Pathways for enhancing service capability of primary healthcare institutions: a dynamic qualitative comparative analysis

Background China has established the world's largest medical service system, with primary healthcare institutions (PHIs) undertaking over half of the country's outpatient services. However, PHIs still face multiple challenges in service capability, particularly the structural imbalance between the inverted triangular healthcare supply and the positive triangular demand. Consequently, improving the service capability of primary healthcare has become the key to advancing graded diagnosis and treatment and optimizing the allocation of medical resources. Objective This study aims to explore pathways for enhancing the service capability of PHIs across China's provinces, identify the key conditions for achieving high-quality services, and thereby lay a foundation for policy-making. Method Using panel data from 30 Chinese provinces covering the period 2016–2021, this study employs the TOE-DC theoretical framework, the rank-sum ratio (RSR) and the Dynamic Qualitative Comparative Analysis (QCA) method to analyze the configurational pathways and spatiotemporal evolution characteristics. Within the Technology-Organization-Environment (TOE) framework, the influencing factors are identified as technological innovation and infrastructure (technology), the healthcare workforce and financial investment (organization), and policy support, economic development, and public demands (environment). Result (1) No single condition constitutes a necessary condition for high service capability, but the necessity of talent pools and economic growth has gradually increased over time; (2) Three pathways to achieve high service capability have been identified; (3) There is a clear spatiotemporal distribution of these pathways— the eastern region mainly adopts the government's technical coordination pathway, while the central and western regions rely more on the comprehensive configuration pathway. Conclusion Future policies should prioritize regionally differentiated pathway selection. Each region can integrate the advantages of government macroeconomic regulation and market micro-vitality, and the government should focus on strengthening services through technical support, enhancing the monitoring of health data and disease trends, and formulating and effectively implementing forward-looking strategic plans.