Access to health care and community social capital

Health Services Research,  Feb, 2002  by Michael S. Hendryx,  Melissa M. Ahern,  Nicholas P. Lovrich,  Arthur H. McCurdy

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This study is not able to examine the direct mechanisms by which social capital may improve access. However, social capital (Putnam 1993) refers to three interdependent community factors, namely, interpersonal trust, civic engagement (i.e., active participation in public affairs), and norms of reciprocity (i.e., generalized expectations of cooperative behavior). Reciprocity norms are thought to lower transaction costs, facilitate cooperation, restrain opportunism, and balance self-interest and solidarity. Networks of civic engagement increase costs to tansgressors in economic exchanges because others know of the transgression. Networks facilitate communication and the flow of information about others' trustworthiness, reinforce reciprocity norms, develop reputations, and facilitate informal problem solving. Arising from reciprocity norms and civic engagement are trust in one another and a "confident self-discipline" (i.e., self-efficacy). Putnam found that social capital improved institutional performance; h e had 12 primary measures of government institutional performance, including the number of family health clinics developed by the government, and the government's local health care spending budget.

If we extend this reasoning to health care institutions, we may argue that social capital improves access in the same manner that social capital improves local government functioning. Social capital may operate to create more humane, efficient, better coordinated, broader, or deeper health care systems. The following speculative features may operate in high social capital communities: Physicians may be more likely to accept underfunded patients. Insurers may be more likely to stay in the market as a community commitment and not just for financial self-interest and may be more likely to retain a fuller range of covered services. Employers may be more likely to provide better coverage to employees. Sectors of the health care system such as physicians and hospitals, or hospitals and aftercare institutions, may be better at coordinating care, and patients may be willing to absorb higher out-of-pocket costs because of perceptions of institutional quality and trust. (In other findings from these data not shown her e, higher out-of-pocket costs were associated with higher social capital, but social capital lowered out-of-pocket costs for the uninsured.) For other discussions of the central role of trust in business and health care system functioning, see Fukuyama (1999) and Annison and Wilford (1998).

These speculations are supported by site visit results in 12 of the CTS locations (Steinberg and Baxter 1998). A key to positive health system change and improved institutional functioning is community accountability. They define community accountability as "the structures and processes communities use to make health system change consistent with local standards of behavior, shared values, or community goals." The accountability mechanisms may be formal, such as health care coalitions and collaborations, contractual agreements or other legal structures, or press coverage, or informal "professional culture." Where communities lack common values and a strong sense of community, few accountability mechanisms were present in this site visit study. Social capital may be the element of values and sense of community that operates to improve both the probability and impact of accountability mechanisms because in higher social capital communities, reputations matter, and shared values and community goals are more lik ely to exist. Conversely, in low social capital communities, common values and goals are lacking, and reputations do not travel through the community because its residents are more disengaged, resulting in weakened accountability mechanisms.