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Informality as an analytical category in research on healthcare

In November 2013, the Academic Swiss Caucasus Net (ASCN) and the Interfaculty Institute for Central and Eastern Europe at the University of Fribourg hosted a conference that aimed to “identify and compare forms, functions and meanings of informal structures and practices in Eastern Europe and Central Asia” (SOYUZ list-serv, call for papers). In this essay, I comment on conversations that emerged from a panel on informality in healthcare systems, as well as other discussions among fellow anthropologists and other social scientists.

The conference’s call for papers started, predictably, with the statement: “in many Eastern European and Central Asian countries the democratization process is hindered by many different forms of informal power networks,” followed by disappointing “it seems obvious that personalized governance networks are not really structures supporting democracy and rule of law; on the contrary, they undermine them.” Nearly prepared to delete the message, I continued reading the next paragraph: “however, it would be erroneous to insist only on the negative effects of informal practices… Informal power networks for political elites should be distinguished from practices and networks at the level of ‘everyday citizen behavior,’ wherein they retain a different meaning (‘to get things done’).” The call for papers concluded with another promising statement, “the meaning of … relations between the informal and the formal, changes depending on specific contexts.” This approach held the promise of discovering new more productive analytical categories in the works of the conference participants.

The interdisciplinary nature of the conference brought up several questions for me. Are we going to speak the same language? Are we going to move beyond the simple framework of “corruption is bad because it undermines liberal democracy”? When will we have the moments of clarity and feel in agreement? What are the analytical categories that will arise from those moments? What are some of the more productive ways of thinking about informality in healthcare? I will venture to provide general background on anthropological approaches to studying what are commonly referred to as informal practices, and then I will think through the panel’s papers in search of interesting common denominators.

Anthropology is in many ways uniquely equipped to shed light on practices that do not fall within the realm of formal social or political institutions, due to its focus on everyday practices and its ethnographic approach. Generally speaking, anthropological scholarship is suspicious of the term “corruption,” defined by the World Trade Organization as “the abuse of public office for private gain,” pointing out that the boundaries between public and private are often not clear-cut, and institutional variables are far from fixed and unproblematic (Haller, Shore 2005). Conceptualizing informal exchanges as corruption reduces the problem to the issue of personal moral flaws, such as greed of officials, and fails to acknowledge situations when corruption is systematic and structural. Haller and Shore (2005:2) succinctly describe this as focusing on “the individual apples rather than the barrel that contains them.” Koycheva (2013:2), for example, states that this definition “establishes a priori a pejorative framework within which various practices which do not fit the dominant Western modern model of governance, order-making, and social relations are classified. Such a framework places any discussion of the economic and political transactions labelled as “corrupt” against a background of an implied moral judgment which condemns not only those involved in the transaction, but often their culture as well.” Even when the term “corruption” is not used, “informality” can evoke the same orientalist conceptualization of opposition between formal (read: moral) and informal (read: immoral). The international policy that proclaims its dedication to transparency, good governance, and liberalization itself has come under anthropological critique (Sanders and West 2003, Sampson 2005). Many scholars question the agendas of various transnational groups that espouse such policies (like the WTO), pointing out that power protects the interests of a privileged few, promotes “the liberal bourgeois public/private distinction…[,] allows for public equality and private inequality… and works to mask implicit forms of privilege, be they of class, gender, or ethnicity” (Zinn 2005:240). Koycheva (2013:2) echoes this critique, explaining that one of the biggest challenges appears to be exactly “how to situate corruption as a practice on the scale running from global to local and cultural.” For instance, why is government lobbying in the West considered to be formal and fully legal, while negotiations between formal parties in post-socialist context is seen as informal and often corrupt? What about those practices that formally satisfy the legal code, but fundamentally violate its spirit? Indeed, Gal (2006:164) reminds us that we live in “standardized regimes,” which command authority and make “other linguistic forms seem inadequate or even invisible.” We therefore need to be mindful of the use of the term “corruption” in academic scholarship, lest it mask more than it tries to unveil.

As an alternative to these definitions, anthropologists have offered a view of informal economy as having a dual nature. On the one hand, informal practices may be seen as privileging a chosen few, undermining development and open-market principles, and creating obstacles to the rule of law. Informal practices occur in the context of power relationships that “marginalize, stratify and exclude” (Zerilli 2005), and often their participants have little choice about whether or not to engage in them for fear of losing access to their “social rights.” On the other hand, informal practices act as a resource and provide “immediate, specific, and concrete benefits to groups which might otherwise be thoroughly alienated from a society” (Huntington 1968). Still, scholarship that takes such a perspective tends to be evaluative in a sense that it analyzes informality against its role in a particular kind of social order—liberal democracy—that privileges only a certain “normative repertoire” (Comaroff and Roberts 1986). I now turn to the conference papers to see what new categories of analysis have emerged.

