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2014 Informality as an Analytical Category in Research on Healthcare. Conference report. Electronic resource.
  Science, Medicine, and Anthropologyhttp://somatosphere.net http://somatosphere.net/?p=6906 Informality as an analytical category in researchon healthcare 2014-01-28 14:12:42By Eugene RaikhelIn November 2013, the Academic Swiss Caucasus Net (ASCN) and theInterfaculty Institute for Central and Eastern Europe at the University ofFribourg hosted a conference that aimed to “identify and compare forms,functions and meanings of informal structures and practices in EasternEurope and Central Asia” (SOYUZ list-serv, call for papers). In this essay,I comment on conversations that emerged from a panel on informality inhealthcare systems, as well as other discussions among fellowanthropologists and other social scientists.The conference’s call for papers started, predictably, with the statement:“in many Eastern European and Central Asian countries thedemocratization process is hindered by many different forms of informalpower networks,” followed by disappointing “it seems obvious thatpersonalized governance networks are not really structures supportingdemocracy and rule of law; on the contrary, they undermine them.” Nearlyprepared to delete the message, I continued reading the next paragraph:“however, it would be erroneous to insist only on the negative effects ofinformal practices… Informal power networks for political elites should bedistinguished from practices and networks at the level of ‘everyday citizenbehavior,’ wherein they retain a different meaning (‘to get thingsdone’).” The call for papers concluded with another promising statement,“the meaning of … relations between the informal and the formal, changesdepending on specific contexts.” This approach held the promise ofdiscovering new more productive analytical categories in the works of theconference participants.The interdisciplinary nature of the conference brought up severalquestions for me. Are we going to speak the same language? Are wegoing to move beyond the simple framework of “corruption is bad becauseit undermines liberal democracy”? When will we have the moments ofclarity and feel in agreement? What are the analytical categories that willarise from those moments? What are some of the more productive ways ofthinking about informality in healthcare? I will venture to provide generalbackground on anthropological approaches to studying what arecommonly referred to as informal practices, and then I will think throughthe panel’s papers in search of interesting common denominators. page 1 / 8  Science, Medicine, and Anthropologyhttp://somatosphere.net Anthropology is in many ways uniquely equipped to shed light on practicesthat do not fall within the realm of formal social or political institutions, dueto 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 ofpublic office for private gain,” pointing out that the boundaries betweenpublic and private are often not clear-cut, and institutional variables are farfrom fixed and unproblematic (Haller, Shore 2005). Conceptualizinginformal exchanges as corruption reduces the problem to the issue ofpersonal moral flaws, such as greed of officials, and fails to acknowledgesituations when corruption is systematic and structural. Haller and Shore(2005:2) succinctly describe this as focusing on “the individual applesrather than the barrel that contains them.” Koycheva (2013:2), forexample, states that this definition “establishes a priori a pejorativeframework within which various practices which do not fit the dominantWestern modern model of governance, order-making, and social relationsare classified. Such a framework places any discussion of the economicand political transactions labelled as “corrupt” against a background of animplied moral judgment which condemns not only those involved in thetransaction, but often their culture as well.” Even when the term“corruption” is not used, “informality” can evoke the same orientalistconceptualization of opposition between formal (read: moral) and informal(read: immoral). The international policy that proclaims its dedication totransparency, good governance, and liberalization itself has come underanthropological critique (Sanders and West 2003, Sampson 2005). Manyscholars question the agendas of various transnational groups thatespouse such policies (like the WTO), pointing out that power protects theinterests of a privileged few, promotes “the liberal bourgeois public/privatedistinction…[,] allows for public equality and private inequality… and worksto mask implicit forms of privilege, be they of class, gender, or ethnicity”(Zinn 2005:240). Koycheva (2013:2) echoes this critique, explaining thatone of the biggest challenges appears to be exactly “how to situatecorruption as a practice on the scale running from global to local andcultural.” For instance, why is government lobbying in the Westconsidered to be formal and fully legal, while negotiations between formalparties in post-socialist context is seen as informal and often corrupt?What about those practices that formally satisfy the legal code, butfundamentally violate its spirit? Indeed, Gal (2006:164) reminds us that welive in “standardized regimes,” which command authority and make“other linguistic forms seem inadequate or even invisible.” We thereforeneed to be mindful of the use of the term “corruption” in academicscholarship, lest it mask more than it tries to unveil.As an alternative to these definitions, anthropologists have offered a view page 2 / 8  Science, Medicine, and Anthropologyhttp://somatosphere.net of informal economy as having a dual nature. On the one hand, informalpractices may be seen as privileging a chosen few, underminingdevelopment and open-market principles, and creating obstacles to therule of law. Informal practices occur in the context of power relationshipsthat “marginalize, stratify and exclude” (Zerilli 2005), and often theirparticipants have little choice about whether or not to engage in them forfear of losing access to their “social rights.” On the other hand, informalpractices act as a resource and provide “immediate, specific, andconcrete benefits to groups which might otherwise be thoroughly alienatedfrom a society” (Huntington 1968). Still, scholarship that takes such aperspective tends to be evaluative in a sense that it analyzes informalityagainst its role in a particular kind of social order—liberal democracy—thatprivileges only a certain “normative repertoire” (Comaroff and Roberts1986). I now turn to the conference papers to see what new categories ofanalysis have emerged.The participants of the panel discussed monetary and non-monetaryinformal exchanges, paying special attention to the issues of moral gainand legitimacy. When I set out to conduct my fieldwork in 2007, I neverintended to delve into the study of informality. Rather, I wanted tounderstand the ways in which male and female physicians participate inhealthcare transformations in a politically volatile and economicallyunstable context. However, their engagement in informal networks was notonly prevalent, but also formative of professional identities. I