Abstract
<title>Abstract</title> <p> <bold>Background:</bold> China's healthcare system faces significant regional disparities in service efficiency. While existing research has examined individual factors affecting efficiency, there is a lack of systematic investigation into the synergistic mechanisms through which technology, organization, and environment dimensions interact to produce high efficiency. This study aims to identify differentiated configurational pathways for improving medical and health service efficiency across China's 31 provincial-level regions. <bold>Methods:</bold> This cross-sectional study applied a super-efficiency slack-based measure (SBM) model with undesirable outputs to measure the efficiency of healthcare services in 31 Chinese provinces from 2013 to 2024, using data from the China Health Statistical Yearbook and China Statistical Yearbook. Core influencing indicators were screened through Pearson correlation analysis. Based on the Technology-Organization-Environment (TOE) framework, seven condition variables were selected across three dimensions. Fuzzy-set qualitative comparative analysis (fsQCA) was employed to reveal multiple configurational pathways leading to high healthcare service efficiency. <bold>Results:</bold> Three distinct configurational pathways to high healthcare service efficiency were identified (overall consistency = 0.91, coverage = 0.43). Pathway H1 (fiscal-driven primary care optimization) was characterized by high fiscal investment intensity combined with high primary care institution density, suited for central and western regions. Pathway H2 (resource-intensive developed region pathway) combined high bed capacity and high health personnel density with strong economic foundations, fitting eastern coastal provinces. Pathway H3 (personnel-optimized metropolis pathway) featured rational health personnel allocation and compliant nurse-to-bed ratios, suitable for centrally-administered municipalities and provincial capitals. No single condition was sufficient for high efficiency, confirming the necessity of multi-dimensional synergy. <bold>Conclusions:</bold> Improving healthcare service efficiency in China requires context-specific configurational pathways matched to regional characteristics. Central and western regions should strengthen fiscal support and primary care network construction. Eastern developed regions should prioritize technological upgrading and resource integration. Municipalities and provincial capitals need to optimize human resource allocation structures. Policymakers should adopt differentiated strategies rather than one-size-fits-all approaches. <bold>Trial registration:</bold> Not applicable. </p>