Primary health care (PHC), as the core of the health system, is provided by primary health care institutions (PHCIs). Each PHCIprovides comprehensive, coordinated and integrated health care to individuals, families, and communities within its service areas(1). PHCIs is construct an effective network to expand the coverage of health services in countries with limited health resources(2). In countries with a national hierarchical health care 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 PHCIs and strengthen PHC service delivery. As an NHMS country, the Chinese health care system is a 3-level hierarchical network. PHCIs 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 patients with difficult, miscellaneous and critical diseases(3).
However, it does not seem easy to gain benefits of investment in PHC. Due to the lack of funds and equipment and the inadequate training of medical staff during an early stage in development of primary health care systems, many countries (such as India, Saudi Arabia, and China) have imperfect PHC systems, and the quantity and quality of health resources in PHCIs are generally lower than those in higher-level hospitals (4). In addition to the asymmetry of medical information, patients have limited choice besides bypassing the PHCIs and go to higher-level hospitals for better health care.
Bypass is generally defined as the behaviour of patients visiting an higher-level health institution instead of one with an acceptable quality of care and closer to them, which reflects the patients' preference for better health care(5-9). In developing countries where the PHC system is imperfect, it is more common for patients to bypass their nearest PHCIs for higher-level health care institutions. With the development of the primary health care system, this conventional concept and behaviour, which is often referred to as “bypass behaviour”, is still preserved(5). For example, the data show that the total number of medical visits in various health institutions in China in 2017 was 8183.11 million person-times, while the PHCIs accounted for only 4428.92 million person-times (54.12%), which indicates that patients bypass the PHCIs to a large extent(10).
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 health care institutions. The prevalence of patients’ bypass has negative impacts on the health system, the health care institutions and the individuals. For the health system, bypass behaviour hinders the operational efficiency of the health system(11), which is not conducive to the overall operation and development of health system and affects the government's strategy on the input of PHC resources. For health care institutions, bypass behaviour limits the utilization of services provided by PHCIs to a certain extent, which reduces the employment of PHC providers, and may even lead to the closure of PHCIs(12). Meanwhile, bypass behaviour will increase visits to higher-level hospitals, resulting in a decrease in the efficiency of the health system. For individuals, bypassing the nearest PHCIs to seek further treatment will cost more time and money, which may hardly be cost-effective. Therefore, reducing bypass behaviour, which is of practical significance, contributes to the greater well-being of the health system and individuals.
Many studies have tried to explain the cause of bypass behaviour to identify the paths of reducing 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)(13, 14), geographic factors, medical expenses(9), and the quality of health care institutions(15) can affect patients' bypass behaviour. Among these factors, the quality of health care institutions is the fundamental cause of patients’ bypass behaviour. Rao, K. D., et al. (2018)(13) 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) (9) studied the bypass behaviour of Sri Lankan residents and the characteristics of bypassed health care institutions. The results show that the quality and price of health services are important factors influencing bypass behaviour. Leonard et al (2003) (11), Kruk et al (2009) (16), and Gauthier et al (2011) (8) 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) (5) studied the influence of subjective quality perception (medical experience indicators) on the bypass behaviour of Japanese residents. The results indicated 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 health caremedical institution and patients’ subjective perception of the quality of PHC services may have varying degrees of impact on their bypass behaviour.
Based on existing studies, perceived quality of health services affects residents' 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 PHCIs. For example, practical experience has shown that patients sometimes bypass PHCIs (perceived lower quality) and instead seek health care in higher-level health care institutions (perceived higher quality) whose actual advantages in quality of services usually do not add extra health outcomes in the treatment of common or chronic diseases (11). 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 health care institution instead of the true structural quality of the health caremedical 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(5), and there is no such systematic study in developing countries. At present, China has conducted some studies related to patient bypass behaviour(17-21). However, on the one hand, these studies do not rigorously define bypass behaviour. On the other hand, the selection of quality measurement indicators for health care institutions is often incomprehensive and mostly limited to objective conditions, such as the number of beds in health care institutions(22-24). The changes in the medical model and in health services require the expansion of the connotation of the quality of 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 health care services and patients’ medical experiences. In addition, due to differences in health 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 PHCIs 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 health care service hardware, management systems and professional configurations, but the government has not taken action against the problem of low-quality perceptions of PHCIs by the residents in China. There are evidences in China that the PHC network have been notably developed and improved in both quality and quantity, but many residents in China are still holding the prejudice that PHCs are providing low quality health care, and this are hindering the further development of PHC in China(25). If it is proven that improvement in the perception of health care service quality can effectively curb the bypass behaviour of Chinese patients, this information would 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.