Making Connections: Social Networks and Healthcare Access in China

Abstract

When there are obstacles to access public services, citizens tend to resort to social connections to get things done. While the existing studies suggest that people rely on connections to compensate for ineffective formal institutions, it remains unclear if people rely less on social connections when the formal institutions are more effective. The use of connections entails unequal public service access between those with and without connections. Social connections may only fill in the gaps when the formal institutions are ineffective lacking adequate information and service provision. Effective formal institutions may mitigate the reliance on social connections to access public services. Therefore, this study examines the influence of formal institutional capacities on the use of social connections in the case of health service access in China. Using the China Family Panel Studies 2010 data and China Health Statistical Yearbook 2010 data, this study finds that greater health institutional capacities indeed mitigate the use of personal connections (guanxi) to access health services. The statistical analyses of the data suggest that there is less use of personal connections (guanxi) to see a doctor in provinces with greater health institutional capacities. The analyses of the Chinese General Social Survey 2010 data also find that the provincial health institutional capacities have a positive influence on perceived healthcare access. These results suggest that in provinces with greater health institutional capacities, people perceive that they can more easily access healthcare services, and they are less likely to rely on personal connections to access health services. Further, the qualitative analyses of the interview data add a more nuanced understanding to the roles of social connections and institutions, and suggest that social connections stay relevant and persist to play important roles even when the institutional capacities are greater. The interviews with women about their prenatal care service access in an urban city in China indicate that most interviewees had access to standardized care services regardless of their use of social connections. Still, there were two institutional gaps: long wait time and short doctor-patient interaction time. These gaps stem from overcrowding hospitals, and made the access to services and information more difficult. Under this context, many interviewees used social connections with friends and colleagues to obtain information about pregnancy and prenatal exams, compensating for the lack of information provided by the doctors. The use of online networks was also popular among them to fill in the informational gap. Interpersonal connections (guanxi) can also facilitate prenatal care service access by making it easier to see a doctor in face of the long wait time and overcrowding hospitals. These findings suggest that social connections play different roles based on particular institutional gaps they fill in. No institutions are fully efficient in providing perfect information and services. While the reliance on or substitutive effect of connections can become mitigated when the formal institutions are more effective, social connections continue to play different roles under different institutional contexts. Social connections and formal institutions interact and shape people’s behaviors and access to public services. This study offers implications for the studies on social connections and governance as well as public service institutional developments in other countries, ongoing health system reforms in China, and for the authoritarian resilience that stems from the government’s public service provision.