Resolving institutional fragmentation in a multilevel governance system: configurational logics of social health insurance integration in China

Institutional fragmentation poses a significant challenge to effective social governance, particularly in the health sector. Prevailing literature often examines the drivers of integration – such as fiscal capacity and political will – in a linear, isolated manner, failing to capture their complex interplay. This study argues for a configurational approach to understanding institutional integration. Using the integration of China’s fragmented social health insurance system as a critical case, we employ fuzzy-set Qualitative Comparative Analysis (fsQCA) to analyse a large sample of 251 cities in their varying integration pathways. The analytical framework captures capacity and incentives as critical factors for institutional integration. The QCA analysis identifies four distinct configurations: the Capacitor, the Stabilizer, the Risk Manager, and the Negotiator. These findings suggest multiple equifinal pathways to successful institutional integration, highlighting the crucial conjunctural effects of economic strength, administrative status, coordinative capacity, and financial conditions.