Primary health care (PHC), as the core of the health system, is provided by primary health care institutions. Each primary health care institution supplies comprehensive, coordinated and integrated health care to individuals, families, and communities living in its service areas(1). PHC is an effective way to expand the coverage of health services in countries with limited medical resources. In countries with a national hierarchical medical system (NHMS), PHC can address the common diseases of residents at a lower cost and improve their welfare, which is cost effective. Therefore, most countries around the world have invested massive resources to build primary health care institutions and strengthen PHC service delivery. As an NHMS country, the Chinese health care system is a 3-level hierarchical network. Primary health care institutions serve as “gatekeepers” to take care of patients with common and frequently occurring diseases; secondary hospitals are regional hospitals that provide comprehensive health care to multiple communities and undertake certain teaching and scientific research tasks; and tertiary hospitals, which are usually composed of provincial and municipal general hospitals, teaching hospitals, and specialized hospitals, implement teaching and scientific research tasks and conduct the diagnosis and treatment of difficult, miscellaneous and critical diseases(2).
However, it does not seem easy to achieve the benefits of PHC investment. Due to the lack of funds and equipment and the inadequate training of medical staff during the early development of primary health care systems, many countries (such as India, Saudi Arabia, and China) have poor PHC services(3), and the quantity and quality of medical resources in PHC facilities are generally lower than those in advanced hospitals. In addition to the asymmetry of medical information, patients have little choice but to bypass the PHC institutions and go to advanced hospitals for better medical care.
Bypass is generally defined as the behaviour of patients visiting an advanced medical institution instead of one with an acceptable quality of care that is closer to them, which reflects the patients' preference for better health care(4–8). In developing countries where the PHC system is imperfect, it is more common for patients to bypass their nearest primary care facility and travel to higher-level medical institutions. With the development of the primary health care system, this traditional concept and behaviour, which is often referred to as “bypass behaviour”, is still preserved. For example, the data show that the total number of medical practitioners in various medical and health institutions in China in 2017 was 818,311 (10,000 person-times), while the primary health care institutions accounted for only 442,892 (54.12%, 10,000 person-times), which indicates that patients bypass the PHC institutions to a large extent.
In developing countries such as China, where the PHC system is imperfect, it is more common for patients to bypass their nearest primary care facility and go to higher-level medical institutions. The prevalence of patient bypass has negative impacts on society, medical institutions and individuals. For society, bypass behaviour hinders the operational efficiency of the medical system(9), which is not conducive to the overall operation and development of society and affects the government's strategy on the input of PHC resources. For medical institutions, bypass behaviour limits the scope of services of PHC institutions to a certain extent, reduces the number of PHC providers, and may even lead to the closure of PHC institutions(10). Meanwhile, bypass behaviour will increase visits to higher-level hospitals, resulting in a decrease in the efficiency of the health system. For individuals, circumventing the nearest medical centre to seek further treatment will cost more time and money, which may be cost ineffective. Therefore, reducing bypass behaviour, which is of practical significance, contributes to the greater well-being of society and individuals.
Many scholars have tried to explain the cause of bypass behaviour to reduce these behaviours. Studies have shown that socioeconomic conditions (such as income), demographic factors (such as gender), the health status of patients (such as disease severity)(11, 12), geographic factors, medical expenses(8), and the quality of medical institutions(13) can affect patients' bypass behaviour. Among these factors, the quality of medical institutions is the fundamental cause of patients’ bypass behaviour. Rao, K. D., et al. (2018)(11) explored the effects of the structural quality of health centres on the bypass behaviour of Indian patients, and the results suggest that improvements in structural quality have a positive impact on the reduction in bypass behaviour. Akin et al. (1999) (8) studied the bypass behaviour of Sri Lankan residents and the characteristics of bypassed medical institutions. The results show that the quality and price of medical services are important factors influencing bypass behaviour. Leonard et al (2003) (9), Kruk et al (2009) (14), and Gauthier et al (2011) (7) studied the bypass behaviour and its influencing factors among African residents. The focus of these studies is on the quality of health care services. Among these studies, Gauthier analysed the influence of subjective quality perception and objective quality on bypass behaviour, but the measurement indicators of subjective quality perception are controversial. Aoki, T. et al (2018) (4) studied the influence of subjective quality perception (medical experience indicators) on the bypass behaviour of Japanese residents. The results indicate that the better patients’ experience of primary care institutions is, the fewer times they bypass gatekeepers. It is obvious that the objective quality of the medical institution and patients’ subjective perception of the quality of PHC services may have varying degrees of impact on their bypass behaviour.
A literature review indicates that subjective quality perception can explain patients’ bypass behaviour on a broader level, which is irreplaceable by the objective quality of primary care institutions. For example, practical experience has shown that patients sometimes bypass PHC institutions (perceived lower quality) and instead seek medical care in higher-level medical institutions (perceived higher quality) whose objective quality of service is not always higher than that of the bypassed institution(9). This phenomenon can be explained by the patient's subjective quality perception—to a large extent, the patient's bypass decision depends on his or her own perceived quality of the care delivered by the medical institution instead of the true structural quality of the medical institution.
However, current research on the impact of patients’ subjective quality perception on bypass behaviour is limited. To our knowledge, only Japan has conducted similar research(4), and there is no such systematic study in developing countries. At present, China has conducted some studies related to patient bypass behaviour(15–19). However, on the one hand, these studies do not rigorously define bypass behaviour. On the other hand, the selection of quality measurement indicators for medical institutions is often incomprehensive and mostly limited to objective conditions, such as the number of beds in medical institutions(20–22). The changes in the medical model and in health services require the expansion of the connotation of the quality of medical and health services, including comprehensive factors such as work efficiency, cost, service attitude, service availability and service fairness. Therefore, the above studies are not a good representation of the actual quality of medical services and patients’ medical experiences. In addition, due to differences in medical systems and socio-cultural factors, the results of other countries' research cannot be directly applied to China. Therefore, this study conducted an in-depth exploration of this issue in China, a country that is representative of developing countries.
In summary, this study aims to explore how Chinese patients’ perceived quality of PHC institutions affects their bypass behaviour. Specifically, this study focuses on whether a patient's perceived quality of PHC affects his or her bypass behaviour and the degree and direction of this effect. At present, most of China's policies on primary health care systems are aimed at improving basic medical service hardware, management systems and professional configurations, but the government has not taken action against the problem of low-quality perceptions of primary medical institutions in China. If it can be proven that improvement in the perception of medical service quality can effectively curb the bypass behaviour of Chinese patients, this information will serve as an important reference for the development of China's PHC system. The results and conclusions of this study will serve as a reference for the construction of primary health care services and the improvement of PHC utilization in China and other developing countries.