thereforeinadvertently embarked on the ethnographic exploration of the informaleconomy in the Ukrainian healthcare system. I suggest that informalpractices are linked to physicians’ considerations of morality andprofessionalism. I use Ledeneva’s (2006:17) definition of informalpractices as “conflicting, fluid, and complex interaction between formalrules and informal norms.” Some informal practices take place outside ofthe formal economy (such as paying physicians for their services in theirfree time), while others penetrate formal economy (such as embezzlementof state budget, misuse of hospital resources, etc.). Some are assigned tothe realm of affect (expression of gratitude) and deemed professional,while others are placed firmly in the realm of obligation and linked tounprofessional monetary pursuits. This understanding avoids defining theunofficial economy in dichotomous terms as universally bad or good. Whileinformal exchanges served as a personalizing reciprocity technique duringSoviet times, post-socialist physicians often see the ability to earn decentincome as evidence of their professional success. They emphasize theirrole as expert clinicians deserving of social and economic recognition andrhetorically separate themselves from what they see as state bureacracy.Physicians are eager to reposition themselves in a way that allows themthe status of respectable experts, but that also allows them to gainadditional dimensions of prestige as economically freed professionals. Thelayered nature of discourses that combine concerns for monetary page 3 / 8  Science, Medicine, and Anthropologyhttp://somatosphere.net remunerations with quandaries about dignity and morality speaks to thisduality.In her work on informality in healthcare in Bosnia, Carna Brkovicconvincingly argues that informality[1] enables people to move acrossdifferent social orders (morality, economy) and navigate differentexpectations. In this argument, she reiterates Ledeneva’s famoussuggestion that economic rationalities and sociability cannot bedisentangled; people are simultaneously friends and economic partners(2006). It would therefore be inadequate to examine informality onlythrough the lens of its role in the liberal transformations of post-socialisthealthcare economies, as impeding or boosting democracy. Brkovicsuggests that informality does not capture a single distinct type ofrelationship between people or institutions, or any degree of “abstract,formal consistency” (2013:7), since it means different things and achievesdifferent results for different people. It might mean paying a physicianunder the table, making phone calls to friends, family and neighbors toensure favorable hospital admission result, or a number of other things.With veze  , “everything is possible and nothing is possible” (Brkovic2013:8).[2]Similar to Brkovic, Marius Wamsiedel reminds us that informality has aninteractional aspect and can therefore take various shapes. He chooses tofocus on non-monetary exchanges in Romanian emergency ward. Heexamines informal referral of patients and falsification of electronic registryentries 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 pragmaticadaptations, and “the interactional construction of concealment…createsthe appearance of moral legitimacy and exempts participants frompotential repercussions for their involvement” (2013:9). It would beinteresting to know the emic perspective of healthcare personnel andpatients involved in these transactions to explore what registers oflegitimacy they might be using.Ekaterina Borozdina continues considering the moral legitimacy of carework in the context of Russian antenatal services. She reminds us thatformal rules of healthcare presume that care can be institutionalized andcommoditized to a degree, when it is transformed into a public good that isto be “distributed according to the logic of social rights” (2013:1). Sheargues, however, that informality in Russian antenatal sphere existsprecisely because this logic of care is at least partially flawed.Obstetricians and gynecologists receive financial incentives from the stateto ensure that they care for women and encourage their healthy lifestyles page 4 / 8  Science, Medicine, and Anthropologyhttp://somatosphere.net and pregnancies ultimately hoping to promote population growth inRussia. At the same time, they are now required to follow strict protocols ina standardized fashion that does not allow any personalized interactions(since they are deemed informal). The new protocols demand competenceand care, but barely provide any tools for accomplishing either. They alsodemand shortened time for consultations, often experienced by patients asa 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 whenphysicians are instructed to refrain from being emotionally invested in anypatient and are required to follow universal rules and abstract moral judgments. Borozdina’s attention to the concept of trust speaks to ourearlier discussion of the “affect” realm as crucial for understanding therole of informality in medical practices not only in post-socialist biomedicalcontext, but everywhere.Finally, Baktygul Tulebaeva confirms what other scholars in this panelseem to agree on: the division of social orders into formal and informal israther arbitrary, since they represent different “normative repertoires”established in particular locales and embedded in specific histories andpower relations (Comaroff and Roberts 1986). Practices often consideredinformal fall somewhere on the spectrum “of rules from which some maybe chosen” as a formal practice, leaving other regimes behind (Koycheva2013:4). Tulebaeva studies childcare practices in Kyrgyzstan, payingspecial attention to the formal order that guides seemingly informal childcare practices not only by parents, but also by physicians. Wamsiedel andTulebaeva agree on this point: informal practices are highly interactionaland performative and are quite “formally” structured. At the same time,she shows how seemingly formal structures of healthcare institutions andNGOs are penetrated by informal beliefs and value systems, drawing intoquestion how useful the formal/informal opposition is in studyingpost-socialist healthcare practices.The most contentious point of the conference was undoubtedly theequation, found in many papers and discussions, of formality withmodernity and “civilized” social orders and informality with barbaricunderdevelopment that is inherently injust and immoral, since itcircumvents the structures put forward to ensure the public good for all. Ithink that the greatest contribution of the healthcare panel lay in its abilityto contradict such simplistic understandings of informality. The panelshowed how informality often serves as a way of countering the structuralviolence of post-socialist as well as other healthcare systems. Indeed, itreminded us to think about the stakes. Healthcare is exactly the kind offield where positive results cannot wait a minute longer, so people’sefforts to alleviate their sufferring and to ensure their dignity are usuallyachieved by any means possible, formal or informal. This shatters to a page 5 / 8
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