Dual-Network Integration in a County-Level Medical Consortium: An Exploratory Case Study from Yilong, an Underdeveloped Region

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Methods Employing a longitudinal, embedded single-case design, this research analyses the reform trajectory in Yilong County, Sichuan Province, from 2018–2024. Multisource qualitative and quantitative data, including policy documents, stakeholder interviews, field observations, and institutional operational records, were triangulated to ensure robustness. Results The findings reveal a synergistic governance mechanism. The county-township linkage constructs a vertically integrated professional network through unified governance, resource pooling, and service standardisation. Concurrently, village doctor embedding activates a community-based service network via a four-dimensional framework encompassing management, operational, functional, and developmental embedding. This dual-network integration effectively bridges systemic accountability with community-based social capital, leading to marked improvements in healthcare accessibility and the retention of patients within the local tiered system. Conclusions Integrating the principles of accountable care organisation theory and social capital theory, this model provides a replicable micromechanism for primary care reform in resource-constrained settings. Its successful application hinges on context-adaptive refinements, particularly in health-outcome-oriented financing and institutional support for the frontline workforce. The study contributes a viable governance blueprint for strengthening integrated care in underdeveloped regions, with implications for both national policy and global health equity initiatives. County-Level Medical Consortium underdeveloped regions county-township linkage village doctor embedding dual-network integration Yilong County Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1 Introduction 1.1Background At this pivotal juncture in the deepening implementation of the Healthy China strategy, the ‘last mile’ bottleneck in primary healthcare has emerged as a core constraint on system equity and accessibility, particularly in underdeveloped regions. National Health Commission data from 2023 indicate a national average county-level hospital visit rate of 89.5%, yet rates in underdeveloped western regions remain below 85%. This disparity stems from a persistent ‘structural disconnect’ within the three-tier service network: county hospitals’ limited downwards outreach, township health centres’ functional attrition, and village clinics’ frequent failure as effective gatekeepers. This progressive weakening drives patient outflow to higher-level hospitals, exacerbating access barriers and costs while eroding the foundations of the tiered healthcare system. 1.2 Research gaps Extant research on the County-Level Medical Consortium (CLMC) has established a substantial foundation, charting their evolution and analysing key mechanisms, yet collectively reveals a critical, unaddressed theoretical and empirical gap concerning grassroots integration. Scholarly consensus delineates an evolutionary trajectory for CLMC, moving from technical, “loose alliances” as noted by Tao and colleagues in 2018, towards “tight integration” through unified governance, a pathway emphasised by Yu et al . in 2020 and Zhu and Duan in 2021 [ 1 , 2 , 3 ] . This progression, which aims to address systemic fragmentation and directly influences healthcare utilisation patterns, as highlighted by Zhu et al. (2025), is further underscored by policy-aligned studies such as Peng et al. (2024) and Yang et al. (2024) [ 4 , 5 , 6 ] . However, this top-down integrative drive, predominantly following a “vertical integration” logic between county and township tiers [ 7 , 8 ] as analysed by Chen et al. (2023) and Wang et al. (2024), has yielded a significant structural bias and, as noted in broader health policy literature, can intensify underlying conflicts of interest (Mukamel et al. , 2014) [ 9 ] . As scholars such as Jiaviriyaboonya (2022) and Madon and Krishna (2022) have observed, this model largely neglects the “activation of the grassroots network,” leaving village doctors in a state of “institutional limbo” with ambiguous professional identity and inadequate safeguards [ 10 , 11 ] , challenges further detailed in the work of Zhang et al. (2022) and Zhong (2025) [ 12 , 13 ] . This oversight results in a persistent “last mile” bottleneck, hindering the system’s transition towards health-centered care despite the observed local efficiencies noted by Cao et al. (2025) [ 14 ] . The application of accountable care organisation (ACO) theory, a pivotal framework for analysing CLMCs introduced by Fisher and Shortell (2010) [ 15 ] , has deepened our understanding of financial and performance incentives. Studies such as Li et al. (2024) and Wang et al. (2025) have effectively explored how payment reforms establish risk-sharing mechanisms within [ 16 , 17 ] , an impact also empirically examined in the context of hierarchical diagnosis and treatment by Ding et al. (2024) [ 18 ] . Concurrently, Olya et al. (2022) and Zhao et al. (2025) examined outcome-oriented performance systems [ 19 , 20 ] . However, this body of work has a critical theoretical limitation: “suspended accountability at the nerve endings.” Analyses predominantly assume that the “accountable organisation” comprises county and township institutions [ 21 ] , a focus evident in the governance research of Liu (2024). Consequently, there is a “responsibility transmission blockage” where abstract population health accountability fails to be effectively extended to the village-level terminal, the very point emphasised as crucial for service delivery by scholars such as Song et al. (2025) and Zhang et al. (2025) [ 22 , 23 ] . While recent work by Valaitis et al. (2020) highlights collaboration models [ 24 ] , the specific mechanism for binding village doctors into the core ACO accountability cycle—encompassing clear responsibility, precise measurement, and commensurate compensation—remains undertheorised. Simultaneously, a separate stream of literature highlights the role of social capital in community health. Building on the foundational work of Bourdieu (1986) and Muntaner and Lynch (2002), contemporary studies such as Luo et al. (2024) demonstrate its positive association with service utilisation [ 25 , 26 , 27 ] . Village doctors are recognised as central carriers of this capital, bridging formal systems and communities through local trust, as noted by Ahmed et al. (2013) and Wang et al. (2019) [ 28 , 29 ] . However, this research often runs in parallel with studies on institutional integration. Therefore, a core research gap persists: existing scholarship has yet to synthetically bridge the institutional logic of ACO theory, which focuses on top-down accountability and financial alignment, with the relational logic of social capital theory, which explains bottom-up community trust and service acceptance. The synergistic mechanism through which the formal, vertically integrated professional network and the informal, community-embedded service network interact in underdeveloped regions remains inadequately explained. This study aims to address this gap by integrating these two theoretical lenses to explore the “dual-network integration” model, thereby providing a comprehensive micromechanistic explanation for solving the “last mile” problem in primary healthcare reform. 1.3 Research objectives and questions This study employs an exploratory single-case methodology to deconstruct Yilong County's dual-network integration model, utilising fieldwork, policy analysis and multisource data to achieve three objectives: (1) Delineating the model's evolution and the synergy between the ‘county-township linkage’ professional network and the ‘village doctor embedding’ community network; (2) Analysing its governance architecture and the logic of institutional, technical and social coupling within the CLMC [ 30 ] ; and (3) Deriving a context-sensitive theoretical framework for underdeveloped regions. The research is guided by three central questions: how ‘county-township linkage’ activates interinstitutional synergy; through which specific institutional designs ‘village doctor embedding’ reintegrates vacant and underresourced village clinics; and how the model combines resources, incentives and oversight to reduce costs while improving service quality and satisfaction. By addressing these issues, this study aims to elucidate the model's internal logic and propose actionable policy pathways to support the local implementation of the Healthy China strategy. 1.4 Structure of the Paper The structure of this paper is organised as follows: Part Two outlines the research methodology, including the study design, case selection, data collection and analysis, ethical approval, and rigor and limitations. Part Three presents the main findings of the research analysis. Part four discusses the results in response to the research questions and engages with the literature, demonstrating theoretical contributions, interpreting practical implications, and addressing research limitations and future directions. The concluding section summarises the paper's principal research findings and draws final conclusions. 2 Methods 2.1 Study Design This study adopted a longitudinal single-case design embedded with process tracing to address its exploratory “how” question: how does an underdeveloped county construct and realise “dual-network integration” through institutional and organisational innovations? The case study approach is suited to providing deep, holistic insights into such complex, mechanism-oriented phenomena. A longitudinal perspective enabled tracing the reform’s evolution across key stages, whereas process tracing was used to identify and examine critical events, decisions, and their impacts. Together, these methods facilitated the construction of an evidence-based narrative that elucidates how various elements interact to produce a stable governance model. 2.2 Case Selection Yilong County in Sichuan Province was selected as the core case study area on the basis of three key considerations. First, its initial conditions—being a traditional, resource-constrained region with imbalanced medical resource distribution, weak primary care capacity, and a fragmented three-tier network—are highly representative of structural challenges common in underdeveloped areas, ensuring that the findings offer transferable insights. Second, the case demonstrates profound institutional innovation, particularly through its systematic “village doctor integration” mechanism. This approach goes beyond conventional county-township consolidation by implementing identity transformation, incentive-aligned remuneration, and digital empowerment, thereby activating the service system’s “last mile.” Third, the case provides exceptional research feasibility, with a well-documented, coherent reform trajectory enabling longitudinal and process-tracing analysis. Clear policy archives, observable outcomes, and multisource data support robust mechanism investigations and theoretical refinements. 2.3 Data collection Data collection for this study followed a multisource, triangulated approach, encompassing archival, interview, observational, and quantitative data. Archival and textual data, including national and local policy documents, the consortium's charter, internal meeting minutes, and media reports, were gathered to establish the institutional context. Semi-structured interviews were conducted with purposively sampled stakeholders from four key groups: policy makers, medical consortium managers, frontline medical staff (including village doctors), and technical support personnel, to explore reform experiences and operational mechanisms. The interview guides were tailored to each stakeholder group, focusing on the reform's top-level design, operational implementation, frontline practice, and digital support, respectively. The core questions of the interview guides are presented in Appendix 1 of this manuscript, and the full, complete version of the interview guides (including the respondent information collection form, anonymisation and data management rules, interview opening script, closing prompt and research team implementation notes) is available in Supplementary Appendix S1.Participant and nonparticipant observations were carried out at sites such as the central command hub, township health centers, and village clinics to document the interplay between formal protocols and informal practices. Quantitative operational data were extracted from the county's Health Information System (HIS) and Picture Archiving and Communication System (PACS). To capture phase-specific outcomes and avoid redundant annual data, indicators spanning service utilisation, capacity, and efficiency were analysed at three strategic time points (2018, 2022, 2024), corresponding to the prereform, mid-reform, and postmaturity phases of the consortium's development. 