| The low rate of health service utilization and the lack of access to health care are serious problems in the rural areas of China, especially in the west rural areas. Rural patients' choice of health care providers is an important aspect of health demand which can contribute to the analysis of rural patients' difficulties in accessing to health care.The literature review indicates that former studies have not examined a range of factors that can be important in influencing rural patients' choice of health care providers in China. Specifically, there is no study investigating the impact of the price of health care services on patients' demands, nor is there research on the determinants of choosing private health care providers, or how distance to health institutions influences rural patients' preferences. Furthermore, previous researches on rural patients' choice of health care providers included only outpatients and did not involve inpatients, nor did they take into consideration the factors that result in rural patients' postponement on a visit to doctors. The literature review also showed that both the determinants of rural patients' visits of different types of health institutions and the trends in rural patients' choice of health care providers have not been studied in China.The aim of this study is to identify the main factors that affect rural patients' health care demand behavior and to use these results to suggest policy changes that would result in better meeting rural patients' demands for health care. More specific objectives of the study are: (1) to elucidate the effects of the factors of distance to health institutions, health care services price, and availability of private health care providers on rural patients' choice of health care providers; (2) to identify the factors that influence postponing a visit to a doctor by rural patients, and to analyze the status of rural patients' visits to different health institutions in order to elucidate rural patients' health care demand behavior from different angles; and, (3) to analyze the trend of rural patients' choice of health care providers in order to elucidate long-term change characteristic of rural patients' demand behaviour for health care, and to provide empirical evidence for the possibilities of improving health care services in rural areas and guiding reasonably rural patients' health care provider choice behaviour.This study is based mainly on data from a household survey in rural areas of Gansu province, China that was completed for the project "To Strengthen Public Health Planning in Poor Rural Areas" in 2004. It was funded by the ASEM (Asian European Meeting). This study also employs data from a household survey in rural areas of Gansu province, China, that were collected for the project "National Health Household Interview Surveys in 2003" and which was supported by the Ministry of Health. In addition, some data come from Chinese Health Statistical Yearbook or Digest 2005-2007. The theoretical framework of this study is based on consumer choice theory and utility theory. Research methods that have been used in different parts of this study include descriptive statistical analysis, bivariate inferential statistics, Multivariate Linear Regression, Mixed Logit Model, and Binary Logistic Regression Model. The data were analyzed in SPSS 12.0 and SAS 9.1.3.The results of Mixed Logit Model analysis on rural outpatients' choice of health care providers indicate that the following determinants were statistically significant: age, the type of disease, whether illness started before the reference period, number of total days when an individual was confined to bed due to illness, distance to health care institutions, patients' income and health care services price. Relative to self-treatment for rural outpatients, an individual, on average, has a lower probability of visiting a county hospital as his/her age increases (the estimated coefficient is -0.0358, holding all other factors constant). Further, on average, the order of probability of an individual choosing a provider, from high to low, is (a) Township Health Center (THC), (b) public village clinic (PUBVC), and (c) private village clinic (PRIVC). Compared to fever patients, chronic patients have higher probability of visiting any of the formal health care providers rather than confining themselves to self-treatment. According to the absolute value of coefficients of chronic illness variables, on average, the order of probability of an individual choosing a provider, from high to low, is (a) county hospital, (b) Township Health Center, (c) private village clinic, and, (d) public village clinic. An individual with ailment which started before the reference period has a lower probability of visiting public village clinic, private village clinic, or township health center in place of self-treatment compared to an individual with ailment started within the reference period.Distance to a health care provider plays a significant role in the patients' choice. About 28% of the rural outpatients prefer a provider who is within of 3 ~ 10 km distance of their home. An individual's likelihood of visiting county hospital increases as his / her bed-days increase. According to the absolute value of the coefficients of bed-days, individuals are most likely to choose a Township Health Center (THC), followed by a private village clinic (PRIVC), and lastly a public village clinic (PUBVC). Price is a significant determinant of health care demand in poor rural areas. Price elasticity of health care is higher for the low-income groups than for the high-income ones. For example, when the price of THC goes up to 50 yuan, the price elasticity of THC in low income group is -0.4535, and that in high group is -0.1357. Between the different provider types, the price elasticity for county hospital is the highest.The results of Binary Logistic Model analysis of the choice of health care providers by rural inpatients indicate that, income, the type of disease, hospital days, occupation, and gender are statistically significant determinants. One unit increase in rural inpatients' income results in a 2.651 times change in the odds of visiting county hospital relative to choosing Township Health Center (THC). Among the sample's types of disease, the odds