Closed-loop constraint model for emergency care in county medical alliances: grounded theory study in western China’s underdeveloped multiethnic region

Increasing emergency medical service (EMS) capacity within integrated delivery systems is essential for universal health coverage, particularly in low- and middle-income countries. However, in underdeveloped ethnic regions of western China, developing EMS capacity within county-level medical alliances (CLMAs) remains a critical challenge. Using classic grounded theory, we conducted semistructured interviews with 47 health care professionals from 11 CLMAs across Guangxi, a representative underdeveloped, multiethnic, mountainous region. Systematic three-level coding of 575 statements revealed 57 initial concepts, 15 categories, and four core dimensions: institutional deficiencies (root cause), inefficient coordination (key bottleneck), resource shortcomings (direct manifestation), and service efficacy constraints (final outcome). These dimensions form a closed-loop constraint model reinforced by reverse feedback. Crucially, service efficacy constraints—specifically, poor emergency care quality and collective public cognitive bias—do not merely represent outcomes but actively reinforce the institutional deficiencies that generated them, trapping the system in a low-level equilibrium. This finding explains why piecemeal interventions fail. Effective strengthening requires simultaneously targeting all four dimensions to disrupt the negative cycle, a transferable strategy for integrated health systems facing analogous constraints worldwide.