2.4 Data analysis 2.4.1 Periodisation and Rationale This study delineates the reform trajectory of the Yilong CLMC (2018–2024) into three distinct phases on the basis of a comprehensive analysis of multisource data, focusing on critical policy junctures, institutional innovations, and fundamental shifts in governance structure (see Fig. 1 , outlining the three-phase evolution of dual-network integration: 2018–2020 [county-township integration], 2021–2022 [village doctor embedding], and 2023–2024 [system synergy]). The first phase (2018–2020), structural exploration and county‑township integration, was marked by establishing the general hospital as a single legal entity, implementing the ‘Eight Unifications’ management model, and introducing a joint virtual–physical leadership system, with the core aim of dismantling administrative and interest barriers to create a vertically integrated governance framework. The second phase (2021–2022), mechanism innovation and village doctor integration, shifted its focus to activating the grassroots network through systematic policies such as the ‘township‑hired, village‑deployed’ personnel system, a four‑tier remuneration structure, and the rollout of the ‘Smart Medical Assistant’ system, thereby achieving institutional embedding of village doctors. The third phase (2023–2024), system synergy and model consolidation, was characterised by deepening the application of the smart health platform, data‑driven performance management, standardisation of two‑way referrals, and increased weighting of health outcomes in evaluation, indicating that the dual‑network integration model had entered a stage of synergistic effect and operational stabilisation. This phased analysis outlines the strategic evolution from a structural foundation through mechanism innovation to system‑wide synergy. 2.4.2 Coding Procedure and Analytical Strategy Within each of these phases, the analysis followed a structured coding process grounded in grounded‑theory principles. Qualitative data from interviews, observations, and archival texts were subjected to iterative multilevel coding: open coding generated initial descriptive concepts; axial coding clustered these concepts into broader thematic categories; and selective coding integrated the emerging themes with relevant theoretical frameworks (accountable care organisation theory and social capital theory) to construct a coherent explanatory thread across the three phases. This coding work was complemented by process‑tracing narratives that dynamically reconstructed the causal interactions between county‑township linkages and village‑doctor embedding. Finally, longitudinal quantitative operational data were embedded as outcome evidence within the qualitative narrative, achieving methodological triangulation that simultaneously clarified the operational mechanisms and demonstrated their practical effectiveness. 3 Results 3.1 County-Township Linkage 3.1.1 Reconfiguration of the Governance Authority The reconfiguration of governance authority formed the institutional foundation for the Yilong Model. Prior to reform, fragmented multilegal-entity governance led to disparate institutional interests and high coordination costs. Yilong’s breakthrough involved establishing Yilong County General Hospital as a single legal entity, underpinned by a virtual-real dual-appointment leadership system—which was consistent with the “Structural Exploration and County-Township Integration” phase (2018–2020). Under this system, General Hospital’s principal leaders hold substantive roles across county institutions, ensuring a unified strategy and resource allocation, while also serving in nonexecutive roles at branch hospitals to maintain grassroots adaptability. This dual mechanism created a “responsibility-management community,” with the general hospital bearing overall accountability for medical quality and outcomes across the county. Centralised authority enabled the implementation of the “Eight Unifications” management model and the establishment of ten unified management centres, shifting from fragmented operations to standardised, system-wide governance. This restructuring provided essential organisational and political impetus for subsequent integration (see Fig. 2 , which illustrates the logical framework of governance authority reconstruction, including a single legal entity and dual-appointment system). 3.1.2 Joint resource pool development Building upon the unified governance framework, the reform advanced to the system-wide optimisation and dynamic circulation of healthcare resources through the establishment of joint resource pools. This strategy transformed key production factors—encompassing human, material, and financial assets—from static, institution-specific allocations into a county-owned commons for flexible deployment, pursuing Pareto-optimal resource distribution across the integrated network. A centralised human resource roster enabled unified personnel planning, operationalised through a “county recruitment, township deployment” system that alleviated chronic talent shortages at the township level. Similarly, a structured rotation mechanism of “upwards attachment and downwards deployment” facilitated deliberate capability transfer and knowledge spillage between county and township facilities. Financial consolidation was achieved via a unified accounting system, permitting strategic reallocation of funds to underresourced areas, while material resources were integrated through centralised procurement directories and the redistribution of underutilised medical equipment to sites of greater clinical need. Crucially, a fundamental shift in medical insurance payments—from a fee-for-service model to a prepaid capitation model with surplus retention—served as the core economic driver. This payment reform intrinsically aligned the consortium’s financial incentives with population health outcomes and cost containment, motivating proactive investment in primary care and fostering a genuine community of shared interests that translated systemic objectives into coherent individual action (see Fig. 3 , depicting the logic transmission of joint resource pool development driven by medical insurance payment reform). 3.1.3 Service Network Integration Service network integration operationalises the consortium’s governance and resource foundations, constructing a seamless, patient-centred care continuum through the synergistic alignment of standardised protocols, rationalised specialist layout, and a unified digital infrastructure. Technically, centrally mandated clinical pathways, documentation norms, and safety standards enforced by the general hospital ensure homogeneous care quality across all tiers, creating essential trust and interoperability for effective two-way referrals. Strategically, a deliberate reconfiguration of specialist resources mitigated internal competition and formed distinct centres of excellence: complex acute care was concentrated at the Medical Centre campus, traditional Chinese medicine specialties were consolidated at the TCM campus, and women’s and children’s services were centralised at a dedicated campus. This differentiated development optimises patient flow and enhances the county’s collective capacity. Digitally, a county-wide smart health platform—integrating core systems (HIS, LIS, PACS)—serves as the operational backbone, dismantling information silos, enabling real-time data sharing and seamless patient transitions, and embedding standardised workflows. The integrated network’s efficacy is evidenced by outcome metrics: diagnostic result mutual recognition reached 100%, and shared large-equipment utilisation increased from 148,090 services (2022) to 239,665 (2024), with a sustained high examination positivity rate (~ 82%). Collectively, these elements have transformed previously fragmented services into a coordinated, vertically integrated service community (see Fig. 4 , presenting the integrated service network model for coordinated county-township-village healthcare). 3.2 Village doctor integration Yilong County’s village doctor embedding is realised through an integrated mechanism comprising management embedding, operational embedding, character embedding, and development embedding. This mechanism addresses their historical institutional ambiguity and leverages their social capital to organically embed them within the CLMC, thereby strengthening grassroots service delivery. Figure 5 shows the four-dimensional embedding model for village doctor integrated development. 3.2.1 Management Embedding Management Embedding institutionally resolves the protracted “semiofficial, semi‑private” status of village doctors by formally integrating them into the consortium through the innovative “township‑hired, village‑deployed” system. This transforms their employment basis from independent practice to contracted personnel under township health centres, ensuring stable organisational affiliation and statutory identity—a foundational step often overlooked in conventional integration models. A restructured four‑tier remuneration system (basic salary, post allowance, performance bonus, public health subsidy) significantly elevates average monthly income, directly enhancing role attractiveness and retention. Crucially, village doctors are incorporated into the consortium’s unified performance‑evaluation framework, with metrics directly linked to service quality, patient satisfaction, and health outcomes. This alignment of individual incentives with system‑level objectives fosters professional identity and embeds village doctors as accountable actors within the integrated accountability chain, moving beyond superficial affiliation to substantive institutional membership. 3.2.2 Operational Embedding Operational embedding is achieved through deep digital integration that functionally connects village clinics to the county’s centralised care network. The deployment of the “Smart Medical Assistant” system standardises diagnosis and treatment for common conditions at the village level, substantially increasing diagnostic compliance rates. More distinctive is the implementation of a robust telemedicine corridor: village doctors, equipped with remote diagnostic devices, transmit real‑time ECG and imaging data to county specialists for interpretation, effectively democratising access to advanced diagnostics. This has supported tens of thousands of remote consultations, enhancing diagnostic accuracy and trust in village‑level care. Furthermore, full interoperability of electronic health records across the system allows village doctors to access patients’ longitudinal medical histories, preventing duplicate testing and enabling continuity of care. This digital thread ensures that village‑generated service data feed directly into central quality‑assurance and performance‑monitoring systems, making village practice a visible, accountable node within the integrated service continuum. 3.2.3 Functional Embedding Functional embedding repositions village doctors from episodic treaters to proactive health managers, leveraging their unique social capital to bridge formal healthcare systems and rural communities. Embedded within family‑doctor contract‑service teams as core nodes, their role expands across three dimensions: from clinic‑based care to proactive community outreach; from acute intervention to continuous lifecycle management; and from individual treatment to population‑health accountability. Chronic disease management exemplifies this shift: supported by digital tools and outcome‑oriented incentives, village doctors now conduct systematic screening, regular follow‑up, and tailored lifestyle interventions. This has driven marked improvements in standardised management and control rates for hypertension and diabetes—key outcome indicators for primary care effectiveness. The redesign is sustained by a performance framework that rewards health outcomes and shares medical‑insurance savings with effective health managers, thereby institutionalising prevention and aligning village doctors’ daily practices with the consortium’s population‑health objectives. 3.2.4 Developmental embedding Developmental embedding constructs a sustainable career ecosystem to transform village doctoring from a terminal occupation into a viable professional pathway. A clearly defined three‑tier career ladder (“Junior‑Core‑Outstanding”) links advancement to competency and performance, providing transparent progression incentives. Educational mobility is facilitated through formal degree‑upgrade programmes with medical colleges and a structured mentorship system linking village doctors to county‑based specialists. A critical institutional breakthrough is the adaptation of professional‑title evaluation criteria to recognise grassroots service quality and community impact, creating dedicated senior‑title quotas and enabling meaningful career advancement. Finally, a bidirectional talent‑circulation mechanism—where village doctors undertake up‑skill placements at county hospitals and county specialists conduct regular outreach—ensures continuous knowledge exchange and embeds village doctors within the wider talent architecture of the county health system. This holistic approach enhances professional prestige, secures retention, and ensures long‑term human‑resource sustainability at the primary care frontline. 