The coastal zone is a major area for human settlement and exploitation of marine resources. The assessment and prediction of ecosystem health in coastal zones is important for its environmental management and the formulation of sustainable development policy. In this study, based on the Pressure-State-Response model and Markov model, the health of the coastal zone ecosystem was assessed and predicted at the county scale. Landsat remote sensing images of the Ningde coastal zone in China captured in 2000, 2009, and 2014 were used. Previous studies have primarily evaluated ecosystem health at macroscopic scales; however, in this study, the research scale was reduced to the county scale to examine and predict coastal ecosystem health. The results of this study showed that the size of the composite indicators for the county ecosystems in the Ningde coastal zone was in the descending order of Fu’an > Jiaocheng > Xiapu > Fuding. The composite indicators of the Fu’an and Xiapu ecosystems were good, whereas those of the Fuding and Xiapu ecosystems were poor and moderate, respectively. In 2024, the stress indicators of the Fuding, Xiapu, Fu’an, and Jiaocheng ecosystems will continue to increase, whereas the state indicators will decline significantly. Increasing the area of forest and grassland will reduce the pressure on the Fuding and Xiapu ecosystems and improve their ecosystem status and service capacity. In contrast, the pressure, state and response indicators of the Fu’an and Jiaocheng ecosystems were unaffected by changes to forest and grassland areas.