When Resources Are Not the Problem: Administrative Coordination Failure and Repair in China's Free Congenital Heart Disease Intervention Programme

Fully funded social programmes frequently fail to reach intended beneficiaries. Drawing on a single-case embedded study of China's National Free Congenital Heart Disease (CHD) Intervention Programme in a rural county (2016–2021), this article examines how governance architecture failures—rather than resource scarcity—produced a severe last-mile delivery gap and how a low-cost administrative innovation repaired it. A 2019 audit identified 67 confirmed or suspected CHD cases accumulated over three years without programme enrolment. Four interacting failure mechanisms were identified: absent programme ownership, information fragmentation across four administrative systems, incentive misalignment at the front line, and clinical awareness deficits among village health workers. A three-component intervention—a patient-linked coordination ledger, a cross-departmental joint action mechanism, and an incentivised identification campaign—raised estimated identification rates from approximately 40 per cent to 85 per cent, increased surgical completions from five to 89, and compressed median case-to-surgery lag from over 52 weeks to approximately 11 weeks within 18 months, at a total coordination cost of approximately USD 3,300. The analysis contributes to social policy implementation theory by integrating street-level bureaucracy and multi-level governance frameworks to explain how coordination architecture shapes welfare delivery outcomes. Five design principles are derived for programmes confronting analogous last-mile gaps in decentralised governance systems.