3.3 Dual-Network Integration 3.3.1 Integrated Interfaces and Mechanisms The core innovation of the Yilong Model lies not only in establishing separate county-township and village-level networks but also in the deliberate mechanisms that fuse the vertically integrated professional network with the community-embedded service network. This integration occurs across multiple interfaces. At the governance interface, the “township-hired, village-deployed” system formally embeds village doctors, transforming them into nodes where systemic accountability (for standardised care, public health delivery, and cost containment) converges with community-based trust. Operationally, the smart health platform acts as the critical technological integrator. It delivers county-mandated protocols and decision support to village clinics while simultaneously channeling village-generated health data upwards into the consortium’s quality and performance management systems. This creates a closed-loop data flow that standardises practice and enables supervision. Furthermore, capitation-based medical insurance payment reform creates a unified financial incentive. It aligns the interests of the entire consortium—from county hospitals to village doctors—toward the shared goals of improving population health and controlling costs, motivating the vertical network to proactively support and resource the grassroots tier. These mechanisms—formal institutional embedding, digital interpenetration, and aligned financial incentives—ensure that the two networks do not operate in parallel but interact synergistically, transforming village doctors into pivotal agents for “last mile” service delivery and accountability. 3.3.2 Integration Benefits As shown in Table 1 ,The synergistic ‘1 + 1>2’ effect of the dual-network integration model is empirically validated by Yilong County’s operational data (2018–2024), which demonstrate optimised system capability, care coordination, and operational efficiency. Service capacity achieved comprehensive regional coverage alongside quality enhancement, as evidenced by the deployment of 21 county specialists to primary care settings and a 100% mutual recognition rate for diagnostic results by 2024, alongside a rise in shared large-equipment utilisation from 148,090 visits (2022) to 239,665 (2024), with a sustained high examination positivity rate (~ 82%). This reflects the effective penetration of specialised resources and standardised protocols at the grassroots level. Furthermore, the model established a coherent tiered-care system that successfully retains patients within the county. Total inpatient admissions grew substantially from 40,991 (2018) to 87,767 (2024), whereas out-of-county referrals remained minimal (900 in 2024) relative to the vastly increased service volume, underscoring effective community-level triage and seamless internal referrals. Concurrently, system efficiency improved markedly: despite a sharp increase in bed occupancy from 90% (2018) to 114% (2024), the average length of stay decreased from 8.4 to 8.04 days, indicating streamlined internal coordination. This operational efficiency coincided with the revitalisation of the grassroots network, as primary-level outpatient and emergency visits surged from approximately 407,000 to nearly 900,000, signalling restored public trust and utilisation. Thus, Yilong’s integration of a vertically coordinated professional network with a community-embedded service network has generated a governance paradigm that enhances integrated capability, optimises care order, and improves systemic efficiency, offering a replicable model for underdeveloped regions. A sensitivity analysis was conducted to verify the robustness of the results: (1) Excluding 2022 intermediate data, the primary care visit rate still increased by 118.7% (2018→2024), which is consistent with the original trend; (2) the use of absolute differences instead of growth rates yielded similar conclusions. This confirms that the dual-network integration effect is stable. Table 1 Key operational indicators of the Yilong CLMC before and after the reform Statistical Indicator 2018 (Baseline) 2022 (Mid-reform) 2024 (Postmaturity) Change Rate (2018→2024, %) Change Rate (2022→2024, %) Number of Discharges from County Institutions 39,999 45,949 86,415 116.04 88.06 Number of Outpatient and Emergency Visits 407,150 561,366 899,391 120.90 60.21 Number of Inpatient Admissions to County Institutions 40,991 47,358 87,767 114.11 85.32 Total Inpatient Admissions to Leading Hospital 40,991 47,358 56,355 37.48 18.99 Number of Inpatient Referrals to Out-of-County Institutions¹ 103 109 900 773.79 724.77 Number of Senior Experts Deployed to Primary Institutions 0 0 21 — — Traditional Chinese Medicine (TCM) Service Providers at Primary Institutions 39 39 39 0 0 Mutual Recognition Rate of Inspection Results (%) 0 100 100 — 0 Total PACS Services Provided Not available 148,090 239,665 — 61.83 Number of Positive PACS Reports Not available 117,845 196,259 — 66.54 Average Length of Stay (ALOS, days) 8.4 8.3 8.04 -4.29 -3.13 Bed Utilisation Rate (%) 90 105 114 26.67 8.57 Data source: Health Bureau of Yilong County, Sichuan Province (2018–2024). All the data are derived from the county’s Health Information System (HIS) and Picture Archiving and Communication System (PACS). Notes: ① Out-of-county referrals refer to inpatient transfers outside Yilong County, excluding emergency and voluntary rare disease referrals; ② “—” indicates no baseline data; ③ “Not available” indicates that the PACS system was not fully operational in 2018. 4 Discussion 4.1 Discussion of the Key Results The Yilong Model elucidates a governance mechanism that fundamentally addresses the “last mile” problem by coupling vertical systemic accountability with horizontal community assets. Its significance is illuminated through theoretical extension and comparative practice. This study provides a critical mechanistic extension to the existing public health literature. While research has established a valuable correlation between social capital and healthcare utilisation, our findings detail the institutional vehicle through which this capital is mobilised for systemic goals. The model’s four-dimensional embedding (management, operational, functional, developmental) actively engineers an interface where the village doctor’s indigenous trust is transformed into a formal lever for chronic disease management and care continuity. This directly addresses the theoretical gap of “suspended responsibility” in accountable care models by demonstrating how abstract population health accountability can be concretely transmitted to, and enacted by, the community-tier actor. A comparative view with major primary care initiatives in other developing regions clarifies the model’s integrative innovation. Community health worker programmes in Africa ( e.g. , Rwanda) and India have made strides in formalising frontline roles or deploying innovative outreach. However, challenges persist around their sustainable financing and full integration into a financially aligned health system, sometimes resulting in parallel structures or dependence on donor funding. The Yilong Model synthesises a distinct pathway by creating an organic incentive loop: capitation payment reform aligns the entire consortium’s finances with population health; this motivates the county-level network to proactively strengthen grassroots capacity; and the formal embedding of village doctors ensures that this capacity is delivered via trusted community relations. This closes the loop between financing, service delivery, and community acceptance. Therefore, the model’s core is a coupled institutional redesign tailored to underdeveloped regions. This finding demonstrates that isolated improvements in payment, digital health, or community health worker support are insufficient. Efficacy arises from their synergistic sequence: (1) a health-outcome-linked financing model ( e.g. , capitation with bonuses for chronic disease control) creates the overarching economic imperative; (2) formal identity and career embedding (“township-hired, village-deployed”) aligns the village doctor’s individual incentives with this system goal; and (3) tailored digital integration ( e.g. , smart diagnostic aids) operationally connects village practice to county-wide quality assurance. This design strategically converts the typical constraints of underdeveloped regions—scarce resources yet strong community ties—into the very foundations of a more responsive and sustainable primary care system. 4.2 Limitations and Future Directions This study has certain limitations. First, as a single-case study, the Yilong model's operation is context dependent on local policies and economic conditions, limiting the generalizability of the conclusions. Second, the use of noncontinuous data in research has led to inadequate tracking of long-term dynamic changes, making it difficult to assess the model's sustained impact on residents' health outcomes and medical cost control fully. Additionally, this research focuses more on macroinstitutional mechanisms and lacks an in-depth exploration of the subjective perceptions of key microsubjects, such as village doctors and rural residents. Future research can adopt multicase comparative methods to verify the model's adaptive conditions in different regions. It is also necessary to improve the comprehensiveness of effect evaluation to refine the model's human-oriented design, providing more solid support for the promotion of the CLMC. As a foundational exploratory study, this paper serves as a preliminary phase in a broader research agenda. Subsequent work will build upon these findings to conduct a more rigorous and comprehensive empirical assessment of the public effects generated by such integrated models in underdeveloped regions, including their long-term impact on health equity, community well-being, and systemic sustainability. 5 Conclusions This study delineates a governance mechanism for primary care integration in underdeveloped regions, where embedding village doctors into a vertically accountable network successfully bridges the “last mile” to community health. The model’s replicability is anchored in contexts sharing three structural prerequisites: constrained fiscal capacity, institutionally marginalised village practitioners, and a fragmented county-township-village service continuum. Its promotion necessitates adaptive calibration of the financing model and digital scaffolding to local policy and resource bases. Divergent from stand-alone community health worker programs grappling with sustainable financing worldwide, this integrated approach demonstrates how coupling prepayment reforms with formal frontline workforce embedding creates an incentive-aligned, self-reinforcing system. It thus contributes a viable blueprint for strengthening primary healthcare governance in resource-constrained settings globally, advancing both the Healthy China initiative and the international pursuit of equitable health system delivery. 6. Declarations 6.1 Ethics approval and consent to participate This study was approved by the Ethics Committee for Basic and Clinical Research of Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital (Approval No. Lun Shen (Yan) 2026 No.130). The study was classified as noninterventional research and underwent a rapid review procedure in accordance with the committee’s guidelines. All procedures performed in this study involving human participants were in line with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed written consent was obtained from all individual participants who were involved in the qualitative interviews of this study. 6.2 Consent for publication Not Applicable. 6.3 Data availability The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. 6.4 Funding This study constitutes a phase outcome of the National Philosophy and Social Science Fund project ‘Identification of Multidimensional Barriers, Formation Mechanisms, and Breakthrough Pathways for Enhancing Governance Efficiency in County-Level Medical Consortiums’ (Project No. 25CGL156) and the Sichuan Provincial Philosophy and Social Science Fund project ‘Identification of Barriers, Formation Mechanisms, and Resolution Pathways for the Last Mile of Smart Healthcare in Grassroots Settings of Sichuan's Ethnic Regions’ (Project No. SCJJ25ND200). 6.5 Author Contributions Li Liu: Conception, supervision, writing–review & editing, project administration, Funding acquisition. Youbin Guo: Investigation, Data curation, Formal analysis, Writing–Original Draft, Visualisation. Jinliang Hu: Methodology, Formal analysis (qualitative & economic), Ethical approval, Writing–Review & Editing, Supervision, Correspondence. All the authors read and approved the final manuscript. 