Factors Contributing to Patients Bypassing Primary Healthcare Facilities: Evidence from Mpumalanga Province, South Africa

Introduction / Objective Primary Healthcare (PHC) facilities are intended to be the first point of contact in South Africa’s health system, yet many patients bypass them and present directly at hospitals. Understanding the drivers of this bypassing is critical for informing policy and improving service delivery. The study seeks to determine the proportion, patterns, and reasons for non-referred patients seeking care directly at public hospitals in Mpumalanga Province. Methods A cross-sectional survey with a sample of 363 non-referred patients presenting in selected public hospitals in Mpumalanga Province. Facilities were purposively selected based on historical outpatient data from the District Health Information System (DHIS). Conveniently sampled patients completed a 28-item structured questionnaire that collected information on socio-demographics, knowledge of the referral policy, and reasons for bypassing PHC facilities. Descriptive statistics were performed using the Statistical Package for the Social Sciences. Results Analysis of routine data from DHIS indicated that 53.9% of outpatient visits in Mpumalanga public hospitals were by non-referred patients, exceeding the national average (41.8%). The highest proportion of non-referred hospital patients was from Ehlanzeni district (59.3%). Among the 363 surveyed non-referred patients, negative perceptions of PHC services, long waiting times, and medicine shortages were among the reported reasons for seeking care directly at hospitals. Discussion Various factors contribute to non-referred patients seeking care directly from the hospital. The implications are significant: inappropriate hospital utilisation strains limited resources, undermines the referral system, and exacerbates inequities in service delivery. Conclusion The study found that surveyed non-referred patients reported patient-level perceptions and health system challenges as reasons for seeking care directly at hospitals. Addressing these reported factors may strengthen the referral system and promote equitable access to PHC services.