How to enhance primary healthcare capacity? Evidence from Chinese provinces through a configurational lens.

Objectives: This study aims to investigate the conditional configurations and influencing mechanisms that contribute to the enhancement of primary healthcare service capacity by examining the effects of seven factors: economic development level, urbanization rate, population size, health expenditure, medical insurance fund revenue, education level, and the implementation of tiered medical care systems. Methods: Guided by systems theory, resource dependence theory, and institutional logic theory, this study develops a multidimensional collaborative governance analytical framework. Using fuzzy-set Qualitative Comparative Analysis (fsQCA) with 31 provincial-level regions in mainland China as cases, it investigates the configurational pathways and interactive effects of seven conditions-economic development level, urbanization rate, population size, healthcare expenditure, medical insurance fund revenue, educational attainment, and hierarchical diagnosis and treatment (HDT)-on PHC capacity. Results: The analysis reveals two key findings. First, none of the individual conditions constitutes a necessary prerequisite for strong PHC capacity. However, high healthcare expenditure consistently emerges as a core condition across all four configurations, underscoring that sustained financial investment is a central component in multiple pathways for strengthening PHC capacity. Second, three distinct configurational patterns are identified as drivers of PHC capacity improvement in China: (1) the "Resource-Intensive Pathway," characterized by a resource compensation effect; (2) the "Fiscal-Led Pathway," representing a single-core driving pattern; and (3) the "Institutional-Synergy Pathway," which combines resource endowment with institutional arrangements. Third, the pathways leading to weak PHC capacity are not mere inverses of the successful ones. The analysis identified two independent failure modes: "Systemic Resource Scarcity," characterized by the fatal dual absence of healthcare expenditure and medical insurance funds, and "Institutional-Resource Double Failure," where the lack of fiscal investment coincides with failed HDT reforms. Conclusion: The study recommends that local governments in China reinforce fiscal guarantees and adopt context-specific, adaptive pathways to achieve systemic improvements and balanced development in PHC capacity. The findings offer important theoretical and practical insights into the driving pathways for enhancing PHC capacity in China.