Unintended Consequences of the Physical and Health Integration Policy in China's Primary Healthcare: A Grounded Theory Study of Policy Implementation Dynamics

Weining Yang¹Xuetao Jiang¹Xue Luo²Xi Zhang¹Lu Yan^1*

• ¹Institute of Physical Education, Kunming University of Science and Technology, Kunming, China
• ²Research Institute of Higher Education, Yunnan University, Kunming, China

Under the framework of the "Healthy China" initiative, the Physical and Health Integration (PHI) policy has emerged as a strategic tool to promote health-oriented transitions in primary healthcare. While much research has examined the design and anticipated outcomes of this policy, limited attention has been paid to its actual implementation and the unintended consequences at the frontline level. Drawing on grounded theory and 20 in-depth interviews with primary healthcare practitioners across China, this study explores the dynamic mechanisms shaping the execution of the PHI policy. Unintended consequences are empirically identified through open, axial, and selective coding of interview data, revealing recurrent patterns of symbolic compliance, resource distortion, and behavioral adaptation. The findings reveal a non-linear, chain-like process encompassing cognitive misalignment, resource and institutional constraints, diversified behavioral strategies, and the emergence of unintended outcomes. The resulting model highlights how these interacting mechanisms form a self-reinforcing cycle that reproduces gaps between policy intention and practice. Frontline actors adopted varying strategies, ranging from passive compliance and symbolic fulfillment to localized adaptation, resulting in fragmented implementation and symbolic compliance in many contexts. This phenomenon of symbolic compliance can be further understood within the context of broader policy implementation theories, such as Lipsky's Street-Level Bureaucracy and Pressman & Wildavsky's Implementation Gap. According to Lipsky's theory, street-level bureaucrats often adapt or distort policy directives to fit their local realities and constraints, which leads to symbolic compliance when they appear to follow the rules but do not make substantive changes. Similarly, Pressman & Wildavsky's Implementation Gap highlights the disconnect between policy intentions and actual outcomes, often due to insufficient resources or unclear guidelines at the local level, resulting in symbolic compliance. Based on these findings, this study develops a "mechanism model of unintended consequences" that highlights the structural challenges in intersectoral coordination, knowledge translation, and performance incentives. The study contributes to the literature on public policy implementation by offering a micro-level explanation of how ambitious health reforms are translated, negotiated, and reframed within the constraints of grassroots realities.