Spatiotemporal distribution, dynamic evolution, and configurational mechanisms of high-quality healthcare resource allocation in China—evidence from panel QCA and NCA within the TOE framework

High-quality healthcare resources remain unevenly distributed across China, with important implications for health equity. Existing studies have examined equity, efficiency, spatiotemporal evolution, and multiple influencing factors, but these strands have rarely been integrated within a unified framework that links spatial dynamics to necessary constraints and alternative sufficient configurations. This study examined the spatiotemporal distribution, dynamic evolution, and configurational mechanisms of high-quality healthcare resource allocation (HQHRA) in China from 2014 to 2023. A balanced panel of 31 mainland Chinese provincial-level regions, comprising 310 province–year observations, was analysed. HQHRA was measured using an equal-weight TOPSIS composite index comprising four positive indicators that capture high-level hospital resource stock, hospital hierarchy, tertiary-hospital accreditation structure, and hospital scale structure. Kernel density estimation, global Moran’s I, and traditional and spatial Markov chains were used to examine distributional change, spatial dependence, and state-transition dynamics. Eight conditions organized within the Technology–Organization–Environment (TOE) framework were analysed using necessary condition analysis (NCA) and panel qualitative comparative analysis (panel QCA). HQHRA improved overall during the study period. The eastern share declined from 43% to 40%, whereas the western share increased from 29% to 33%, narrowing the eastern–western gap from 14 to 7 percentage points. Kernel-density distributions shifted rightward but remained dispersed, indicating broad improvement without uniform provincial convergence. Global Moran’s I remained positive (0.100–0.220). Markov transitions occurred predominantly within the same or adjacent states and varied across neighbourhood contexts, indicating gradual evolution, path dependence, and spatially conditioned persistence. NCA identified technological innovation capacity, clinical workforce capacity, and regional economic development as necessary but insufficient constraints. At the 90% HQHRA target, their minimum required levels were 59.9%, 39.3%, and 53.9% of their respective observed ranges. Panel QCA found no single set-theoretically necessary condition but identified four sufficient configurations: an innovation-led pattern; economic-reinforcement and ageing-context variants of an innovation–demand pattern; and a multi-capacity–demand synergy pattern. The overall solution consistency and coverage were 0.864 and 0.686, respectively. China’s HQHRA became moderately more regionally balanced, but substantial interprovincial differentiation and spatially conditioned path dependence persisted. The combined findings demonstrate constrained equifinality: achieving high-level HQHRA requires certain minimum levels of technological innovation, clinical workforce capacity, and economic development, while different technological, organizational, and environmental configurations can produce the outcome. Policy should prioritize low-HQHRA provinces embedded in disadvantaged neighbourhood contexts and move beyond uniform institutional expansion. Regional medical-centre and counterpart-assistance programmes should combine infrastructure investment with technology transfer, specialist rotations, workforce development and retention, referral coordination, and local capacity building. Provincial interventions should focus on innovation absorption, demand-responsive specialty services, ageing-oriented integrated care, or regional capability diffusion according to local bottlenecks. Policy performance should be assessed through reductions in avoidable patient outflow, increases in locally managed complex cases, workforce retention, and the adoption of transferred technologies.