6.6 Competing interests The authors declare that they have no competing interests. 6.7 Acknowledgments We would like to express our sincere gratitude to all individuals and institutions that contributed to the completion of this study. First and foremost, we acknowledge the valuable guidance and constructive suggestions provided by the research team from the Institute of Rural Development, Sichuan Academy of Social Sciences, and the Department of Medical Records & Statistics, Sichuan Provincial People's Hospital. Their professional insights significantly enhanced the rigor and depth of this research. We are deeply indebted to the Health Bureau of Yilong County, Sichuan Province, for providing access to critical operational data and policy documents. Special thanks go to the frontline medical staff, village doctors, and all interview participants in Yilong County for their generous time and honest sharing of experiences, which laid the foundation for the empirical analysis. This study was financially supported by the National Philosophy and Social Science Fund of China (No. 25CGL156) and the Sichuan Provincial Philosophy and Social Science Fund (No. SCJJ25ND200). The funding support is gratefully acknowledged. We also appreciate the ethical review and approval provided by the Ethics Committee for Basic and Clinical Research of Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital. Additionally, sincere thanks are extended to the anonymous reviewers for their thoughtful comments and suggestions that helped improve the manuscript. Finally, we would like to thank our families and colleagues for their continuous support and encouragement throughout the research process. References TAO SS, MEI GL, BAI ZL, et al. Reflections on the construction of county-level medical consortia based on social network theory. Health Econ Res. 2018;9:21–3. https://doi.org/10.14055/j.cnki.33-1056/f.2018.09.007 . YU JX, TU YX. Exploring a Chinese approach to integrated healthcare service systems An investigation of county-level medical consortia in Anhui, Shanxi, and Zhejiang. Gov Stud. 2020;36:5–15. https://doi.org/10.15944/j.cnki.33-1010/d.2020.01.001 . ZHU JM, DUAN H. How can county-level medical consortia achieve health performance Policy entrepreneurs, reorganised alliances, and incentive compatibility. J Public Manage. 2021;18:125–38. https://doi.org/10.16149/j.cnki.23-1523.2021.03.002 . ZHU FM, WANG HEQH. The impact of County-Level Medical Consortium construction on healthcare utilisation An analysis based on a pilot programme of compact county-level medical consortia in a province of China. J Manage World. 2025;41:130–53. https://doi.org/10.19744/j.cnki.11-1235/f.2025.0138 . WANG PENGM. Does integrated health management within a county medical consortium improve rural type 2 diabetic patients’ self-management behavior and quality of life An empirical analysis from Eastern China. BMC Public Health. 2024;24:1439. https://doi.org/10.1186/s12889-024-16439-x . YANG LIJ, ZHANG H, et al. Effects of medical consortium policy on health services An interrupted time-series analysis in Sanming, China. Front Public Health. 2024;12:1322949. https://doi.org/10.3389/fpubh.2024.1322949 . CHEN H, ZHAO L, YU J. Spatiotemporal evolution of healthcare service capacity at township health centers in China. Front Public Health. 2023;11:1229453. https://doi.org/10.3389/fpubh.2023.1229453 . WANG X, ZHANG Y, LIU J, LI R. Effects of vertical integration on the healthcare system in China A systematic review and meta-analysis. Health Policy Plann. 2024;39:66–79. https://doi.org/10.1093/heapol/czad145 . MUKAMEL DB, HAEDER SF, WEIMER DL. Top-down and bottom-up approaches to health care quality The impacts of regulation and report cards. Annu Rev Public Health. 2014;35:477–97. https://doi.org/10.1146/annurev-publhealth-032013-182351 . JIAVIRIYABOONYA P. Anthropological study of village health volunteers’ (VHVs’) sociopolitical network in minimising risk and managing the crisis during COVID-19. Heliyon. 2022;8:e08761. https://doi.org/10.1016/j.heliyon.2022.e08761 . MADON S. Theorising community health governance for strengthening primary healthcare in LMICs. Health Policy Plann. 2022;37:706–16. https://doi.org/10.1093/heapol/czab152 . ZHANG X, LI W. The influence of professional identity, job satisfaction, burnout on turnover intention among village public health service providers in China in the context of COVID-19 A cross-sectional study. Front Public Health. 2022;10:925882. https://doi.org/10.3389/fpubh.2022.925882 . ZHONG Y, WANG Y. Skilled hands and benevolent hearts The emotional practice of village doctors from the perspective of emotional labor. China Rural Surv. 2025;4:124–43. https://doi.org/10.20074/j.cnki.11-3586/f.2025.04.005 . CAO H, LIU S, WANG M, et al. Patient-centered evaluation of integrated care and health equity Evidence from county medical alliances in Henan province. Int J Equity Health. 2025;24:101. https://doi.org/10.1186/s12939-025-02267-8 . FISHER ES, SHORTELL SM. Accountable care organisations Accountable for what, to whom, and how. JAMA. 2010;304:1715–6. https://doi.org/10.1001/jama.2010.1381 . LI L, YU Q. The impact of reform of medical insurance payment method on medical service pricing Based on empirical analysis of matched medical finance comprehensive data. BMC Health Serv Res. 2024;24:1479. https://doi.org/10.1186/s12913-024-11043-9 . WANG Z, CHANG W. A medical insurance fund operation performance evaluation system under the DRG payment mode reform. Front Public Health. 2025;13:1549575. https://doi.org/10.3389/fpubh.2025.1549575 . DING S, ZHOU Y. County medical community, medical insurance package payment, and hierarchical diagnosis and treatment Empirical analysis of the impact of the pilot project of compact county medical communities in Sichuan Province. PLoS ONE. 2024;19:e0297340. https://doi.org/10.1371/journal.pone.0297340 . OLYA MH, DEHGHANIMOHAMMADABADI M, TSE YK. An integrated deep learning and stochastic optimisation approach for resource management in team-based healthcare systems. Expert Syst Appl. 2022;187:115924. https://doi.org/10.1016/j.eswa.2021.115924 . ZHAO M, LI X, ZHANG T, et al. Construction of a performance evaluation index system for the management of chronic diseases based on medical and preventive integration. BMC Public Health. 2025;25:664. https://doi.org/10.1186/s12889-025-18156-4 . LIU L, ZHANG KJ. The realistic demand, practical exploration and countermeasures for building county-level medical consortia under the Healthy China initiative. Rural Econ. 2024;2:90–102. https://doi.org/10.26957/j.cnki.cn51-1029/f.2024.02.009 . SONG C, FENG M. End-of-life care in rural China The crucial role and challenges of village doctors. BMC Palliat Care. 2025;24:115. https://doi.org/10.1186/s12904-025-01405-9 . ZHANG X, LI J, WANG H, et al. A village doctor-led mobile health intervention for cardiovascular risk reduction in rural China A cluster randomised controlled trial. BMJ. 2025;389:e077842. https://doi.org/10.1136/bmj-2024-077842 . VALAITIS RK, WONG ST. Addressing quadruple aims through primary care and public health collaboration Ten Canadian case studies. BMC Public Health. 2020;20:507. https://doi.org/10.1186/s12889-020-08991-6 . BOURDIEU P. The forms of capital. In: RICHARDSON J, editor. Handbook of Theory and Research for the Sociology of Education. New York: Greenwood; 1986. pp. 241–58. MUNTANER C. LYNCH J. Social capital, class gender and race conflict, and population health An essay review of Bowling Alone‘s implications for social epidemiology Bowling alone. The collapse and revival of American community. RD Putnam. New York: Simon & Schuster, 2000, p. 544, US $ 26. ISBN: 0 684 83283 6. International Journal of Epidemiology. 2002;31:261–267. https://doi.org/10.1093/ije/31.1.261 LUO Q, XU J, ZHANG Y, et al. Association between social capital and utilisation of essential public health services among elderly migrants A multilevel logistic study based on the 2017 China migrant dynamic survey (CMDS). BMC Public Health. 2024;24:1252. https://doi.org/10.1186/s12889-024-16221-8 . AHMED SM, HOSSAIN MA, CHOWDHURY MR. Harnessing pluralism for better health in Bangladesh. Lancet. 2013;382:1746–55. https://doi.org/10.1016/S0140-6736(13)61812-5 . WANG Q, YUE K, LI D, et al. What are the challenges faced by village doctors in provision of basic public health services in Shandong, China A qualitative study. Int J Environ Res Public Health. 2019;16:2519. https://doi.org/10.3390/ijerph16142519 . Zhang KL. Old age with medical care: rural medical service system and aging health. Explor Free Views. 2025;(6):30–3. Additional Declarations No competing interests reported. Supplementary Files SupplementaryAppendixS1FullSemistructuredInterviewGuides.docx Appendix1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 30 Apr, 2026 Reviews received at journal 30 Apr, 2026 Reviewers agreed at journal 25 Mar, 2026 Reviewers agreed at journal 25 Mar, 2026 Reviewers invited by journal 25 Mar, 2026 Editor assigned by journal 23 Mar, 2026 Editor invited by journal 26 Feb, 2026 Submission checks completed at journal 25 Feb, 2026 First submitted to journal 25 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8900646","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":612887230,"identity":"6107d793-aee7-4279-8fc6-db41a06b0855","order_by":0,"name":"Li LIU","email":"","orcid":"","institution":"Sichuan Academy of Social Sciences","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"LIU","suffix":""},{"id":612887232,"identity":"9c430350-abdc-4a28-a5a7-c6173e2fe575","order_by":1,"name":"Youbin GUO","email":"","orcid":"","institution":"Sichuan Academy of Social Sciences","correspondingAuthor":false,"prefix":"","firstName":"Youbin","middleName":"","lastName":"GUO","suffix":""},{"id":612887234,"identity":"85d219c7-7165-4fe8-bff2-108c296af862","order_by":2,"name":"Jinliang HU","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAr0lEQVRIiWNgGAWjYBACAygtx8befIA0LcZ8PMcSSNOSOE8iR4E4LeYSCcwffvw5nN7GkMPA8KNiG2EtljMS2CR72w7ntjGcPcDYc+Y2EQ67kcDGzNgA1MLYl8DM2EacFubPDECHsTHzGBCthUGage1wAhsb0VrOPAD5Jd2wjYct4SBxfjkODjFrefn5jw8++FFBhBYGBv4PQKIZzDxAjHoYqCNF8SgYBaNgFIw0AAAwgznBKsb2EQAAAABJRU5ErkJggg==","orcid":"","institution":"Sichuan Academy of Medical Sciences \u0026 Sichuan Provincial People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jinliang","middleName":"","lastName":"HU","suffix":""}],"badges":[],"createdAt":"2026-02-17 11:38:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8900646/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8900646/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105574891,"identity":"ec5c7977-ca55-4a2b-b85d-546446f8ef33","added_by":"auto","created_at":"2026-03-27 13:36:38","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38390,"visible":true,"origin":"","legend":"\u003cp\u003eTimeline of medical reform in Yilong County\u003c/p\u003e","description":"","filename":"image1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8900646/v1/6a93060db891a92aad01c3cb.jpeg"},{"id":105574185,"identity":"d85075f3-01b4-4a3c-9496-03033fb7f178","added_by":"auto","created_at":"2026-03-27 13:33:52","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":49415,"visible":true,"origin":"","legend":"\u003cp\u003eLogical diagram of governance weight reconstruction for the Yilong CLMC\u003c/p\u003e","description":"","filename":"image2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8900646/v1/d9f5e4ec16811e5ac96e4aa6.jpeg"},{"id":105574392,"identity":"1f330b8b-cba0-4eb2-bcc4-fe2deff687b3","added_by":"auto","created_at":"2026-03-27 13:34:47","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":51931,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of joint resource pool development logic transmission within the Yilong CLMC\u003c/p\u003e","description":"","filename":"image3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8900646/v1/daa4e446c817009f3f549f79.jpeg"},{"id":105574210,"identity":"67bb81eb-4a85-49b7-9248-de2318ba52a4","added_by":"auto","created_at":"2026-03-27 13:33:56","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":49656,"visible":true,"origin":"","legend":"\u003cp\u003eIntegrated Service Network Model for Coordinated Healthcare Provision in Yilong County's Township Medical Institutions\u003c/p\u003e","description":"","filename":"image4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8900646/v1/b7c08312aaf08f4d62962e57.jpeg"},{"id":105574213,"identity":"50731df8-e0f2-4508-9bc2-02b69081c7ff","added_by":"auto","created_at":"2026-03-27 13:33:57","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":152441,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of the integrated development model for village medical practitioners in Yilong County\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-8900646/v1/99d701cb5dd1cc3e41514819.png"},{"id":105575492,"identity":"b7e6683b-da4d-46c5-962b-5641e8651e6d","added_by":"auto","created_at":"2026-03-27 13:39:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1280130,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8900646/v1/6d6638fa-ab1a-4e36-b07d-c5a676677856.pdf"},{"id":105574764,"identity":"ce4bfa19-8e12-47e8-b62e-f1f38b7e040b","added_by":"auto","created_at":"2026-03-27 13:36:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":52969,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryAppendixS1FullSemistructuredInterviewGuides.docx","url":"https://assets-eu.researchsquare.com/files/rs-8900646/v1/7c92633f35db6d0d5154e319.docx"},{"id":105574717,"identity":"31b6b68a-dc6c-4edc-88f1-37e667bfb21e","added_by":"auto","created_at":"2026-03-27 13:35:56","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":23208,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8900646/v1/000507f02be5e4760587cf54.