Closed-loop constraint model for emergency care in county medical alliances: grounded theory study in western China's...

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.