Association between China's Tiered Diagnosis and Treatment System and the utilization of basic public health services...

Despite national policies granting universal eligibility, China's migrant population faces significant practical barriers to accessing Basic Public Health Services (BPHSs), often stemming from the Hukou (household registration) system. The Tiered Diagnosis and Treatment System (TDTS) was introduced as a major reform to strengthen primary care. This study examines the association between exposure to TDTS pilots and the utilization of BPHSs among migrants.

This cross-sectional study used microdata from the 2018 China Migrants Dynamic Survey (N = 132,598). Multivariate linear probability models were used to assess the association between residing in a TDTS pilot city and two outcomes: establishing a health record (EHR) and registering with a family doctor (RFD). The analysis controlled for individual and household characteristics, as well as province and concurrent policy (digital infrastructure) fixed effects. Propensity score matching and placebo tests were performed to assess robustness.

Residing in a TDTS pilot area was associated with a 6.6% point increase (p < 0.05) in the probability of establishing an EHR and a 4.9% point increase (p < 0.01) in registering with an RFD. In relative terms, this corresponds to an increase of 23.7% and 40.2% over the baseline, respectively. The association was more pronounced for female and older migrants, with no significant differences observed across education or Hukou type.

A significant positive association exists between the TDTS and BPHS utilization among migrants in China. The findings suggest that strengthening primary healthcare systems is a promising strategy for mitigating practical access barriers and improving health equity for vulnerable populations, even within challenging institutional contexts.