A market of distrust and obligation: the micropolitics of unofficial payments for Hospital Care in China

Abstract

Based on ethnographic studies in public hospitals in Guangzhou and Beijing in 2010-2011, this paper examines the institutional and cultural factors behind the practice of unofficial payments for hospital care in mainland China. It challenges the conventional “imperfect market” assumption, and instead offers a cultural and economic sociological interpretation of the problem. Our findings reveal that the practice of delivering hongbao (red packets containing money) to physicians and other medical practitioners has its root cause in the contradictory institutional demands on public hospitals in post-Mao China. The dual character of public hospitals as both socialist and profit-oriented, eventually resulted in earning them widespread distrust. The generalized distrust in hospitals and physicians induced patients to revive a tradition of delivering hongbao to physicians, but imbued it with new meanings and new practices. Patients offered hongbao not only to gain preferential treatment in the context of over-demand for quality services but, more importantly, to boost their confidence in physicians whom they generally distrusted. Hongbao exchanges are found to be highly associated with the use of Chinese guanxi. We analyze how hongbao exchanges among strangers are different from hongbao exchanges among socially connected ties in their practical impacts, due to cultural meanings and expectations.