Riding the tiger of performance legitimacy? Chinese villagers' satisfaction with state healthcare provision
| Published date | 01 March 2022 |
| DOI | 10.1177/0192512120927482 |
| Date | 01 March 2022 |
| Author | Kerry Ratigan |
| Subject Matter | Articles |
https://doi.org/
International Political Science Review
2022, Vol. 43(2) 259 –278
© The Author(s) 2020
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DOI: 10.1177/0192512120927482
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Article
Riding the tiger of
performance legitimacy?
Chinese villagers’ satisfaction
with state healthcare
provision
Kerry Ratigan
Amherst College, USA
Abstract
Authoritarian regimes often rely on performance legitimacy, but cannot always fulfill policy prom-
ises, thereby undermining the regime. In 21st-century China, a reliance on performance legitimacy
may seem unwise, as policy outcomes have been mixed. However, the Chinese government has
managed to navigate gaping inequality and ineffective social policy. Why have policy failures not
produced greater discontent? Using my original survey data to examine rural healthcare, I argue
that the Chinese government is pursuing an objectively minimal but subjectively sufficient course of
action in healthcare provision. Regression analysis of my survey data, coupled with responses from
open-ended questions and semi-structured interviews, demonstrates that the deficiencies in cur-
rent policy have not threatened regime legitimacy because villagers have low expectations for state
provision of healthcare. The data also suggest that, as China continues to urbanize, villagers’
expectations are likely to rise, presenting new policy challenges for the state.
Keywords
Social policy, China, healthcare, authoritarianism, legitimacy
Corresponding author:
Kerry Ratigan, Department of Political Science, Amherst College, 72 College Street, Amherst, Massachusetts 01002, USA.
Email: kratigan@amherst.edu
260 International Political Science Review 43(2)
Introduction
The government should act vigorously for the people, if it does not then [the people] won’t
support it. (#1220, Villager from Jiangsu Province, 2012)
1
Authoritarian regimes are caught in a legitimacy paradox: performance is often an accessi-
ble source of legitimacy for non-democracies, and yet, on average, autocrats may be less
effective at delivering some goods than their democratic counterparts. Coercive autocrats
are less likely to be willing and able to adapt to new circumstances as societal needs and
expectations change. While scholars have observed these tendencies cross-nationally, China
seems to deviate from this pattern. The Chinese party-state has relied on performance
legitimacy, which worked well during the economic growth of the early reform period.
However, in the 21st century, policy outcomes in the issues that matter to the population
are mixed. Nonetheless, scholars generally find that satisfaction in the regime is high. I argue
that, although performance legitimacy is indeed crucial to the Chinese regime, the party-
state mitigates discontent by pursuing an objectively minimal but subjectively sufficient
course of action. That is, although an outside observer may critique policy outcomes, pop-
ular expectations do not yet outstrip current performance. While performance may have
bolstered legitimacy thus far, the Chinese communist party (CCP) could face difficulty
maintaining its rule as expectations rise. As the Chinese idiom goes, ‘when riding a tiger,
it is hard to dismount,’ lest the animal feel hungry. This study examines two related research
questions: Are expectations about performance associated with trust in government in
China? And who is likely to have higher expectations for government performance? I exam-
ine these questions through an analysis of villagers’ expectations for state healthcare
provision.
I first discuss performance legitimacy and autocratic governance broadly and in China.
Then, I evaluate alternative explanations for popular quiescence around healthcare provi-
sion and provide background on healthcare in China. Next, I introduce the data: my orig-
inal survey of 801 Chinese villagers conducted in 2012, supplemented with semi-structured
interviews. Through a generalized structural equation model, I demonstrate that villagers’
expectations for state healthcare provision are inversely correlated with trust in government,
suggesting that low expectations contribute to state legitimacy. Although expectations
matter for trust in local government, the central government appears to be insulated from
this factor. I also find that relatively cosmopolitan villagers tend to have higher expectations.
As villagers become more knowledgeable about life beyond the village, they are more likely
to demand better social welfare at home. While ongoing healthcare reforms may be suffi-
cient to satisfy rural China in the near term, my findings suggest that, as the countryside
develops and urbanization accelerates, villagers may become more clamorous for robust
social welfare.
Performance legitimacy and authoritarian durability
Why do some regimes persist while others succumb to destabilizing forces? To answer this
question, many scholars focus on legitimacy, or the idea that popular support (or lack
thereof) can determine the resilience of a ruling regime to potential challengers. Where
democratic procedures are absent, performance legitimacy—in which the regime’s right to
rule is derived from policy outcomes—may support autocratic rule. Following this logic,
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