What determines the success or failure of policy experiments?—A qualitative field study of China's healthcare reform pilots

Background: Policy experimentation has become a central strategy for governments seeking to navigate complexity in healthcare reform. In China, extensive rounds of county-level healthcare reform pilots aim to strengthen primary care and improve service equity. However, while some pilots expand successfully, others stagnate or are suspended. The underlying mechanisms that generate these divergent outcomes remain insufficiently examined. Objectives: This study investigates how healthcare reform pilots evolve in practice by identifying the key actors involved in pilot management, analyzing the driving forces that shape pilot performance, and explaining the different developmental trajectories of pilots within China's county medical service community (CMSC) reform. Methods: Drawing on large-scale fieldwork across 23 CMSCs, we collected qualitative data through semi-structured interviews and focus group discussions with 127 internal and external stakeholders. Using grounded theory, the data were analyzed through open, axial, and selective coding, and subsequently integrated to construct a typological framework explaining variations in policy pilot outcomes. Results: Drawing on the coding framework, the analysis identifies two overarching forces shaping CMSC pilot implementation: institutional compatibility and policy potential energy. Institutional compatibility reflects the alignment of CMSC policy design, healthcare insurance payment rules, interdepartmental coordination, incentive structures, and resource-benefit allocation. Policy potential energy derives from the redistribution of administrative power, political momentum from higher-level governments, the capacity of policy entrepreneurs, and the contextual foundations of social capital and trust. Mapping these dynamics reveals four pilot trajectories: upscaling, adjustment, suspension, and autonomy.