Placing Health Equity at the Center of Development: Organizational Agency and Emergency Service Disparities in China‘s County Medical Alliances: a cross-sectional study

Background Placing health equity at the center of health system development requires confronting systemic disparities in service capacity. China's Compact-Type County Medical Alliance (CCMA) policy integrates primary care resources, yet policy design tacitly assumes that hospital grade determines service capacity, with tertiary hospitals expected to outperform secondary ones. Whether this holds for emergency medical service (EMS) capacity in resource-limited western regions, and what this implies for health equity, remains unexamined. Methods We conducted a policy diagnostic study in 11 Guangxi CCMA pilot counties, developing separate EMS evaluation systems for leading hospitals (61 indicators) and member institutions (43 indicators) via Delphi (n = 20), AHP weighting, and TOPSIS-RSR across Donabedian's structure-process-outcome dimensions. Results The core diagnostic finding is a systematic structure-function mismatch: process indicators (particularly referral coordination and information system utilization) were weakest in both leading hospitals (mean Ci = 0.465) and member institutions (mean Ci = 0.347), while structural inputs scored substantially higher (mean Ci = 0.698 and 0.535, respectively). This mismatch disproportionately affects member institutions serving vulnerable populations, creating systemic gaps in emergency care coordination. Evidence from other settings suggests that these gaps may translate into preventable mortality differentials. Exploratory analyses generated hypotheses regarding organisational agency and grade-performance relationships, reported in full in the Additional files, which require validation in larger samples. Conclusions Our primary contribution is diagnostic: we identify a systematic structure-function mismatch in emergency service capacity, with process integration deficits as the key bottleneck. This is a governance failure that perpetuates health inequity across county health system tiers. The findings point toward recalibrating national monitoring frameworks toward functional integration, with tiered interventions matched to performance strata. This study provides an empirical foundation for re-centering health equity in health system governance, with implications for the post-2030 SDG agenda in resource-limited settings.