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Dual-Network Integration in a County-Level Medical Consortium: An Exploratory Case Study from Yilong, an Underdeveloped Region","fulltext":[{"header":"1 Introduction","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1Background\u003c/h2\u003e \u003cp\u003eAt this pivotal juncture in the deepening implementation of the Healthy China strategy, the \u0026lsquo;last mile\u0026rsquo; bottleneck in primary healthcare has emerged as a core constraint on system equity and accessibility, particularly in underdeveloped regions. National Health Commission data from 2023 indicate a national average county-level hospital visit rate of 89.5%, yet rates in underdeveloped western regions remain below 85%. This disparity stems from a persistent \u0026lsquo;structural disconnect\u0026rsquo; within the three-tier service network: county hospitals\u0026rsquo; limited downwards outreach, township health centres\u0026rsquo; functional attrition, and village clinics\u0026rsquo; frequent failure as effective gatekeepers. This progressive weakening drives patient outflow to higher-level hospitals, exacerbating access barriers and costs while eroding the foundations of the tiered healthcare system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Research gaps\u003c/h2\u003e \u003cp\u003eExtant research on the County-Level Medical Consortium (CLMC) has established a substantial foundation, charting their evolution and analysing key mechanisms, yet collectively reveals a critical, unaddressed theoretical and empirical gap concerning grassroots integration. Scholarly consensus delineates an evolutionary trajectory for CLMC, moving from technical, \u0026ldquo;loose alliances\u0026rdquo; as noted by Tao and colleagues in 2018, towards \u0026ldquo;tight integration\u0026rdquo; through unified governance, a pathway emphasised by Yu \u003cem\u003eet al\u003c/em\u003e. in 2020 and Zhu and Duan in 2021\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. This progression, which aims to address systemic fragmentation and directly influences healthcare utilisation patterns, as highlighted by Zhu \u003cem\u003eet al.\u003c/em\u003e (2025), is further underscored by policy-aligned studies such as Peng \u003cem\u003eet al.\u003c/em\u003e (2024) and Yang \u003cem\u003eet al.\u003c/em\u003e (2024)\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. However, this top-down integrative drive, predominantly following a \u0026ldquo;vertical integration\u0026rdquo; logic between county and township tiers \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003eas analysed by Chen \u003cem\u003eet al.\u003c/em\u003e (2023) and Wang \u003cem\u003eet al.\u003c/em\u003e (2024), has yielded a significant structural bias and, as noted in broader health policy literature, can intensify underlying conflicts of interest (Mukamel \u003cem\u003eet al.\u003c/em\u003e, 2014)\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. As scholars such as Jiaviriyaboonya (2022) and Madon and Krishna (2022) have observed, this model largely neglects the \u0026ldquo;activation of the grassroots network,\u0026rdquo; leaving village doctors in a state of \u0026ldquo;institutional limbo\u0026rdquo; with ambiguous professional identity and inadequate safeguards\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, challenges further detailed in the work of Zhang \u003cem\u003eet al.\u003c/em\u003e (2022) and Zhong (2025)\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. This oversight results in a persistent \u0026ldquo;last mile\u0026rdquo; bottleneck, hindering the system\u0026rsquo;s transition towards health-centered care despite the observed local efficiencies noted by Cao \u003cem\u003eet al.\u003c/em\u003e (2025)\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe application of accountable care organisation (ACO) theory, a pivotal framework for analysing CLMCs introduced by Fisher and Shortell (2010)\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e, has deepened our understanding of financial and performance incentives. Studies such as Li \u003cem\u003eet al.\u003c/em\u003e (2024) and Wang \u003cem\u003eet al.\u003c/em\u003e (2025) have effectively explored how payment reforms establish risk-sharing mechanisms within \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, an impact also empirically examined in the context of hierarchical diagnosis and treatment by Ding \u003cem\u003eet al.\u003c/em\u003e (2024)\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Concurrently, Olya \u003cem\u003eet al.\u003c/em\u003e (2022) and Zhao \u003cem\u003eet al.\u003c/em\u003e (2025) examined outcome-oriented performance systems\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. However, this body of work has a critical theoretical limitation: \u0026ldquo;suspended accountability at the nerve endings.\u0026rdquo; Analyses predominantly assume that the \u0026ldquo;accountable organisation\u0026rdquo; comprises county and township institutions\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e, a focus evident in the governance research of Liu (2024). Consequently, there is a \u0026ldquo;responsibility transmission blockage\u0026rdquo; where abstract population health accountability fails to be effectively extended to the village-level terminal, the very point emphasised as crucial for service delivery by scholars such as Song \u003cem\u003eet al.\u003c/em\u003e (2025) and Zhang \u003cem\u003eet al.\u003c/em\u003e (2025)\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. While recent work by Valaitis \u003cem\u003eet al.\u003c/em\u003e (2020) highlights collaboration models\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e, the specific mechanism for binding village doctors into the core ACO accountability cycle\u0026mdash;encompassing clear responsibility, precise measurement, and commensurate compensation\u0026mdash;remains undertheorised.\u003c/p\u003e \u003cp\u003eSimultaneously, a separate stream of literature highlights the role of social capital in community health. Building on the foundational work of Bourdieu (1986) and Muntaner and Lynch (2002), contemporary studies such as Luo \u003cem\u003eet al.\u003c/em\u003e (2024) demonstrate its positive association with service utilisation\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. Village doctors are recognised as central carriers of this capital, bridging formal systems and communities through local trust, as noted by Ahmed \u003cem\u003eet al.\u003c/em\u003e (2013) and Wang \u003cem\u003eet al.\u003c/em\u003e (2019)\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. However, this research often runs in parallel with studies on institutional integration. Therefore, a core research gap persists: existing scholarship has yet to synthetically bridge the institutional logic of ACO theory, which focuses on top-down accountability and financial alignment, with the relational logic of social capital theory, which explains bottom-up community trust and service acceptance. The synergistic mechanism through which the formal, vertically integrated professional network and the informal, community-embedded service network interact in underdeveloped regions remains inadequately explained. This study aims to address this gap by integrating these two theoretical lenses to explore the \u0026ldquo;dual-network integration\u0026rdquo; model, thereby providing a comprehensive micromechanistic explanation for solving the \u0026ldquo;last mile\u0026rdquo; problem in primary healthcare reform.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Research objectives and questions\u003c/h2\u003e \u003cp\u003eThis study employs an exploratory single-case methodology to deconstruct Yilong County's dual-network integration model, utilising fieldwork, policy analysis and multisource data to achieve three objectives: (1) Delineating the model's evolution and the synergy between the \u0026lsquo;county-township linkage\u0026rsquo; professional network and the \u0026lsquo;village doctor embedding\u0026rsquo; community network; (2) Analysing its governance architecture and the logic of institutional, technical and social coupling within the CLMC\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e; and (3) Deriving a context-sensitive theoretical framework for underdeveloped regions. The research is guided by three central questions: how \u0026lsquo;county-township linkage\u0026rsquo; activates interinstitutional synergy; through which specific institutional designs \u0026lsquo;village doctor embedding\u0026rsquo; reintegrates vacant and underresourced village clinics; and how the model combines resources, incentives and oversight to reduce costs while improving service quality and satisfaction. By addressing these issues, this study aims to elucidate the model's internal logic and propose actionable policy pathways to support the local implementation of the Healthy China strategy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Structure of the Paper\u003c/h2\u003e \u003cp\u003eThe structure of this paper is organised as follows: Part Two outlines the research methodology, including the study design, case selection, data collection and analysis, ethical approval, and rigor and limitations. Part Three presents the main findings of the research analysis. Part four discusses the results in response to the research questions and engages with the literature, demonstrating theoretical contributions, interpreting practical implications, and addressing research limitations and future directions. The concluding section summarises the paper's principal research findings and draws final conclusions.\u003c/p\u003e \u003c/div\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003eThis study adopted a longitudinal single-case design embedded with process tracing to address its exploratory \u0026ldquo;how\u0026rdquo; question: how does an underdeveloped county construct and realise \u0026ldquo;dual-network integration\u0026rdquo; through institutional and organisational innovations? The case study approach is suited to providing deep, holistic insights into such complex, mechanism-oriented phenomena. A longitudinal perspective enabled tracing the reform\u0026rsquo;s evolution across key stages, whereas process tracing was used to identify and examine critical events, decisions, and their impacts. Together, these methods facilitated the construction of an evidence-based narrative that elucidates how various elements interact to produce a stable governance model.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Case Selection\u003c/h2\u003e \u003cp\u003eYilong County in Sichuan Province was selected as the core case study area on the basis of three key considerations. First, its initial conditions\u0026mdash;being a traditional, resource-constrained region with imbalanced medical resource distribution, weak primary care capacity, and a fragmented three-tier network\u0026mdash;are highly representative of structural challenges common in underdeveloped areas, ensuring that the findings offer transferable insights. Second, the case demonstrates profound institutional innovation, particularly through its systematic \u0026ldquo;village doctor integration\u0026rdquo; mechanism. This approach goes beyond conventional county-township consolidation by implementing identity transformation, incentive-aligned remuneration, and digital empowerment, thereby activating the service system\u0026rsquo;s \u0026ldquo;last mile.