Healthcare access, care substitution and population retention in rural China: the labour-allocation effect of public services

Abstract Rural public services are commonly expected to enhance place attractiveness and strengthen population retention. This study examines a further possibility: improvements in local healthcare may also ease household caregiving constraints and expand the employment and mobility options available to working-age family members. Using a balanced panel of 157 county-level units in Henan Province, China, from 2010 to 2022, the study investigates the relationship between healthcare access and population retention using county fixed-effects estimation, mediation and moderation analyses, and spatial econometric models. Healthcare access increased substantially over the study period, while population retention declined overall. Meanwhile, the coupling coordination degree between the two indices increased, revealing a pattern of apparent coordination. The fixed-effects estimates show a statistically significant negative average association between healthcare access and population retention. Mediation results are consistent with the proposed care-substitution pathway: healthcare access is positively associated with county-level care-substitution capacity, which is negatively associated with population retention. The estimated indirect component accounts for 53.1% of the total association within the mediation specification. Higher infrastructure connectivity attenuates the negative association. Regional analyses show a statistically significant negative association in southern Henan and a statistically significant positive association in central Henan. Spatial Durbin estimates show negative average indirect effects under all four spatial weight matrices, with statistical significance only under the inverse-squared geographical-distance matrix with a 200-km threshold. The study develops the concept of the labour-allocation effect of public services to interpret these relationships, complementing conventional accounts of welfare and place attractiveness with attention to household care constraints, employment opportunities and regional labour-market connections.