of inpatients with respiratory system diseases visiting county hospital is 0.101 times that of inpatients with diseases of digestive system relative to choosing THC. One unit increase in hospital days of rural inpatients results in a 1.105 times change in the odds of visiting county hospital relative to choosing THC. The odds of the second occupational group inpatients (including workers in sample rural areas, village teachers, village cadres, village doctors, etc.) visiting a county hospital is 3.439 times that of ordinary rural inpatients.The results of Binary Logistic Model analysis on the determinants of postponing a visit to a doctor indicate that the type of disease, age, income, and lack of medical insurance are statistically significant determinants of rural patients' postponing a visit. to a doctor. The odds of a chronic patient whose disease started before the reference period and lasted into the reference period postponing a visit to a doctor is 2.126 times that of an acute patient whose disease started within the reference period. The odds of postponing a visit to a doctor by patients having no any medical insurance coverage is 2.141 times that of patients having medical insurance coverage. The odds of postponing a visit to a doctor by low-income groups is 2.452 times that of high-income groups.According to the descriptive statistical analysis of the status of rural chronic patients' visits to different types of health institutions, rural chronic patients who had received formal treatment during the year previous to the study, 30.05% of them sought treatment only at village clinics, and 23.48% of them sought treatment only at county-level and above hospitals. The lowest proportion, 12.48%, sought treatment only at a Township Health Center. Among rural chronic patients who had sought self-medication as a way of treatment, 41.50% did not seek any other formal treatment during the previous year. In addition, among rural chronic patients who had visited more than one type of health care institution, the number of cases who had sought treatment at both village clinics and county-level and above hospitals is the largest.In this study, trends in rural patients' choice of health care providers have been analyzed using national health statistical data. The results indicate that from 1999 to 2006, both the number of outpatients visits and the number of inpatients in Township Health Centers decreased across the entire country. Data from the National Health Household Interview Surveys showed that, among two-week visit outpatients, the proportion visiting village clinics decreased by 6.67 percentage points from 1998 to 2003. At the same time, the proportion of visiting county-level and above hospitals rose 4.04 percentage points. As for rural inpatients, the proportion choosing Township Health Centers dropped by 6.62 percentage points, while the proportion of choosing county-level and above hospitals rose by 8.71 percentage points.According to the analysis and discussion of the research results, the following suggestions on relevant policy improvements are brought forward. Firstly, in the area of health care financing and allocation it is suggested: (1) to improve the equity in health care financing and the financing mechanism of new rural cooperative medical insurance system; (2) to perfect the policy of health funding utilization to support health care demand. Namely, to add a number of new rural cooperative medical insurance system fixed-point medical institutions, to perfect the outpatient expenses' reimbursement policy for rural chronic patients, and to combine implementing of a new rural cooperative medical insurance system with the reforming of the rural medical provider system; (3) to allocate more the goverment fund for village and town health institutions. Secondly, in order to strengthen the administration and regulation of rural health institutions it is suggested: (1) to control the health care services prices and regulate rural health care market; (2) to perfect the mechanism for supervising and evaluating the delivery of health care services; (3) to strengthen the reform of organization and administration of rural health institutions; (4) to make the best use of rural private health institutions' positive actions; (5) to enhance the professional qualities of health professionals at rural and grass-root levels; (6) to accelerate the change of the model of health service delivery in rural health institutions. Finally, in order to strengthen the health seeking guidance and poverty aid for rural patients it is suggested: (1) to strengthen the propaganda on rural health institutions, popularize basic health knowledge in order to guide rural patients' health care seeking behavior; (2) to increase the extent of medical aid for rural needy patients.This study makes an original contribution to the field of rural patients' health care demand by using new perspectives to analyze rural patients' choice of providers. To our knowledge, it is the first study to examine the impact of health care services price on rural patients' choice of providers in China and to obtain the corresponding price elasticities. This study provides insight into the effect of distance on rural patients' choice of health care. Furthermore, this study is the first to examine the determinants of inpatients' choice of health care providers in China. In addition, this study is the first study that examines the factors that affect postponing a visit to a doctor by rural patients, the status of rural chronic patients' visits of different types of health care institutions, and the long-term trend of rural patients' choice of health care providers. In addition, this study adds to the area of research that employs the Mixed Logit Model following Boarh (2006) and Jose (2007). The main limitations of the study are that, due to the lack of relevant data, the indirect cost of medical care and the impact of health care quality were not included into analysis of rural patients' health care provider choice behaviour. Another limitation is related to a fact that the analysis on inpatients' choice of health care providers in this study does not refer to the price variable. These limitations are worthy of further investigation.
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