The participants of the panel discussed monetary and non-monetary informal exchanges, paying special attention to the issues of moral gain and legitimacy. When I set out to conduct my fieldwork in 2007, I never intended to delve into the study of informality. Rather, I wanted to understand the ways in which male and female physicians participate in healthcare transformations in a politically volatile and economically unstable context. However, their engagement in informal networks was not only prevalent, but also formative of professional identities. I therefore inadvertently embarked on the ethnographic exploration of the informal economy in the Ukrainian healthcare system. I suggest that informal practices are linked to physicians’ considerations of morality and professionalism. I use Ledeneva’s (2006:17) definition of informal practices as “conflicting, fluid, and complex interaction between formal rules and informal norms.” Some informal practices take place outside of the formal economy (such as paying physicians for their services in their free time), while others penetrate formal economy (such as embezzlement of state budget, misuse of hospital resources, etc.). Some are assigned to the realm of affect (expression of gratitude) and deemed professional, while others are placed firmly in the realm of obligation and linked to unprofessional monetary pursuits. This understanding avoids defining the unofficial economy in dichotomous terms as universally bad or good. While informal exchanges served as a personalizing reciprocity technique during Soviet times, post-socialist physicians often see the ability to earn decent income as evidence of their professional success. They emphasize their role as expert clinicians deserving of social and economic recognition and rhetorically separate themselves from what they see as state bureacracy. Physicians are eager to reposition themselves in a way that allows them the status of respectable experts, but that also allows them to gain additional dimensions of prestige as economically freed professionals. The layered nature of discourses that combine concerns for monetary remunerations with quandaries about dignity and morality speaks to this duality.

In her work on informality in healthcare in Bosnia, Carna Brkovic convincingly argues that informality[1] enables people to move across different social orders (morality, economy) and navigate different expectations. In this argument, she reiterates Ledeneva’s famous suggestion that economic rationalities and sociability cannot be disentangled; people are simultaneously friends and economic partners (2006). It would therefore be inadequate to examine informality only through the lens of its role in the liberal transformations of post-socialist healthcare economies, as impeding or boosting democracy. Brkovic suggests that informality does not capture a single distinct type of relationship between people or institutions, or any degree of “abstract, formal consistency” (2013:7), since it means different things and achieves different results for different people. It might mean paying a physician under the table, making phone calls to friends, family and neighbors to ensure favorable hospital admission result, or a number of other things. With veze, “everything is possible and nothing is possible” (Brkovic 2013:8).[2]

Similar to Brkovic, Marius Wamsiedel reminds us that informality has an interactional aspect and can therefore take various shapes. He chooses to focus on non-monetary exchanges in Romanian emergency ward. He examines informal referral of patients and falsification of electronic registry entries to discover that participants of the exchange utilize various “concealment” tactics to effectively move the practice to the “moral” realm (Wamsiedel 2013:8), or what I call in my essay the “affect” realm (practices that are seen as good, even if they formally violate the rules). Wamsiedel concludes that non-monetary exchanges are pragmatic adaptations, and “the interactional construction of concealment…creates the appearance of moral legitimacy and exempts participants from potential repercussions for their involvement” (2013:9). It would be interesting to know the emic perspective of healthcare personnel and patients involved in these transactions to explore what registers of legitimacy they might be using.

Ekaterina Borozdina continues considering the moral legitimacy of care work in the context of Russian antenatal services. She reminds us that formal rules of healthcare presume that care can be institutionalized and commoditized to a degree, when it is transformed into a public good that is to be “distributed according to the logic of social rights” (2013:1). She argues, however, that informality in Russian antenatal sphere exists precisely because this logic of care is at least partially flawed. Obstetricians and gynecologists receive financial incentives from the state to ensure that they care for women and encourage their healthy lifestyles and pregnancies ultimately hoping to promote population growth in Russia. At the same time, they are now required to follow strict protocols in a standardized fashion that does not allow any personalized interactions (since they are deemed informal). The new protocols demand competence and care, but barely provide any tools for accomplishing either. They also demand shortened time for consultations, often experienced by patients as a decrease in the quality of care, a critique typical of Western healthcare. Borozdina points out that trust is a prerequisite of the delivery of “care” via institutions such as antenatal clinics and is difficult to achieve when physicians are instructed to refrain from being emotionally invested in any patient and are required to follow universal rules and abstract moral judgments. Borozdina’s attention to the concept of trust speaks to our earlier discussion of the “affect” realm as crucial for understanding the role of informality in medical practices not only in post-socialist biomedical context, but everywhere.

Finally, Baktygul Tulebaeva confirms what other scholars in this panel seem to agree on: the division of social orders into formal and informal is rather arbitrary, since they represent different “normative repertoires” established in particular locales and embedded in specific histories and power relations (Comaroff and Roberts 1986). Practices often considered informal fall somewhere on the spectrum “of rules from which some may be chosen” as a formal practice, leaving other regimes behind (Koycheva 2013:4). Tulebaeva studies childcare practices in Kyrgyzstan, paying special attention to the formal order that guides seemingly informal child care practices not only by parents, but also by physicians. Wamsiedel and Tulebaeva agree on this point: informal practices are highly interactional and performative and are quite “formally” structured. At the same time, she shows how seemingly formal structures of healthcare institutions and NGOs are penetrated by informal beliefs and value systems, drawing into question how useful the formal/informal opposition is in studying post-socialist healthcare practices.

