Impact of the Family Doctor Contracting System on unmet healthcare needs in Shandong Province, China

Abstract Unmet healthcare needs are a significant concern in China, possibly due to the underutilization of primary healthcare services. Patients disproportionately seek tertiary hospital services, reflecting the historical underinvestment in community healthcare and a weak referral system. This misallocation of medical resources burdens the capacity of tertiary hospitals and limits access to necessary healthcare. To address this, the Family Doctor Contracting System (FDCS) was introduced to enhance community health services and reduce unmet healthcare needs. This study empirically analyzes the impact of the FDCS on unmet healthcare needs using data from the 2018 National Health Service Survey in Shandong Province, which included 27 447 individuals aged ≥18 years. An entropy balancing method was employed to address self-selection bias. Logistic regression results show that individuals contracted with family doctors (FDs) are associated with a 1.6% lower probability of experiencing unmet outpatient healthcare needs compared to those who did not participate, although the FDCS had no significant impact on unmet inpatient needs. A potential mechanism is that the FDCS has improved the accessibility of outpatient services. We found that signing up with FDs reduced the likelihood of citing inaccessibility as the main reason for unmet outpatient care needs by 43.7 percentage points, while the impact on unacceptability and unavailability was relatively more minor at 0.5 percentage points. The findings highlight the effectiveness of the FDCS in enhancing the role of primary care and improving access to healthcare. Future policy initiatives should focus on promoting the benefits of the FDCS and encouraging utilization of the FD service while strengthening community-based primary care by providing adequate infrastructure, resources, and training.