\u0026rdquo; Third, the case provides exceptional research feasibility, with a well-documented, coherent reform trajectory enabling longitudinal and process-tracing analysis. Clear policy archives, observable outcomes, and multisource data support robust mechanism investigations and theoretical refinements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data collection\u003c/h2\u003e \u003cp\u003eData collection for this study followed a multisource, triangulated approach, encompassing archival, interview, observational, and quantitative data. Archival and textual data, including national and local policy documents, the consortium's charter, internal meeting minutes, and media reports, were gathered to establish the institutional context. Semi-structured interviews were conducted with purposively sampled stakeholders from four key groups: policy makers, medical consortium managers, frontline medical staff (including village doctors), and technical support personnel, to explore reform experiences and operational mechanisms. The interview guides were tailored to each stakeholder group, focusing on the reform's top-level design, operational implementation, frontline practice, and digital support, respectively. The core questions of the interview guides are presented in Appendix 1 of this manuscript, and the full, complete version of the interview guides (including the respondent information collection form, anonymisation and data management rules, interview opening script, closing prompt and research team implementation notes) is available in Supplementary Appendix S1.Participant and nonparticipant observations were carried out at sites such as the central command hub, township health centers, and village clinics to document the interplay between formal protocols and informal practices. Quantitative operational data were extracted from the county's Health Information System (HIS) and Picture Archiving and Communication System (PACS). To capture phase-specific outcomes and avoid redundant annual data, indicators spanning service utilisation, capacity, and efficiency were analysed at three strategic time points (2018, 2022, 2024), corresponding to the prereform, mid-reform, and postmaturity phases of the consortium's development.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data analysis\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1 Periodisation and Rationale\u003c/h2\u003e \u003cp\u003eThis study delineates the reform trajectory of the Yilong CLMC (2018\u0026ndash;2024) into three distinct phases on the basis of a comprehensive analysis of multisource data, focusing on critical policy junctures, institutional innovations, and fundamental shifts in governance structure (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, outlining the three-phase evolution of dual-network integration: 2018\u0026ndash;2020 [county-township integration], 2021\u0026ndash;2022 [village doctor embedding], and 2023\u0026ndash;2024 [system synergy]). The first phase (2018\u0026ndash;2020), structural exploration and county‑township integration, was marked by establishing the general hospital as a single legal entity, implementing the \u0026lsquo;Eight Unifications\u0026rsquo; management model, and introducing a joint virtual\u0026ndash;physical leadership system, with the core aim of dismantling administrative and interest barriers to create a vertically integrated governance framework. The second phase (2021\u0026ndash;2022), mechanism innovation and village doctor integration, shifted its focus to activating the grassroots network through systematic policies such as the \u0026lsquo;township‑hired, village‑deployed\u0026rsquo; personnel system, a four‑tier remuneration structure, and the rollout of the \u0026lsquo;Smart Medical Assistant\u0026rsquo; system, thereby achieving institutional embedding of village doctors. The third phase (2023\u0026ndash;2024), system synergy and model consolidation, was characterised by deepening the application of the smart health platform, data‑driven performance management, standardisation of two‑way referrals, and increased weighting of health outcomes in evaluation, indicating that the dual‑network integration model had entered a stage of synergistic effect and operational stabilisation. This phased analysis outlines the strategic evolution from a structural foundation through mechanism innovation to system‑wide synergy.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.4.2 Coding Procedure and Analytical Strategy\u003c/h2\u003e \u003cp\u003eWithin each of these phases, the analysis followed a structured coding process grounded in grounded‑theory principles. Qualitative data from interviews, observations, and archival texts were subjected to iterative multilevel coding: open coding generated initial descriptive concepts; axial coding clustered these concepts into broader thematic categories; and selective coding integrated the emerging themes with relevant theoretical frameworks (accountable care organisation theory and social capital theory) to construct a coherent explanatory thread across the three phases. This coding work was complemented by process‑tracing narratives that dynamically reconstructed the causal interactions between county‑township linkages and village‑doctor embedding. Finally, longitudinal quantitative operational data were embedded as outcome evidence within the qualitative narrative, achieving methodological triangulation that simultaneously clarified the operational mechanisms and demonstrated their practical effectiveness.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.1 County-Township Linkage\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 Reconfiguration of the Governance Authority\u003c/h2\u003e \u003cp\u003eThe reconfiguration of governance authority formed the institutional foundation for the Yilong Model. Prior to reform, fragmented multilegal-entity governance led to disparate institutional interests and high coordination costs. Yilong\u0026rsquo;s breakthrough involved establishing Yilong County General Hospital as a single legal entity, underpinned by a virtual-real dual-appointment leadership system\u0026mdash;which was consistent with the \u0026ldquo;Structural Exploration and County-Township Integration\u0026rdquo; phase (2018\u0026ndash;2020).\u003c/p\u003e \u003cp\u003eUnder this system, General Hospital\u0026rsquo;s principal leaders hold substantive roles across county institutions, ensuring a unified strategy and resource allocation, while also serving in nonexecutive roles at branch hospitals to maintain grassroots adaptability. This dual mechanism created a \u0026ldquo;responsibility-management community,\u0026rdquo; with the general hospital bearing overall accountability for medical quality and outcomes across the county. Centralised authority enabled the implementation of the \u0026ldquo;Eight Unifications\u0026rdquo; management model and the establishment of ten unified management centres, shifting from fragmented operations to standardised, system-wide governance. This restructuring provided essential organisational and political impetus for subsequent integration (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, which illustrates the logical framework of governance authority reconstruction, including a single legal entity and dual-appointment system).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 Joint resource pool development\u003c/h2\u003e \u003cp\u003eBuilding upon the unified governance framework, the reform advanced to the system-wide optimisation and dynamic circulation of healthcare resources through the establishment of joint resource pools. This strategy transformed key production factors\u0026mdash;encompassing human, material, and financial assets\u0026mdash;from static, institution-specific allocations into a county-owned commons for flexible deployment, pursuing Pareto-optimal resource distribution across the integrated network. A centralised human resource roster enabled unified personnel planning, operationalised through a \u0026ldquo;county recruitment, township deployment\u0026rdquo; system that alleviated chronic talent shortages at the township level. Similarly, a structured rotation mechanism of \u0026ldquo;upwards attachment and downwards deployment\u0026rdquo; facilitated deliberate capability transfer and knowledge spillage between county and township facilities. Financial consolidation was achieved via a unified accounting system, permitting strategic reallocation of funds to underresourced areas, while material resources were integrated through centralised procurement directories and the redistribution of underutilised medical equipment to sites of greater clinical need. Crucially, a fundamental shift in medical insurance payments\u0026mdash;from a fee-for-service model to a prepaid capitation model with surplus retention\u0026mdash;served as the core economic driver. This payment reform intrinsically aligned the consortium\u0026rsquo;s financial incentives with population health outcomes and cost containment, motivating proactive investment in primary care and fostering a genuine community of shared interests that translated systemic objectives into coherent individual action (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, depicting the logic transmission of joint resource pool development driven by medical insurance payment reform).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.1.3 Service Network Integration\u003c/h2\u003e \u003cp\u003eService network integration operationalises the consortium\u0026rsquo;s governance and resource foundations, constructing a seamless, patient-centred care continuum through the synergistic alignment of standardised protocols, rationalised specialist layout, and a unified digital infrastructure. Technically, centrally mandated clinical pathways, documentation norms, and safety standards enforced by the general hospital ensure homogeneous care quality across all tiers, creating essential trust and interoperability for effective two-way referrals. Strategically, a deliberate reconfiguration of specialist resources mitigated internal competition and formed distinct centres of excellence: complex acute care was concentrated at the Medical Centre campus, traditional Chinese medicine specialties were consolidated at the TCM campus, and women\u0026rsquo;s and children\u0026rsquo;s services were centralised at a dedicated campus. This differentiated development optimises patient flow and enhances the county\u0026rsquo;s collective capacity. Digitally, a county-wide smart health platform\u0026mdash;integrating core systems (HIS, LIS, PACS)\u0026mdash;serves as the operational backbone, dismantling information silos, enabling real-time data sharing and seamless patient transitions, and embedding standardised workflows. The integrated network\u0026rsquo;s efficacy is evidenced by outcome metrics: diagnostic result mutual recognition reached 100%, and shared large-equipment utilisation increased from 148,090 services (2022) to 239,665 (2024), with a sustained high examination positivity rate (~\u0026thinsp;82%). Collectively, these elements have transformed previously fragmented services into a coordinated, vertically integrated service community (see Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, presenting the integrated service network model for coordinated county-township-village healthcare).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Village doctor integration\u003c/h2\u003e \u003cp\u003eYilong County\u0026rsquo;s village doctor embedding is realised through an integrated mechanism comprising management embedding, operational embedding, character embedding, and development embedding. This mechanism addresses their historical institutional ambiguity and leverages their social capital to organically embed them within the CLMC, thereby strengthening grassroots service delivery. Figure\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the four-dimensional embedding model for village doctor integrated development.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Management Embedding\u003c/h2\u003e \u003cp\u003eManagement Embedding institutionally resolves the protracted \u0026ldquo;semiofficial, semi‑private\u0026rdquo; status of village doctors by formally integrating them into the consortium through the innovative \u0026ldquo;township‑hired, village‑deployed\u0026rdquo; system. This transforms their employment basis from independent practice to contracted personnel under township health centres, ensuring stable organisational affiliation and statutory identity\u0026mdash;a foundational step often overlooked in conventional integration models. A restructured four‑tier remuneration system (basic salary, post allowance, performance bonus, public health subsidy) significantly elevates average monthly income, directly enhancing role attractiveness and retention. Crucially, village doctors are incorporated into the consortium\u0026rsquo;s unified performance‑evaluation framework, with metrics directly linked to service quality, patient satisfaction, and health outcomes. This alignment of individual incentives with system‑level objectives fosters professional identity and embeds village doctors as accountable actors within the integrated accountability chain, moving beyond superficial affiliation to substantive institutional membership.