Decentralized governance in tiered healthcare systems: Supporting equity with blockchain

Tiered healthcare systems seek to support equity by coordinating care across primary, secondary, and tertiary healthcare delivery organizations, yet fragmented cross-tier coordination and persistent differences in organizational capacity and authority can create avoidable disadvantages. Blockchain can distribute selected operational functions across organizations, but technical decentralization alone does not determine how such coordination is governed or how existing power asymmetries are affected. Drawing on 45 semi-structured interviews with key actor groups in China's tiered healthcare systems, supplemented by targeted follow-up clarification of selected operational changes and technical conditions, this article examines how decentralized governance is organized in blockchain-enabled healthcare systems. We identify three connected processes: on-chain governance, cross-organization decision-making, and cross-tier care coordination. Together, these processes show how operational decentralization may support specific equity-oriented aims in cross-tier care while authority and organizational capacity remain uneven.