This study aims to generate a profile of high performing PHC organizations from the perspective of patients in China. Based on a qualitative study, we found that the profile of high performing PHC organizations include five domains and 14 attributes. From patients’ perspective, high performing PHC organizations should be near home with a comfortable environment and sufficient organizational resources; have efficient service delivery and clinical practice approach; and provide high-quality and low-cost comprehensive services, through an integrated approach supported by an efficient organizational structure.

The provision of basic medical services and public health services are the two main functions of PHC organizations as required by the Chinese government. As one key component of a PHC organization, organizational resources, including equipment, human resources and information systems, were valued by most participants in this study. The participants argued that basic medical equipment should be adequately provided in high performing PHC organizations—a finding that is consistent with the conclusions from a study in Germany [25]. From the perspective of our participants, a PHC organization with conventional medical equipment could perform its functions well. It is not necessary to invest into more advanced medical equipment, which might lead to resource waste and higher costs for the patients. Meanwhile, studies have also shown that healthcare professionals in well-equipped health organizations may not necessarily provide high quality care [26, 27]. As a result of significant investment in PHC during the past decade, adequate basic equipment is now available in most PHC organizations in China [28].

However, challenges remain in relation to health information system building and training enough general practitioners in China to better meet patient expectations in these areas. Health information systems are suffering from inadequate integration in China, such as the difficulty in linking the Electronic Medical Record Systems in PHC organizations with the systems used in public hospitals [9]. The number of qualified general practitioners remains insufficient and unequally distributed geographically. In 2020, the average number of general practitioners in China was 2.90 per 10,000 population (3.43 in eastern region, 2.53 in central region, and 2.47 in western region) [29]. These proportions are much lower than those in some developed countries, with 12.30 in Canada, 10.19 in Australia and 7.76 in the UK [30].

Among the three attributes of general features, short distance between a PHC organization and home was valued most by the participants. Similarly, previous studies in China and other countries have shown that distance is a predictor of patients’ choice of healthcare providers [25, 31, 32]. As places for treating many minor acute conditions, PHC organizations should be near home to ensure speedy treatment. In addition, there is substantial evidence of a distance-decay association whereby increased patient-provider distance impacts patient access to health services and health outcomes [33, 34]. In 2017, a national policy was issued to ensure that each Chinese resident reaches the nearest healthcare organization within 30 min in order to increase service accessibility [35]. Recent Chinese data show that the percentage of residents who could reach the nearest healthcare facility in less than 30 min increased from 95.8% in 2008 to 98.7% in 2018 [29].

Regarding the service delivery and clinical practice domain, the participants expressed strong expectations regarding a broader scope of services provided in an integrated manner. For internal integration, the consultation process was expected to be simple and smooth, specifically including front desk guides, clear signage, and reasonable department locations. The studies from the UK, US and Denmark also revealed that smooth consultation process could reduce waiting time and improve service efficiency [36]. In China, efficient service process requirements were already set out in a national 2019 guideline for PHC organization service capacity evaluation [12]. However, the policy seems to be poorly implemented by frontline PHC organizations, revealing the lack of collaboration between internal departments and cumbersome patient flow processes [37].

For external integration, PHC organizations were expected to maintain close connections with other health care providers through efficient referral systems, and to facilitate clinical communication—a finding that resonates with conclusions from a US study involving PHC patients [31, 38]. Prior studies suggest that efficient referral systems could prevent unnecessary financial and health losses for patients when the PHC organization capacity is limited [32, 38, 39]. China is currently examining different types of integrated care models, mainly focusing on reforming governance structures, payment methods, and care delivery models [40]. However, the referral system has not been well implemented [14]. Cross-referrals from either the PHC organizations or hospitals are limited due to profitability considerations [6]. In addition, cross-referrals are currently not supported due to a lack of integrated health information systems.

Quality of care, including effectiveness, safety, and patient experience, were given higher priority by participants than cost. These characteristics are recognized globally as important elements of a health system output [41]. Supported by the national essential medicine and medical insurance policy reform, out-of-pocket costs for PHC services have been greatly reduced in China. Yet the current quality of care in PHC organizations remains a challenge, with frequent diagnostic and treatment errors and overuse of antibiotics [42,43,44,45]. To improve the quality of PHC services, China could develop a PHC organization accreditation system based on the 2019 PHC Organization Service Capacity Evaluation Guidelines and the 2020 PHC Performance Evaluation Guidelines [12, 15].

Another important finding was that nearly 60% of our study participants desired high performing PHC organizations to have efficient organizational structures, particularly the continuous learning mechanism, transparent and efficient management, positive organizational culture and regular performance monitoring. There is growing evidence from other countries to support the positive impact of these organizational characteristics on performance within health care organizations [46,47,48,49]. These organizational variables represent potential management reform levers that could be used to better meet patients’ expectations and improve service performance. As China is moving towards building high quality primary care system, further studies are needed to examine the effect of these features on quality of care in Chinese PHC settings.

This study captured patient priorities regarding high performing PHC organizations in China and have some implications for practice and policy. The five domains and 14 attributes can be used by policy makers and PHC managers to guide future reform and restructuring efforts and to identify gaps in the organization of services. Based on the analysis of patient expectations and recent policy reform efforts in PHC, we found that China has made significant achievements during the past decade towards building well-equipped PHC organizations to better meet public expectations in the field of organizational resources and geographical accessibility. However, there are still challenges to improve service delivery and clinical practice, especially in quality, integration, and management, which have also been highlighted in many other low-and-middle income countries. In recent years, China has made efforts to address these challenges, mainly through building a family doctor contract service model and tiered health-care delivery system with bidirectional referral mechanisms [13, 14]. However, challenges remain in translating these policy efforts into daily practice among front-line PHC organizations. Our framework provides a comprehensive list of important elements to consider in implementing solutions at the organizational level. It is equally important to take into account the lessons learned and innovative solutions from international experiences of primary care reform, such as the Family Health Teams in Ontario [50] and Family Medicine Groups in Quebec [51].

The main strength of this research is that it reflects patient preferences regarding high performing PHC organizations. Our sample was diverse and included participants from a vast geographical area (eastern, middle, and western China) and participants of different genders, age, and health insurance types. Second, we used an established analytical framework—the Classification System of PHC Organizational Attributes, which was developed based on a comprehensive scanning study of literature on the organization of PHC. This scientific framework was used to organize the preliminary structure of the domains and attributes while considering the primary care context in China. However, the following limitations should also be considered. There is a high demand for health care among the rural population. Their expectations were not explored in this study. Because of the differences in primary care systems and health insurance programs between urban and rural areas in China, the transferability of our results is limited. Future studies could investigate the preferences of rural populations regarding PHC organizations and compare them with those of urban populations. Finally, translating data from Mandarin into English may have resulted in some linguistic inconsistencies.