Michele Rivkin-Fish
During fieldwork in St Petersburg in the summer of 1998, I asked a friend of mine named Valya about her strategies for accessing competent, reliable health care.1 Valya was 30 years old and spending considerable time and effort undergoing gynaecological procedures in the hopes of eventually becoming pregnant. Socially and economically, she occupied an interesting place in the emerging fabric of post-Soviet Russian society: she had been raised in modest conditions in a provincial town four hours from Leningrad, with parents who were both engineers, and had completed two degrees of higher education. In 1994, when I first met her, she and her husband had just started what soon became a highly successful business in the import sector. Having grown up with no special privileges besides those obtained through cultural forms of capital associated with higher education, by the late 1990s, Valya had access to money, and quite a bit of it. So my questions regarding her strategies of accessing health care immediately opened our discussion to issues of how the social changes of the last decade, in particular, market reforms, were being inscribed in her daily life, and how she was interpreting and improvising with these forces in seeking health care. The first thing Valya explained was that her treatment in a well-respected clinic was arranged by her long-term friend, Nina, who had recently begun practising medicine. Some of the procedures Valya needed were being undertaken by Nina herself, while other, more complicated ones were being referred to one of Nina’s more experienced colleagues, Vladimir Sergeevich. I then asked Valya if she was paying for the treatments, and if so, how. She explained that Nina had arranged an agreement with Vladimir Sergeevich for Valya to pay him $150 and a few bottles of vodka. The payment would go to Vladimir Sergeevich personally and would not go through the
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hospital administration. I then asked Valya a question that turned out to raise a set of issues that provided many insights into the ways money was coming to inform ideological changes in the aftermath of the socialist era. ‘How did you feel about making these payments for health care? Do you think it’s right for doctors to take money for services?’ My questions alluded to the fact that paying physicians for medical care had been illegal during the Soviet period; a doctor who demanded money was viewed as engaging in the worst form of corruption imaginable – selfishly withholding humanitarian assistance unless he was compensated by personal, material gain.
This entailed a betrayal not only of Soviet laws, but of the Hippocratic oath and its universal ethics of professional and human morality. Yet when I asked Valya if she considered it appropriate to pay her doctor, she answered immediately and without ambivalence: ‘Oh, definitely,’
she asserted. ‘We have to get over that Soviet nonsense that people should work for free. I feel that I should pay, I have the money, and so it’s right that I pay for their professionalism and time.’
With this comment, Valya made the use of money significant symbolically. She defined paying for health care as a moral action that conveyed recognition and respect for the professional’s attention and expertise. Moreover, she equated a personal obligation to pay for services with the process of transcending Soviet-era values and modes of interrelating. Yet when Nina suggested that Valya pay Vladimir Sergeevich ‘$150 and a few bottles of vodka’, Valya sent the informal payment to the doctor through her friend as an intermediary. Nonetheless, both Valya and Nina considered this informal presentation distinct from earlier, Soviet-style informal exchanges: no longer an illicit act of ‘bribery’, it was now considered a ‘payment’, a proper and ethical compensation for a patient to offer.
In Valya’s understanding, paying for health care raised her integrity as a recipient of care, for by paying money, she was paying respect – both to her doctor and to herself. Acquiring new ways of relating to money and relating to people, she implied, are central developments for the creation of a post-socialist society.
Still, the unofficial way in which Valya accessed and paid for her services suggests that the ethics of such health care relations and payments are rather paradoxical: why was it necessary to go through an acquaintance, if official channels of accessing special levels of care were being established; why did Valya not wish to pay through official channels, at a cashier, where her payment would be direct and where she would get a receipt, and, most interestingly, why was it not ethically problematic to pay the doctor personally? In this chapter, I begin by exploring why familiar strategies such as mobilizing acquaintance relations are being combined with new practices, such as paying for services unofficially. I then examine how
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Rethinking Corruption in Post-Soviet Russian Health Care 49 patients and providers distinguish these monetary exchanges from earlier, illicit exchanges considered to be ‘bribes’. A new category has emerged to describe this relationship between a doctor and patient – lichnyi vrach – a personal doctor. The concept of lichnyi vrach implies that a personal agreement has superseded the official, institutional framework of state health care, that the doctor and patient share a degree of trust, and that the patient most likely pays the doctor personally and monetarily (unless he or she is a very close friend). I claim that such unofficial relations and payments should not be dismissed summarily as the incorrigible persistence of Russian ‘corruption’, as proof of the inability of Russians to comply with the disciplines of private enterprise and the democratic ‘rule of law’. Rather, these unofficial practices make sense as ethical forms of interaction within the broader context of institutional changes taking place in the post-Soviet era. As patients seek out informal relations such as the lichnyi vrach, they strive to obtain competent and professional treatment and also demonstrate their respect and gratitude for providers’ time and effort. The official framework of fee- for-service health care, however, is perceived to reflect the continuing injustice of Russian bureaucratic institutions – the ‘genuine’ source of corruption, where only higher-ups, not the ordinary person or provider, will benefit. Where official channels of payment are viewed as ethically problematic and unjust, patients often view unofficial payments directly to their provider as constituting important, moral forms of exchange.
INSTITUTIONAL CONSTRAINTS, PERSONALIZED SOLUTIONS:
A PATIENT’S PERSPECTIVE
Universal, free health care was a hallmark of the Soviet welfare system, but most women I met felt that the quality of care afforded by that system was severely compromised. Long queues and the need for a rapid rate of patient turnover meant that care was inconvenient and harried, and gave the clinic a factory-like atmosphere. Doctors were widely viewed as having neither the time nor energy to pay close attention to patients’ concerns. Women described the care available through official channels as an experience of being on a ‘conveyor’, given standardized diagnoses and prescriptions rather than being closely examined and understood individually, and often being vulnerable to providers’ ‘indifference’. Speaking of the dental care provided to her children at schools, one woman explained that ‘It’s traumatic and they don’t give good service at all – they must work so quickly, and they don’t care about you.’ Not incidentally, this woman was, herself, an obstetrician who worked for the state health system.
