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International Health

October 25, 2018

Improved clinician ability reduces patient bypassing of primary healthcare centers more than improvements in infrastructure quality,  study finds

The study also found primary healthcare centers in India need to focus more on the needs of the community to prevent widespread bypassing

Many low- and middle-income countries continue to make significant investments in strengthening primary health care services by improving facility infrastructure and provider ability. Despite this, bypassing of primary health care center (PHC) remains high.  Determining why patients choose to bypass nearby PHCs and seek care elsewhere (usually private providers) has implications for the design of primary health care systems. 

A primary health care center in Chhattisgarh, India
A primary health care center in Chhattisgarh, India. Photo credit: Power for All 

A new study analyzed data from a household and facility survey from Chhattisgarh, India, to better understand patient bypassing behavior. The study, published in the June edition of Social Science & Medicine, was led by Krishna Rao, PhD, an assistant professor in International Health at the Johns Hopkins Bloomberg School of Public Health and Ashley Sheffel, MPH, an International Health doctoral student at the Bloomberg School.

The results show that over two-thirds of patients living in a vicinity of a PHC chose to seek more expensive treatment somewhere other than their low-cost PHC. Factors other than distance and cost influenced patient choice of where to seek care because the PHC was located nearby and offered low-cost health services. Bypassing primary health centers fell as clinician ability increased; however, after a certain threshold, improving provider ability had no effect on bypassing. The quality of facility infrastructure had little impact on bypassing. Better clinician ability reduced bypassing more than better structural quality. Patients that bypassed PHCs had higher out-of-pocket health expenditures.

 “Even in the best case scenario—a facility with a regularly present, highly competent provider—fewer than half of patient visits were made at the local PHC. Clearly, efforts to strengthen facility-based primary care services need to go beyond simply focusing on improving quality of clinical care or ensuring that clinical care providers are regularly available in their posts.”

For more details: Quality of clinical care and bypassing of primary health centers in India, by Krishna D.Rao ( and Ashley Sheffel