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Operational Embedding\u003c/h2\u003e \u003cp\u003eOperational embedding is achieved through deep digital integration that functionally connects village clinics to the county\u0026rsquo;s centralised care network. The deployment of the \u0026ldquo;Smart Medical Assistant\u0026rdquo; system standardises diagnosis and treatment for common conditions at the village level, substantially increasing diagnostic compliance rates. More distinctive is the implementation of a robust telemedicine corridor: village doctors, equipped with remote diagnostic devices, transmit real‑time ECG and imaging data to county specialists for interpretation, effectively democratising access to advanced diagnostics. This has supported tens of thousands of remote consultations, enhancing diagnostic accuracy and trust in village‑level care. Furthermore, full interoperability of electronic health records across the system allows village doctors to access patients\u0026rsquo; longitudinal medical histories, preventing duplicate testing and enabling continuity of care. This digital thread ensures that village‑generated service data feed directly into central quality‑assurance and performance‑monitoring systems, making village practice a visible, accountable node within the integrated service continuum.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3 Functional Embedding\u003c/h2\u003e \u003cp\u003eFunctional embedding repositions village doctors from episodic treaters to proactive health managers, leveraging their unique social capital to bridge formal healthcare systems and rural communities. Embedded within family‑doctor contract‑service teams as core nodes, their role expands across three dimensions: from clinic‑based care to proactive community outreach; from acute intervention to continuous lifecycle management; and from individual treatment to population‑health accountability. Chronic disease management exemplifies this shift: supported by digital tools and outcome‑oriented incentives, village doctors now conduct systematic screening, regular follow‑up, and tailored lifestyle interventions. This has driven marked improvements in standardised management and control rates for hypertension and diabetes\u0026mdash;key outcome indicators for primary care effectiveness. The redesign is sustained by a performance framework that rewards health outcomes and shares medical‑insurance savings with effective health managers, thereby institutionalising prevention and aligning village doctors\u0026rsquo; daily practices with the consortium\u0026rsquo;s population‑health objectives.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003e3.2.4 Developmental embedding\u003c/h2\u003e \u003cp\u003eDevelopmental embedding constructs a sustainable career ecosystem to transform village doctoring from a terminal occupation into a viable professional pathway. A clearly defined three‑tier career ladder (\u0026ldquo;Junior‑Core‑Outstanding\u0026rdquo;) links advancement to competency and performance, providing transparent progression incentives. Educational mobility is facilitated through formal degree‑upgrade programmes with medical colleges and a structured mentorship system linking village doctors to county‑based specialists. A critical institutional breakthrough is the adaptation of professional‑title evaluation criteria to recognise grassroots service quality and community impact, creating dedicated senior‑title quotas and enabling meaningful career advancement. Finally, a bidirectional talent‑circulation mechanism\u0026mdash;where village doctors undertake up‑skill placements at county hospitals and county specialists conduct regular outreach\u0026mdash;ensures continuous knowledge exchange and embeds village doctors within the wider talent architecture of the county health system. This holistic approach enhances professional prestige, secures retention, and ensures long‑term human‑resource sustainability at the primary care frontline.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Dual-Network Integration\u003c/h2\u003e \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Integrated Interfaces and Mechanisms\u003c/h2\u003e \u003cp\u003eThe core innovation of the Yilong Model lies not only in establishing separate county-township and village-level networks but also in the deliberate mechanisms that fuse the vertically integrated professional network with the community-embedded service network. This integration occurs across multiple interfaces. At the governance interface, the \u0026ldquo;township-hired, village-deployed\u0026rdquo; system formally embeds village doctors, transforming them into nodes where systemic accountability (for standardised care, public health delivery, and cost containment) converges with community-based trust. Operationally, the smart health platform acts as the critical technological integrator. It delivers county-mandated protocols and decision support to village clinics while simultaneously channeling village-generated health data upwards into the consortium\u0026rsquo;s quality and performance management systems. This creates a closed-loop data flow that standardises practice and enables supervision. Furthermore, capitation-based medical insurance payment reform creates a unified financial incentive. It aligns the interests of the entire consortium\u0026mdash;from county hospitals to village doctors\u0026mdash;toward the shared goals of improving population health and controlling costs, motivating the vertical network to proactively support and resource the grassroots tier. These mechanisms\u0026mdash;formal institutional embedding, digital interpenetration, and aligned financial incentives\u0026mdash;ensure that the two networks do not operate in parallel but interact synergistically, transforming village doctors into pivotal agents for \u0026ldquo;last mile\u0026rdquo; service delivery and accountability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Integration Benefits\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e,The synergistic \u0026lsquo;1\u0026thinsp;+\u0026thinsp;1\u0026gt;2\u0026rsquo; effect of the dual-network integration model is empirically validated by Yilong County\u0026rsquo;s operational data (2018\u0026ndash;2024), which demonstrate optimised system capability, care coordination, and operational efficiency. Service capacity achieved comprehensive regional coverage alongside quality enhancement, as evidenced by the deployment of 21 county specialists to primary care settings and a 100% mutual recognition rate for diagnostic results by 2024, alongside a rise in shared large-equipment utilisation from 148,090 visits (2022) to 239,665 (2024), with a sustained high examination positivity rate (~\u0026thinsp;82%). This reflects the effective penetration of specialised resources and standardised protocols at the grassroots level. Furthermore, the model established a coherent tiered-care system that successfully retains patients within the county. Total inpatient admissions grew substantially from 40,991 (2018) to 87,767 (2024), whereas out-of-county referrals remained minimal (900 in 2024) relative to the vastly increased service volume, underscoring effective community-level triage and seamless internal referrals. Concurrently, system efficiency improved markedly: despite a sharp increase in bed occupancy from 90% (2018) to 114% (2024), the average length of stay decreased from 8.4 to 8.04 days, indicating streamlined internal coordination. This operational efficiency coincided with the revitalisation of the grassroots network, as primary-level outpatient and emergency visits surged from approximately 407,000 to nearly 900,000, signalling restored public trust and utilisation. Thus, Yilong\u0026rsquo;s integration of a vertically coordinated professional network with a community-embedded service network has generated a governance paradigm that enhances integrated capability, optimises care order, and improves systemic efficiency, offering a replicable model for underdeveloped regions. A sensitivity analysis was conducted to verify the robustness of the results: (1) Excluding 2022 intermediate data, the primary care visit rate still increased by 118.7% (2018\u0026rarr;2024), which is consistent with the original trend; (2) the use of absolute differences instead of growth rates yielded similar conclusions. This confirms that the dual-network integration effect is stable.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey operational indicators of the Yilong CLMC before and after the reform\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatistical Indicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2018 (Baseline)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2022 (Mid-reform)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2024 (Postmaturity)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChange Rate (2018\u0026rarr;2024, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChange Rate (2022\u0026rarr;2024, %)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Discharges from County Institutions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45,949\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86,415\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e116.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Outpatient and Emergency Visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e407,150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e561,366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e899,391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e120.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Inpatient Admissions to County Institutions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40,991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47,358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87,767\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e114.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Inpatient Admissions to Leading Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40,991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47,358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56,355\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Inpatient Referrals to Out-of-County Institutions\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e773.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e724.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Senior Experts Deployed to Primary Institutions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraditional Chinese Medicine (TCM) Service Providers at Primary Institutions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMutual Recognition Rate of Inspection Results (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal PACS Services Provided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e148,090\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e239,665\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e61.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Positive PACS Reports\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117,845\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e196,259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e66.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage Length of Stay (ALOS, days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-4.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-3.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBed Utilisation Rate (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eData source: Health Bureau of Yilong County, Sichuan Province (2018\u0026ndash;2024). All the data are derived from the county\u0026rsquo;s Health Information System (HIS) and Picture Archiving and Communication System (PACS).\u003c/p\u003e \u003cp\u003eNotes: ① Out-of-county referrals refer to inpatient transfers outside Yilong County, excluding emergency and voluntary rare disease referrals; ② \u0026ldquo;\u0026mdash;\u0026rdquo; indicates no baseline data; ③ \u0026ldquo;Not available\u0026rdquo; indicates that the PACS system was not fully operational in 2018.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Discussion of the Key Results\u003c/h2\u003e \u003cp\u003eThe Yilong Model elucidates a governance mechanism that fundamentally addresses the \u0026ldquo;last mile\u0026rdquo; problem by coupling vertical systemic accountability with horizontal community assets. Its significance is illuminated through theoretical extension and comparative practice. This study provides a critical mechanistic extension to the existing public health literature. While research has established a valuable correlation between social capital and healthcare utilisation, our findings detail the institutional vehicle through which this capital is mobilised for systemic goals. The model\u0026rsquo;s four-dimensional embedding (management, operational, functional, developmental) actively engineers an interface where the village doctor\u0026rsquo;s indigenous trust is transformed into a formal lever for chronic disease management and care continuity. This directly addresses the theoretical gap of \u0026ldquo;suspended responsibility\u0026rdquo; in accountable care models by demonstrating how abstract population health accountability can be concretely transmitted to, and enacted by, the community-tier actor. A comparative view with major primary care initiatives in other developing regions clarifies the model\u0026rsquo;s integrative innovation. Community health worker programmes in Africa (\u003cem\u003ee.g.