Which Medical Institution Should Perform Gatekeeping in Rural China? Results from a Cross-Sectional Study

Background: China's healthcare system is developing very fast but needs a regulatory practice, which helps to improve effectiveness and efficiency. This is a problem in rural China, in particular. The government is promoting a providing system with gatekeeping and mandatory referral procedures in order to limit resulting problems. However, there exists little evidence, which of the primary healthcare facilities in rural China should be given these functions. Objective: It is this study's objective to determine the impact of the specific medical institution of an initial visit on the patients' following move through the healthcare system. On that reason, we want to find evidence which level of primary health sectors in rural China is more appropriate to perform gatekeeping and to integrate care based on referrals. The alternatives are either to prefer village clinics or township health centers. Methods: The data were collected through a cross-sectional study in 2012, which used a stratified random sampling method to select 4 counties. 420 patients who wanted to see the doctors more than 3 times during the past 6 months were included as the study sample. We described the patients' move through the healthcare system by measuring the density, dispersion and sequence of visits according to the Continuity of Care model (COC). The logistic regression model was used to determine the influence of medical institution of initial visit on patients' moves after controlling other variables. Results: We found that patients who chose the county hospital as medical institution for their initial visit had 5.88 times of the odds of high (vs. low) density, 4.17 times the odds of high (vs. low) dispersion, and 2.86 times the odds of high (vs. low) sequence of visits than those choosing village clinics as medical institution for the initial visit. However, patients choosing the county hospitals as medical institution of initial visit did not report higher density, dispersion or sequence of visit than the patients who chose the township health centers. Conclusion: For the overwhelming majority of rural areas in China, the township health centers are more appropriate to perform the gatekeeping role than village clinics are. We see that as the conclusion at least at the present stage of the system's development.