The most contentious point of the conference was undoubtedly the equation, found in many papers and discussions, of formality with modernity and “civilized” social orders and informality with barbaric underdevelopment that is inherently injust and immoral, since it circumvents the structures put forward to ensure the public good for all. I think that the greatest contribution of the healthcare panel lay in its ability to contradict such simplistic understandings of informality. The panel showed how informality often serves as a way of countering the structural violence of post-socialist as well as other healthcare systems. Indeed, it reminded us to think about the stakes. Healthcare is exactly the kind of field where positive results cannot wait a minute longer, so people’s efforts to alleviate their sufferring and to ensure their dignity are usually achieved by any means possible, formal or informal. This shatters to a degree our analytic divisions and suggests that perhaps what we need to do is “to start from the bottom up and probe the shifting and ambiguous ways in which formal and informal, official and unofficial, visible and invisible, compliant and non-compliant are constitutive of the state-citizen relationship” (Koycheva 2013:4).

 

Maryna Bazylevych is an Assistant Professor of Anthropology and Women & Gender Studies at Luther College in Northeast Iowa. She serves as a book review editor for the Anthropology of East Europe Review journal. Maryna’s work centers on health care transformations in Ukraine, paying special attention to the gendered ways in which physicians experience social change. Her recent research has focused on vaccination anxieties in Ukraine, and has been published in the Medical Anthropology Quarterly. She is currently working on a piece interrogating the changing meanings of the Hippocratic Oath in Ukrainian medical profession.

References

Bazylevych, Maryna. 2013. Moral Economy and Informal Exchanges in the Ukrainian Healthcare System. Paper presented at the International Conference “Informal Practices and Structures in Eastern Europe and Central Asia.”

Borozdina, Ekaterina. 2013. Formalizing Informal: Care Relations as an Element of Russian Antenatal Healthcare Services. Paper presented at the International Conference “Informal Practices and Structures in Eastern Europe and Central Asia.”

Brkovic, Carna. 2013. Navigating to Survive: Veze in the Governance of Life in a Bosnian Town. Paper presented at the International Conference “Informal Practices and Structures in Eastern Europe and Central Asia.”

Gal, Susan. 2006. Contradictions of Standard Language in Europe: Implications for the Study of Practices and Publics. Social Anthropology 14(2):163-181.

Huntington, S.P. 1968. Political Order in Changing Societies. Yale University Press.

Koycheva, Lora. 2013. Fading Ink and the Elusive State: Technologies of (Dis)Trust, The Permeability of Paperwork and Postsocialist Modernity in Bulgaria. Paper presented at the International Conference “Informal Practices and Structures in Eastern Europe and Central Asia.”

Ledeneva, Alena. 2006. How Russia Really Works. The Informal Practices that Shaped Post-Soviet Politics and Business. Cornell University Press.

Sampson, S. 2005. Integrity Warriors: Global Morality and the Anti-corruption Movement in the Balkans. In Haller and Shore Eds. Corruption. Anthropological Approaches. London, Ann Arbor, MI. Pluto Books.

Sanders and West Eds. 2003.Transparency and Conspiracy. Ethnographies of Suspicion in the New World Order. Duke University Press.

SOYUZ list-serv. Call for Papers “Informal Practices and structures in Eastern Europe and Central Asia” (March 29, 2013)

Tulebaeva, Baktygul. 2013. Formal and Informal Institutions in the Child Health Care System in Kyrgyzstan. Paper presented at the International Conference “Informal Practices and Structures in Eastern Europe and Central Asia.”

Wamsiedel, Marius. 2013. Non-Monetary Informal Practices and Their Concealment in a Romanian Hospital. Paper presented at the International Conference “Informal Practices and Structures in Eastern Europe and Central Asia.”

Zerilli, F. 2005. Corruption, Property Restitution and Romanianness. In Haller and Shore Eds. Corruption. Anthropological Approaches. London, Ann Arbor, MI. Pluto Books.

Zinn, D. 2005. Afterword – Anthropology and Corruption: The State of the Art. In Haller and Shore Eds. Corruption. Anthropological Approaches. London, Ann Arbor, MI. Pluto Books.


[1] The word she uses, Veze, literally means “relations, connections” (per Brkovic, 2013:1)

[2] Brkovic’s conference paper is based on her upcoming book: Brković, Čarna. In Press. Navigating to Survive: The Politics of Favours in a Bosnian Town. In Exploring the Grey Zones.  Harboe, Ida. Frederiksen, Martin Demant Eds. London: Anthem Press.


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