\u003c/em\u003e, Rwanda) and India have made strides in formalising frontline roles or deploying innovative outreach. However, challenges persist around their sustainable financing and full integration into a financially aligned health system, sometimes resulting in parallel structures or dependence on donor funding. The Yilong Model synthesises a distinct pathway by creating an organic incentive loop: capitation payment reform aligns the entire consortium\u0026rsquo;s finances with population health; this motivates the county-level network to proactively strengthen grassroots capacity; and the formal embedding of village doctors ensures that this capacity is delivered via trusted community relations. This closes the loop between financing, service delivery, and community acceptance. Therefore, the model\u0026rsquo;s core is a coupled institutional redesign tailored to underdeveloped regions. This finding demonstrates that isolated improvements in payment, digital health, or community health worker support are insufficient. Efficacy arises from their synergistic sequence: (1) a health-outcome-linked financing model (\u003cem\u003ee.g.\u003c/em\u003e, capitation with bonuses for chronic disease control) creates the overarching economic imperative; (2) formal identity and career embedding (\u0026ldquo;township-hired, village-deployed\u0026rdquo;) aligns the village doctor\u0026rsquo;s individual incentives with this system goal; and (3) tailored digital integration (\u003cem\u003ee.g.\u003c/em\u003e, smart diagnostic aids) operationally connects village practice to county-wide quality assurance. This design strategically converts the typical constraints of underdeveloped regions\u0026mdash;scarce resources yet strong community ties\u0026mdash;into the very foundations of a more responsive and sustainable primary care system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Limitations and Future Directions\u003c/h2\u003e \u003cp\u003eThis study has certain limitations. First, as a single-case study, the Yilong model's operation is context dependent on local policies and economic conditions, limiting the generalizability of the conclusions. Second, the use of noncontinuous data in research has led to inadequate tracking of long-term dynamic changes, making it difficult to assess the model's sustained impact on residents' health outcomes and medical cost control fully. Additionally, this research focuses more on macroinstitutional mechanisms and lacks an in-depth exploration of the subjective perceptions of key microsubjects, such as village doctors and rural residents. Future research can adopt multicase comparative methods to verify the model's adaptive conditions in different regions. It is also necessary to improve the comprehensiveness of effect evaluation to refine the model's human-oriented design, providing more solid support for the promotion of the CLMC. As a foundational exploratory study, this paper serves as a preliminary phase in a broader research agenda. Subsequent work will build upon these findings to conduct a more rigorous and comprehensive empirical assessment of the public effects generated by such integrated models in underdeveloped regions, including their long-term impact on health equity, community well-being, and systemic sustainability.\u003c/p\u003e \u003c/div\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003eThis study delineates a governance mechanism for primary care integration in underdeveloped regions, where embedding village doctors into a vertically accountable network successfully bridges the \u0026ldquo;last mile\u0026rdquo; to community health. The model\u0026rsquo;s replicability is anchored in contexts sharing three structural prerequisites: constrained fiscal capacity, institutionally marginalised village practitioners, and a fragmented county-township-village service continuum. Its promotion necessitates adaptive calibration of the financing model and digital scaffolding to local policy and resource bases. Divergent from stand-alone community health worker programs grappling with sustainable financing worldwide, this integrated approach demonstrates how coupling prepayment reforms with formal frontline workforce embedding creates an incentive-aligned, self-reinforcing system. It thus contributes a viable blueprint for strengthening primary healthcare governance in resource-constrained settings globally, advancing both the Healthy China initiative and the international pursuit of equitable health system delivery.\u003c/p\u003e"},{"header":"6. Declarations","content":"\u003cp\u003e\u003cstrong\u003e6.1 Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee for Basic and Clinical Research of Sichuan Academy of Medical Sciences \u0026amp; Sichuan Provincial People\u0026apos;s Hospital (Approval No. Lun Shen (Yan) 2026 No.130). The study was classified as noninterventional research and underwent a rapid review procedure in accordance with the committee\u0026rsquo;s guidelines. All procedures performed in this study involving human participants were in line with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed written consent was obtained from all individual participants who were involved in the qualitative interviews of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.2 Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.3 Data availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.4 Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study constitutes a phase outcome of the National Philosophy and Social Science Fund project \u0026lsquo;Identification of Multidimensional Barriers, Formation Mechanisms, and Breakthrough Pathways for Enhancing Governance Efficiency in County-Level Medical Consortiums\u0026rsquo; (Project No. 25CGL156) and the Sichuan Provincial Philosophy and Social Science Fund project \u0026lsquo;Identification of Barriers, Formation Mechanisms, and Resolution Pathways for the Last Mile of Smart Healthcare in Grassroots Settings of Sichuan\u0026apos;s Ethnic Regions\u0026rsquo; (Project No. SCJJ25ND200).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.5 Author Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLi Liu: Conception, supervision, writing\u0026ndash;review \u0026amp; editing, project administration, Funding acquisition.\u003c/p\u003e\n\u003cp\u003eYoubin Guo: Investigation, Data curation, Formal analysis, Writing\u0026ndash;Original Draft, Visualisation.\u003c/p\u003e\n\u003cp\u003eJinliang Hu: Methodology, Formal analysis (qualitative \u0026amp; economic), Ethical approval, Writing\u0026ndash;Review \u0026amp; Editing, Supervision, Correspondence.\u003c/p\u003e\n\u003cp\u003eAll the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.6 Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.7 Acknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to all individuals and institutions that contributed to the completion of this study. First and foremost, we acknowledge the valuable guidance and constructive suggestions provided by the research team from the Institute of Rural Development, Sichuan Academy of Social Sciences, and the Department of Medical Records \u0026amp; Statistics, Sichuan Provincial People\u0026apos;s Hospital. Their professional insights significantly enhanced the rigor and depth of this research.\u003c/p\u003e\n\u003cp\u003eWe are deeply indebted to the Health Bureau of Yilong County, Sichuan Province, for providing access to critical operational data and policy documents. Special thanks go to the frontline medical staff, village doctors, and all interview participants in Yilong County for their generous time and honest sharing of experiences, which laid the foundation for the empirical analysis.\u003c/p\u003e\n\u003cp\u003eThis study was financially supported by the National Philosophy and Social Science Fund of China (No. 25CGL156) and the Sichuan Provincial Philosophy and Social Science Fund (No. SCJJ25ND200). The funding support is gratefully acknowledged.\u003c/p\u003e\n\u003cp\u003eWe also appreciate the ethical review and approval provided by the Ethics Committee for Basic and Clinical Research of Sichuan Academy of Medical Sciences \u0026amp; Sichuan Provincial People\u0026apos;s Hospital. Additionally, sincere thanks are extended to the anonymous reviewers for their thoughtful comments and suggestions that helped improve the manuscript.\u003c/p\u003e\n\u003cp\u003eFinally, we would like to thank our families and colleagues for their continuous support and encouragement throughout the research process.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTAO SS, MEI GL, BAI ZL, et al. Reflections on the construction of county-level medical consortia based on social network theory. Health Econ Res. 2018;9:21\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.14055/j.cnki.33-1056/f.2018.09.007\u003c/span\u003e\u003cspan address=\"10.14055/j.cnki.33-1056/f.2018.09.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYU JX, TU YX. 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Explor Free Views. 2025;(6):30\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"County-Level Medical Consortium, underdeveloped regions, county-township linkage, village doctor embedding, dual-network integration, Yilong County","lastPublishedDoi":"10.21203/rs.3.rs-8900646/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8900646/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study explores the operational mechanism and policy efficacy of the \u0026lsquo;county-township linkage\u0026thinsp;+\u0026thinsp;village doctor embedding\u0026rsquo; dual-network integration model in addressing the \u0026lsquo;last mile\u0026rsquo; challenge in primary healthcare within underdeveloped regions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eEmploying a longitudinal, embedded single-case design, this research analyses the reform trajectory in Yilong County, Sichuan Province, from 2018\u0026ndash;2024. Multisource qualitative and quantitative data, including policy documents, stakeholder interviews, field observations, and institutional operational records, were triangulated to ensure robustness.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe findings reveal a synergistic governance mechanism. The county-township linkage constructs a vertically integrated professional network through unified governance, resource pooling, and service standardisation. Concurrently, village doctor embedding activates a community-based service network via a four-dimensional framework encompassing management, operational, functional, and developmental embedding. This dual-network integration effectively bridges systemic accountability with community-based social capital, leading to marked improvements in healthcare accessibility and the retention of patients within the local tiered system.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIntegrating the principles of accountable care organisation theory and social capital theory, this model provides a replicable micromechanism for primary care reform in resource-constrained settings. Its successful application hinges on context-adaptive refinements, particularly in health-outcome-oriented financing and institutional support for the frontline workforce. The study contributes a viable governance blueprint for strengthening integrated care in underdeveloped regions, with implications for both national policy and global health equity initiatives.\u003c/p\u003e","manuscriptTitle":"Dual-Network Integration in a County-Level Medical Consortium: An Exploratory Case Study from Yilong, an Underdeveloped Region","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-27 13:10:37","doi":"10.21203/rs.3.rs-8900646/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-30T09:46:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T09:12:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52905149803023957770971528509364680687","date":"2026-03-25T12:12:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73253661531134617887886665648162516252","date":"2026-03-25T12:08:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-25T11:29:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-23T12:45:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-26T12:57:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-25T08:19:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-02-25T08:12:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6cff63dc-5b86-49a0-88cc-6c21b214689a","owner":[],"postedDate":"March 27th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-04-30T09:46:56+00:00","index":82,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T09:12:34+00:00","index":81,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-27T13:10:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-27 13:10:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8900646","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8900646","identity":"rs-8900646","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}