Introduction
China has a three-tier hospital system, of which the lowest level (level 1), together with unrated facilities, forms the primary care system.1–3 As there is no formal gatekeeper role, however, patients may access the system at any level and facility of their choice.1 Chinese patients often choose to directly access higher level hospitals, thus bypassing primary care facilities. As a result, higher level hospitals are overcrowded, while primary care facilities remain underutilised.4 The health reform initiated in 2009 has brought considerable investments to strengthen primary care, and a series of policies aimed at improving the utilisation of the facilities at lower levels.1 5 6 Still, the number of visits to primary care facilities continues to form a decreasing share of the total number of visits, while the share of visits to higher level hospitals continues to increase.7 These developments are counter to the Declaration of Alma-Ata, which states that primary care facilities should serve as a first contact and provide access as close as possible to where people live and work.8
The lack of efficient utilisation of primary care is seen as a cause for the relatively modest improvements in health outcomes achieved for the Chinese population through the continuous and considerable health system investments made over the last decade.9 This especially holds true for rural residents, resulting in worsening disparity in health service access and health outcomes between rural and urban residents.4 10 Further, the overcrowding of higher level hospitals has contributed to deterioration of patient–doctor relationships11 12 and quality of care.9 Thus, it is important to understand the health-seeking behaviour of the Chinese population, and hence develop measures that can more effectively direct patient flow towards lower levels.
Determinant models form a classical approach to understand decision making in health service utilisation, by identifying the factors (determinants) which influence the choice.13 There is a growing body of literature adopting this approach, especially from Western contexts,14–17 which includes the well-known Behavioral Model of Health Services Use by Andersen and Davidson.16 This model conceptualises access to care in the USA using individual and contextual determinants.16 The model can be viewed to be static, as it does not address how the dynamics of disease and health service provisioning influence the choices and choice processes.
Another approach to advance scientific understanding of facility choice is to develop process models which conceptualise patient responses to sickness as a dynamic behavioural process, for example, in the form of a sequence of steps.13 18 To the best of our knowledge, however, there is very little empirical research that has validated or adopted either of these models to understand choice of system access level since the new round of healthcare reform in 2009. This holds particularly true for the processes by which Chinese patients choose health system access levels.
As context attributes play important roles in decision making18 and the validity of such behavioural models cannot be assumed to remain valid when transferred from one society to another,19 20 empirical models in the Chinese context are called for. A systematic review of recent empirical research in China to elicit evidence on the determinants of facility level choice identifies four categories of factors influencing choice: patient, provider, context and composite factors.21 Whether a patient is classified as ‘rural’ (as opposed to ‘urban’) is an example of a patient factor, while travel distance from the patient home to the facility is an example of a composite factor (composed of patient attribute home location and provider attribute facility location).
While there is considerable Chinese evidence to support determinant models,21–24 there is little evidence on the choice process. Hence, it appears unknown whether patients consider factors simultaneously and weigh them against each other, or alternatively whether (partial) orders exist in which the factors are considered. The answers to these questions may differ among socioeconomic groups and depend on health conditions.24 25 These differences regard the set of factors considered, as well as the effect of factors on choice. For the Chinese context, there is evidence that such differences exist between rural residents and urban residents, and between patients with chronic diseases and the general population.21 Little is known, however, about how these subpopulations differ in their considerations of these factors. Do they consider different factors, weigh them differently, in a different order or at different occasions? Pursuing these unaddressed directions, our research questions are as follows:
What are the factors that influence choice of healthcare facility level for Chinese urban and rural populations, and specifically for the chronically ill?
What is the process of decision making in which these factors are taken into account by these Chinese populations?