Uneven integration of health in China’s territorial spatial planning 2035

BACKGROUND: Spatial planning plays a pivotal role in shaping the health and well-being of urban populations. Since 2016, most Chinese cities have incorporated health-related elements into their Territorial Spatial Planning (TSP) 2035 Schemes as part of national healthy city initiatives. It is essential to examine how health is represented in these statutory planning documents and whether the level of attention varies across cities. METHODS: We developed an analytical framework for healthy city planning by synthesizing international scholarly literature and governmental policy documents. Using this framework, the TSP 2035 Schemes of 36 major Chinese cities were examined through a mixed-method design combining thematic dimension analysis, keyword network analysis, and disparity measures. RESULTS: All 36 cities have placed healthy city development on their planning schemes, focusing primarily on eight dimensions: (1) green and open space, (2) climate change and disaster response, (3) physical education (PE) facilities and public services, (4) environmental pollution prevention and control, (5) medical and health services, (6) elderly dimension, (7) health equity, and (8) healthy travel. Of these dimensions, green and open space along with climate change and disaster response receive the most emphasis. Notable healthy city keywords include 'park', 'green space', 'healthcare', 'livability', 'sports', 'resilience', 'pollution control', 'disaster prevention', 'walking', and 'jogging'. Cross-city comparisons reveal substantial disparities: cities with higher administrative status generally articulated more extensive and more diverse health-related planning content, whereas many lower-tier cities pay relatively little attention to equity-sensitive dimensions. CONCLUSIONS: Health has become a visible component of statutory planning discourse in China, but its integration remains selective and uneven across cities. The results suggest that China's healthy city development has reached an intermediate stage of "health promotion and education", and in terms of health-spatial planning integration, China has moved beyond a narrow environmental health orientation, yet important gaps remain in equity-sensitive and people-centered dimensions. Recommendations include strengthening legislation to support healthy city planning, improving the openness and transparency of TSP 2035 Schemes, and more differentiated policy support across cities.