Trust Leap and Convenience Paradox: Primary Care Bypassing among Rural-to-Urban Migrants in China

Abstract

BackgroundSince the 2009 health reforms, China has sought to strengthen primary health care (PHC) through expanded insurance coverage, greater investment in community-level institutions, hierarchical diagnosis and treatment, and the rollout of family doctor contracting. Yet existing studies on primary care bypassing in China have focused mainly on health system conditions and care preferences in the general population rather than on migrants as a distinct group under this reform era. This literature has also been dominated by quantitative approaches, which have been useful for identifying broad patterns in utilization and institutional performance, but have focused more on how the system functions than on how migrants themselves experience and interpret it in everyday life. Rural-to-urban migrants are not simply another urban patient group. Their healthcare decisions are shaped not only by ongoing reforms, but also by unequal incorporation into urban services, differing levels of social integration, and the continuing influence of earlier experiences with lower-level care in places of origin. Understanding migrants’ care-seeking decisions is therefore important not only for improving health equity, but also for assessing how China’s tiered healthcare reforms have actually been experienced by one of the country’s largest and most mobile populations. Methods This study adopted a qualitative realist approach to investigate how healthcare choices are produced through the interaction of context, reasoning, and healthcare options. Semi-structured interviews were conducted with 13 rural-to-urban migrants residing in multiple Chinese cities. Participants differed in age, occupation, family roles, and migration histories. Interview data were analyzed using a Context–Mechanism–Outcome (CMO) framework in order to identify how specific contextual conditions activated particular perceptions of risk, trust, and convenience, and how these in turn shaped patterns of healthcare utilization. Results The findings indicate that bypassing CHCs was driven not only by structural constraints, but also by two recurring mechanisms. First, participants often made what this study conceptualizes as a “Trust Leap”, favoring tertiary hospitals because they were perceived as more authoritative, more reliable, and more diagnostically reassuring than CHCs or other grassroots facilities. This tendency was shaped in part by the legacy of earlier rural medical experiences, as some migrants continued to associate lower-level care with weak professionalism, limited diagnostic capacity, and institutional opacity even after moving to the city. It was especially pronounced when respondents were making decisions for children, older parents, or illnesses perceived as potentially serious. Second, the study identifies a “convenience paradox,” whereby the traditional accessibility advantage of CHCs was weakened by digital hospital registration, online consultation, and app-based pharmacy services. Under these conditions, CHCs often occupied a narrowed and conditional role within migrants’ care pathways rather than functioning as a routine first point of contact. Minor illnesses were commonly managed through self-medication or pharmacies, while more serious or uncertain concerns prompted direct attendance at higher-level hospitals. These patterns were not uniform across the sample, but were shaped by age, digital literacy, family responsibility, and prior experiences of lower-level care. Conclusion This study argues that healthcare bypassing among rural-to-urban migrants cannot be understood solely in terms of physical or financial access. Rather, it emerges from the interaction of migration experience, unequal incorporation into urban health systems, institutional distrust, family responsibility, perceived medical risk, and the changing convenience of alternative care pathways. Policies aimed at strengthening primary care utilization among migrants should therefore move beyond service expansion alone and place greater emphasis on the specific forms of reassurance, transparency, and accessibility that migrants appear to value in practice.