots CDC capacity. Ultimately, building on the survey findings, we plan to design and implement intervention studies. Utilizing pre-post comparisons or quasi-experimental designs with control groups, these studies will seek to scientifically evaluate the effectiveness of various interventions aimed at enhancing local CDC capacity, thereby generating targeted empirical evidence to inform public health policy.

This study has several limitations. Firstly, the qualitative design and sample restricted to Jiangxi Province limit the generalizability of the findings to other regions. Future efforts should expand to other regions to conduct comprehensive qualitative and quantitative research on grassroots-level public health emergency response capabilities, thereby providing a more robust and scientific basis for standardizing China's standardized capacity assessment toolkit. Secondly, the self-reported data may be influenced by recall and social desirability bias. Future research should employ methodological triangulation by integrating multiple data sources. For instance, interviews with participants could be supplemented with the collection and analysis of documentary evidence, such as policy documents, meeting min, work logs, or communication records. This approach would help verify the accuracy of participant recall and provide supplementary details they may have omitted. Finally, the study did not include perspectives from external stakeholders such as health commissions or medical institutions, which could have provided a more complete picture of inter-agency coordination during emergencies. To be comprehensive, future studies should broaden their scope to include all key stakeholders shaping emergency response capacity at the grassroots level. This means including not only the agencies already studied but also extending to bodies like health commissions, hospitals, and community health service centers.

In conclusion, to strengthen the capacity of grassroots CDCs in responding to and managing public health emergencies, we should focus on recruiting and training personnel skilled in epidemiological investigation, data analysis, and early warning systems, while continuously developing their expertise. It is also essential to enhance the predictive and early warning capabilities of these institutions. Future efforts should expand to other regions to conduct comprehensive qualitative and quantitative research on public health emergency response capacities at the grassroots level. This will provide a more robust and scientific basis for standardizing China's public health emergency response assessment toolkit.