Exploring the role of community connections and capabilities to access health services: a social network analysis in rural uganda

Biggeri, Mario; Nannini, Maria (2019). 'Exploring the role of community connections and capabilities to access health services: a social network analysis in rural Uganda' Paper presented at the annual conference of the HDCA 2019, London, UK.


In Low and Middle-Income Countries, access to health care is seriously hampered by financial, geographical, and cultural obstacles at the time of service utilization. Major health shocks constitute an especially adverse event for the household well-being given the unpredictability and the cumbersome burden they imply both in terms of material and immaterial resources (Alam & Mahal, 2014). Illness may lead to multidimensional impoverishing consequences for the household members’ capabilities. First, health problems among family members have a “negative and statistically significant effect on consumption or income” (Islam & Maitra, 2012, p. 232). Second, obstacles to access health care are likely to negatively affect households’ health seeking behaviours: for example, many households tend not to utilise services rather than become poorer and the delay in seeking care may exacerbate the burden of disease (Gilson, 1997; Xu et al., 2003). Third, the impoverishing consequences of illness are likely to hold in the long run in case productive assets are sold or educational investments are reduced (Gotsadze et al., 2009; Wagstaff & Manachotphong, 2012).

In resources-constrained settings, the bulk of coping strategies and risk management mechanisms relies on informal institutions and collective capabilities (Ibrahim, 2006; Biggeri et al. 2012). In fact, Informal Risk Sharing Arrangements, such as savings and credit associations, burial societies, and friends’ groups, are very frequent in these contexts (Ndiaye et al., 2007), where they represent the only mean for rural households to secure their livelihoods (Cecchi et al., 2016; Townsend, 1994; Udry, 1994; DeWeerdt & Fafchamps, 2011). In order to access and utilise health services, local communities often face very limited government resources and need to rely on these informal networks (Hollard & Sene, 2016).

As argued by Amoah and colleagues (2017), social networks are critical for many people not only to ensure material resources but also to provide knowledge and information to make decisions about accessing health services increasing collective and individual capabilities (Greco et al, 2016; Biggeri, Ferrannini & Arciprete, 2017). A recent study in Ghana (Amoah et al., 2018) reports that social networks play a significant role in facing barriers to access health care. In general, several works indicate that social networks influence demand for health services. For example, they alter the perception about efficacy or desirability of services through close social acquaintances providing financial, informational, and emotional support for the most vulnerable (Amoah et al., 2017, Derose et al., 2009; Deri, 2005; Hendryx et al., 2002; Devillanova, 2008).

The level of social connectivity enjoyed by the household is interpreted as a specific individual and collective capability that has the potential to improve accessibility to health services. Social connectivity and access to information tend to shape social learning and behaviour change: a study from China shows that individuals and families adopt insurance through their social networks (Liu et al., 2014). Many applications of social capital in the health field postulate that social networks positively affect health-related behaviours though various channels (Kawachi et al., 1997; Kawachi et al., 1999; Kennedy et al., 1998). Information and collective action represent two key examples about the impact of social capital on health in Africa (Hollard & Sene, 2016); in many cases lack of adequate information tends to prevent individuals from seeking good health behaviours (Ensor & Cooper, 2004; Jyotsna & Somanathan, 2008). Moreover, “social capital can also operate through the ability of local communities to engage in collective action” (Hollard & Sene, 2016, p. 3).

This study aims to explore the role played by social capital and households’ connectivity to access health services within a community in rural Uganda. The country constitutes a key example of low-income African country where impoverishing effects due to health care access and utilisation are critical for the well-being of local population. The district of Oyam, in the Northern region, is the case study for our analysis. The investigation uses a mixed method approach and involves a household survey targeting 320 households (about 1720 individuals) plus eight focus group discussions. A descriptive social network analysis is intended to shed lights on the role played by social connections in improving financial protection and health seeking behaviours. In addition, we test whether being part of Informal Risk Sharing Arrangements affects the level of households’ resilience to health shocks. Overall, the level of social connectivity enjoyed by the household is analysed as a capability that has the potential to improve accessibility to health services at individual and collective level.

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