Equity in patient experiences of primary care in community health centers using primary care assessment tool: a comparison of rural-to-urban migrants and urban locals in Guangdong, China

Health equity refers to an absence of disparities in health care or its socio-determinants between groups within different socioeconomic classes or resulting from social, political, economic or other factors that might have an effect on health care status and equity [1‐3]. An important social determinant of health care in China is the long existing household registration (‘hukou’) system, which was implemented in 1950s and categorizes people into urban and rural [4] groups; this is a very strong determinant of the rights and privileges affecting socioeconomic wellbeing [5]. When rural people migrate to search for jobs in urban areas, it is never easy for them to convert their household registration to an official urban residency [6]. Since China’s public policies have long been introduced based on this ‘hukou’ system, rural-to-urban migrants have always been identified as being vulnerable due to their poor living conditions [7], lack of social support [8], lack of health risk awareness [9], high medical costs [10, 11] and limited access to health care [12], jobs and insurances [13, 14]. In 2015, the number of migrants in China had reached approximately 247 million, which accounts for 18% of the total Chinese population [15]. Guangdong Province in southeastern China accounts for a large amount of migration, especially in the several cities in the Pearl River Delta region [16]. The increasing number of rural-to-urban migrants and their perception of the fairness of the health care system has caused a great deal of concern for most governments and citizens.

To decrease the disparities between rural-to-urban migrants and urban locals, China has been embarking on health care reform to provide equal access and affordable healthcare for all by 2020 [17]. One of the important measures is the strengthening of primary care, starting with increasing the number of and funding for community health centers (CHCs) in urban areas to make health care services more accessible and less expensive [18]. Being the most financially and geographically accessible approach to health care, primary care provides access to rural-to-urban migrants to obtain health care and reduces the socioeconomic and geographic disparities among different groups [19, 20]. Another goal of China’s current healthcare reform is to establish universal insurance coverage for the whole population. Since the New Rural Cooperative Medical System has been merged into the Urban Resident Basic Medical Insurance in most developed areas, including in Guangdong Province since 2014 [21], the current health care system includes Urban Resident Basic Medical Insurance (URBMI) and Urban Employee Basic Medical Insurance (UEBMI). Financed by employers and employees, migrant workers employed in urban formal sectors, including state-owned, collective, private enterprises and NGOs, are eligible for UEBMI. In some cities, UEBMI also covers part-time workers. The funds are managed to cover outpatient and inpatient services [22]. Migrants who work in urban informal sectors or who are unemployed or self-employed can enroll in URBMI on an individual basis, which is financed mainly by individuals, with few government subsidies. URBMI covers hospital care and catastrophic illness [23]. Evidence has shown that medical health insurance provides positive financial protection for migrants regardless of the type of scheme [22, 24].

All of these efforts can improve patients’ utilization of the health care system by improving geographical and financial access. Furthermore, the patient experience is another important determinant of health care utilization; it may receive comparatively less attention in the literature but is of central importance to patients’ future health care-seeking behavior. According to The Beryl Institute, patient experience is defined as the sum of all interactions shaped by an organization’s culture that influence patient perceptions across the continuum of care [25]. Evidence has shown that how patients perceive the process of consultation may influence their future decisions about seeking care [26]. Saether and colleagues [27] investigated migrants’ access to antiretroviral therapy in Thailand and found that participants experienced discrimination such as rude doctors and challenges accessing health care a second time. Another study in Poland found that when migrants felt a general sense of insecurity about the host area’s health care system, either due to misunderstandings or feeling disregarded by the doctors for being migrants, they might change their health care-seeking strategy, stop visiting doctors in the host area and try to consult doctors in their familiar homeland [28]. In other words, even though equity in financial and geographical accessibility has been achieved, equity in the patient experience could be a significant factor influencing patients’ health care utilization.

We are aware that patient experiences in primary care can be contextualized to measure primary care’s five core dimensions (first-contact utilization, first-contact accessibility, continuity, coordination, and comprehensiveness) and three derivative dimensions (family centeredness, community orientation, and cultural competence). This approach has been widely used in recent years, because it directly describes the primary care process [29‐32]. First-contact utilization measures the extent to which primary care acts as an entry point for other levels of care, whereas first-contact accessibility measures the extent to which patients are able to access primary care for each new problem. Continuity of care refers to the longitudinal use of a usual source of care over time. Coordination of care is the linking of health care visits and services between different levels of care so that patients can receive appropriate care and meet health needs. Comprehensiveness of care refers to the availability of a wide range of services in primary care and their appropriate provision. Family centeredness reflects the participation of family in the assessment and treatment of a patient. Community orientation measures providers’ knowledge of community health care needs. Cultural competence measures whether the patient recommends the primary care provider to others [33, 34]. In China, rural-to-urban migrants experience less satisfaction in terms of the types of drugs available, attitudes of health workers, and waiting times than local residents in community health centers [35]. Their experiences of primary care did not show higher scores in any of the domains mentioned above in CHCs than in tertiary hospitals [36].

Studies have focused on equity in primary care experiences between groups with different levels of social disadvantage, such as health status [37], household income [38], age [39], race and ethnicity [40], and disability [41]. People with high self-ratings of health scored higher in the family/community orientation dimension and total primary care scores [37]. The higher household income group was more likely to experience better primary care, such as comprehensiveness [38]. Older individuals reported significantly better experiences across many dimensions of primary care, such as first-contact utilization and continuity [39]. However, no studies have focused on equity in patient experiences of primary care between rural-to-urban migrants and urban locals. Using a patient perception primary care assessment survey [the Primary Care Assessment Tool (PCAT)] administered in 2014, we aimed to determine whether the patient experience of primary care is equal between rural-to-urban migrants and urban locals.

Since medical health insurance can influence patients’ health seeking behavior and affect patients’ health care utilization [42, 43], we first stratified our data into three layers based on the different medical health insurance conditions, including UEBMI, URBMI and individuals without basic medical insurance coverage (WBMI). According to our previous studies, patients’ socioeconomic characteristics have a significant impact on their primary care experiences [44], which may limit the extent to which household registration results in equal access to health care. To adjust for confounding variables and improve causal inferences, we conducted propensity score matching (PSM) within each insurance layer to generate comparable samples between the rural-to-urban migrants and urban locals. PSM has been widely used in primary care observational studies [45‐47]. After matching, we compared the patient experiences of the rural-to-urban migrants to the urban locals within each layer. It is also hoped that policy implications regarding the management of issues related to rural-to-urban migrants can be drawn from the analysis.

Our study demonstrates that rural-to-urban migrants receiving primary care from CHCs reported equal primary care experiences when compared to urban locals in the same medical health insurance context. The hope of health care equity between rural-to-urban migrants and urban locals seems to have been achieved in the CHCs to some extent. However, there is room for improvement in the equity of coordination of care and comprehensiveness. Policy makers should consider strengthening coordination of care and comprehensiveness in primary care by integrating health care systems. More attention should be focused on helping migrants break down language and cultural barriers and improving the patient-physician communication process.