Urban health performance configurations in Chinese cities: longitudinal fsQCA, 2019–2024

Introduction Composite city indices can rank urban health but rarely explain which conjunctions of public provision, economic capacity, resident action, and environmental conditions are sufficient, whether those conjunctions persist, or how cities move between them over time. This study addresses this configurational and temporal gap using longitudinal evidence from Chinese cities. Methods We analyzed a balanced panel of 296 Chinese cities from 2019 to 2024, comprising 1,776 city-year observations. Urban health utility (HR), derived from the Tsinghua Urban Health Index (TUHI), was used as the outcome, while government health services (HS), health infrastructure (HI), health industry (HP), health behavior (HA), and health environment (HE) were treated as conditions. Longitudinal fuzzy-set qualitative comparative analysis (fsQCA) was conducted using pooled calibration anchors, supplemented by annual models, pooled/between-year/within-city diagnostics, dominant-configuration transitions, robustness analyses, and a 1-year lag model. Results No single condition met the necessity-consistency threshold of 0.90. Two sufficient configurations for high HR were identified: ~HS * HI * HA * ~HE (consistency = 0.926; raw coverage = 0.329) and HS * HI * HP * HA (consistency = 0.877; raw coverage = 0.476). Their union had a consistency of 0.872 and coverage of 0.540. The four-domain HS * HI * HP * HA configuration recurred from 2021 to 2024 and was reproduced unchanged in the lagged model. Sample perturbations generally retained the main configurations, whereas compressed calibration anchors and subgroup analyses revealed sensitivity and heterogeneity. Discussion High urban health performance is associated with multiple sufficient configurations rather than a single necessary condition. The longitudinal strategy distinguishes recurring configurational relations from changing city membership over time and supports differentiated policy portfolios while retaining environmental safeguards. These findings represent set-theoretic associations rather than causal effects.