Objective In China, patients increasingly choose to access already severely overcrowded higher level hospitals, leaving lower level facilities with low utilization rates. This situation undermines the effectiveness and efficiency of the health system. The situation tends to worsen despite policy measures aimed at improvement. We systematically review the factors affecting patient choice to synthesize scientific understanding of health system access in China. The review provides an evidence base for measures to direct patient flow towards lower level facilities.
Methods We screened the peer-reviewed literature published from April 2009 to January 2016 that investigates Chinese patients' choice of health care facilities at different levels and assessed 45 studies in total. We applied two structured forms to extract data on each study's characteristics, methodology, and factors.
Results of data synthesis The results identified four factor types: 1) patient, 2) provider, 3) context and 4) composite: combined patient, provider, and/or context attributes. Patient factors are mentioned the most, but the evidence on patient factors is often inconclusive. Evidence suggests that the provider factors 'drug variety' and 'equipment', and composite factor 'perceived quality', push patients from lower levels towards higher levels.
Conclusion Underuse of primary care facilities and overcrowding of higher level facilities will likely be amplified by current demographic trends. Evidence suggests that improving drug availability, equipment and perceived quality of primary care services can improve the situation. Well-designed research that considers the interactions between factors is called for to better inform future interventions.

Additional Metadata
Persistent URL dx.doi.org/10.1371/journal.pone.0201887, hdl.handle.net/1765/109922
Journal PLoS ONE
Liu, Y, Kong, Q, Yuan, S, & van de Klundert, J.J. (2018). Factors influencing choice of health system access level in China. PLoS ONE, 13(8). doi:10.1371/journal.pone.0201887