From lucid waters and lush mountains to health dividends: policy effects of China’s national ecological civilization pilot zones and pathways to high health Levels

Ecological civilization construction is an important institutional approach for coordinating environmental protection, green development, and social well-being. However, whether the National Ecological Civilization Pilot Zone (NECPZ) policy can generate measurable health dividends for residents, and under what broader regional conditions high residents’ health levels are more likely to emerge, remain insufficiently examined. This study evaluates the effect of the NECPZ policy on residents’ composite health levels and further contextualizes the condition combinations associated with high health levels. Using provincial panel data from 31 Chinese provinces from 2012 to 2022, this study constructs a composite health index from maternal, child, and overall health indicators. A multi-period difference-in-differences (DID) model estimates the average association between NECPZ implementation and the health index, supplemented by heterogeneity-robust estimators for staggered adoption. In a second, theoretically linked but non-causal analytical layer, Necessary Condition Analysis (NCA) and dynamic fuzzy-set Qualitative Comparative Analysis (dynamic fsQCA) assess whether high health levels are associated with necessary conditions or with equifinal configurations predicted by the social determinants of health and causal-complexity perspectives. The DID estimates indicate a statistically significant but moderate improvement in the composite health index in pilot provinces, and the heterogeneity-robust estimates are similar in direction and magnitude. NCA identifies no stable single necessary condition. Dynamic fsQCA identifies two configurations associated with high health levels: a green innovation–public space pathway and a governance attention–green innovation–low climate risk pathway. Because the configurational analysis uses all provinces and does not treat NECPZ as a condition, these pathways are interpreted as contextual associations rather than as mechanisms of the estimated policy effect. The quasi-experimental evidence is consistent with a measurable but moderate health dividend from NECPZ, although non-random pilot selection and time-varying provincial confounding cannot be eliminated completely. The configurational results further show that high health levels can occur under more than one regional condition package. Ecological civilization evaluation should therefore incorporate carefully defined health outcomes while avoiding uniform prescriptions or causal interpretations of the fsQCA pathways.