Why patients prefer high-level healthcare facilities

__Introduction__ Despite policy measure to strengthen andpromote primary care, Chinese patients increasinglychoose to access higher level hospitals. The resultingovercrowding at higher level hospitals and underutilisationof primary care are viewed to diminish the effects ofthe continuing health system investments on populationhealth. We explore the factors that influence the choice ofhealthcare facility level in rural and urban China and aim toreveal the underlying choice processes. __Methods__ We conducted eight semistructured focusgroup discussions among the general population andthe chronically ill in a rural area in Chongqing and anurban area in Shanghai. Respondents’ discussions of(evidence-based) factors and how they influenced theirfacility choices were analysed using qualitative analysistechniques, from which we elicited choice process mapsto capture the partial order in which the factors wereconsidered in the choice process. __Results__ The factors considered, after initial illnessperception, varied over four stages of health serviceutilisation: initial visit, diagnosis, treatment and treatmentcontinuation. The factors considered per stage differedconsiderably between the rural and urban respondents, butless so between the general population and the chronicallyill. Moreover, the rural respondents considered thetownship health centres as default and prefer to continuein primary care, yet access higher levels when necessary.Urban respondents chose higher levels by default andseldom moved down to primary care. __Conclusions__ Disease severity, medical staff,transportation convenience, equipment and drugavailability played important roles when choosinghealthcare facilities in China. Strengthening primary carecorrespondingly may well be effective to increase primarycare utilisation by the rural population but insufficient forthe urban population. The developed four-stage processmaps are general enough to serve as the basis for(partially) ordering factors influencing facility level choicesin other contexts.