Understanding smart health and elderly care implementation in China: a qualitaframework analysis of 24 casestive TOE-C

Rapid population aging and digital transformation are accelerating the global proliferation of smart health and elderly care (SHEC) systems. In China, national policies have actively promoted SHEC as a strategic pathway toward achieving age-friendly cities and communities (AFCC). Yet, the practical mechanisms by which SHEC initiatives translate policy goals into inclusive, community-based care are insufficiently explored. Existing studies predominantly examine either technological or organizational dimensions in isolation, paying limited attention to the role of user capability and its interaction with institutional arrangements. This study adopts a qualitative multiple-case research design to examine the implementation mechanisms of SHEC in China. Drawing on 24 nationally recognized demonstration cases, we conducted a framework-based qualitative analysis using an extended Technology–Organization–Environment–Capability (TOE-C) framework. Case materials were systematically coded and analyzed to identify patterns of interaction among technological infrastructures, organizational arrangements, policy environments, and user capabilities. The findings indicate that effective SHEC operate as a complex socio-technical system, dynamically shaped by the interplay of technology, organization, environment, and capability. While technological infrastructures facilitate data integration and service delivery, user capability emerges as a critical mediating factor, determining whether such systems achieve meaningful and sustainable service outcomes aligned with AFCC goals. Organizational coordination, policy support, and capability-building mechanisms collectively shape service accessibility, adaptability, and continuity. The results further reveal that capability is not merely an individual trait but a structurally embedded element shaped by governance arrangements, service design, and institutional support, which are essential for realizing inclusive digital health. This study advances existing research by extending the traditional TOE framework to incorporate capability as a core analytical dimension. The proposed TOE-C framework provides a more comprehensive explanation of how SHEC systems function in practice, particularly in contexts characterized by population aging and digital inequality. By highlighting the structural role of capability in mediating technological and organizational interventions, this study offers both theoretical contributions and practical insights for policymakers and practitioners seeking to develop inclusive, sustainable, and people-centered smart elderly care systems that effectively support the goals of AFCC.