As a consequence of these inadequacies, women with acquaintances in
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health care tried hard to arrange care through personal channels. This is not to say that patients asked their friends for recommendations of ‘good doctors’, in the way that Americans, for example, do. When American patients seek out the care of a recommended physician, they generally do so through formal channels, by calling the office and making an appointment. By contrast, Russians who counted physicians among their personal friends asked these doctors to treat them, their relatives, and other friends, as a personal favour. And patients without physician acquaintances sought out kin, neighbours, and acquaintances who did, with the same hopes in mind. Such a connection allowed people to bypass official channels of accessing health care where they would be just another anonymous patient.
From the late 1980s and early 1990s, the Russian state public health care system began to permit hospitals to charge for elective services such as abortions, and for non-medical aspects of care, such as private rooms for childbirth. In this way, the realm of health care reflected broader economic and social transformations in Russia at large. In 1991 price controls ended, inflation soared and, within a relatively short period of time, a massive influx of goods appeared in stores, albeit at prices very few Russians could afford. Basic medical needs, including pre-natal care and childbirth remained officially free, but clinics and hospitals now had the legal right to offer services with official price tags, too. Market reforms thus granted money a pragmatic importance it lacked during most of the Soviet era, when personal relationships were the most important currency for obtaining items in short supply or for ensuring bureaucratic efficiency. For women without acquaintances in health care, money opened up a new strategy for trying to access improved levels of care beyond the state system.
Yet fee-for-service payment was not established evenly throughout the health care system; not all services could be purchased, and not all providers were able to charge fees. I discuss these constraints further below. At present, it is important to recognize that even when money was given in exchange for services, it was not viewed as a perfect substitute for all other kinds of offerings, and did not entirely replace them. When I asked Valya why she gave the physician vodka in addition to the money, she explained that it was a gift, conveying a sense of gratitude and, I would add, obligation. In other words, the gift offered a way of diminishing the sense created by the exchange of money that the services he provided were indistinguishable from any other commodity exchange: the care and expertise he provided as a doctor were different and special, and she wanted to thank him, not only pay him for them. Thus, despite the emergence of market reforms and the growing importance of money in daily life,
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Rethinking Corruption in Post-Soviet Russian Health Care 51 alternative forms of exchange, and informal modes of acknowledging and repaying debt, continue.
Additionally, while money had unquestionably become important in post-Soviet health care, many of those I interviewed stated that accessing paid forms of health care through official channels was not the most effective way of ensuring competent health care – and nor was it the most ethical way of conveying the payments.
The best tactic, people said, was to continue the familiar strategy of accessing health care through personal acquaintances, while paying these acquaintances unofficially for their work. Again, the use of money did not simply substitute for the use of personal relations; a universal currency did not make the perceived need for acquaintances obsolete. Instead, money became integrated into pre- existing patterns of accessing health care through unofficial channels of personal relations. The establishment of official payments at a kassa (cashier) was considered a new and improved option over the socialist requirement that all health care would be free and equal – which was taken to mean it would be equally impoverished and equally bureaucratized for everyone. But services paid for officially and through official channels of payment would not necessarily surpass the level of care one could expect from acquaintances.
In discussing this preference for paying physicians unofficially even when official administrative procedures for collecting fees had been established, Russians explained that official payments would most likely be consumed by hospital administrators, with the actual caregiver receiving at best only a small portion of the payment. It was common knowledge that physicians’ salaries remained very low, hovering at about $100 per month, while the costs of living a post-Soviet life had skyrocketed. And money was not merely a pragmatic necessity, either: having money had become an important marker of success and professional status. It was a symbolic means for conveying physicians’ high standards, competence, and public recognition. But the newly established channels for payment would not, it seemed, fulfil such needs of the provider. They worked mainly to legitimate the exchange of money for health care in an abstract sense. The creation of official prices paved the way for the use of money to be symbolically transformed from a ‘dirty’ act that tainted the doctor’s integrity, as it had been portrayed in Soviet times, to a ‘normal’, acceptable and even imperative kind of exchange. But because official channels of payment did not function effectively to provide the means for compensating the actual physicians who cared for a patient, Valya and others strove to ensure that the money would reach her doctor, and only her doctor, unofficially.
Day-to-day life thus involved both the struggle to fulfil one’s needs satisfactorily and to maintain a sense of integrity, to ‘do the right
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thing’. In seeking competent health care, Russians often expected to make payments. Paying unofficially could be considered ethical, morally clean and just, as long as it was given in an appropriate manner (see also Ledeneva 1998). Yet what was ‘appropriate’ had little to do with adhering to official institutional regulations or legal channels of payment. What had changed little since Soviet times was the view that institutions were still unaccountable to people’s needs – either as workers or as recipients of services – and that fulfilling one’s needs through the personal obligations of kinship and friendship continued to be an ethical means of action.
In this story of post-socialist change, my discussions with Valya offered insights into the perspective of the health care user. I find Valya’s comment interesting because of the ways she connected a new ethics of payment with the transcendence of the Soviet era – through her everyday practices, she was enacting different values from those associated with the Soviet era, and making new distinctions. The need to make unofficial payments was no longer considered an illicit act, nor were professionals who accepted them regarded in a negative light as corrupt. It had been transformed into a positive act that represented her respect for the provider’s efforts and expertise.2 For Valya, what remained ‘corrupt’ and unethical was the overall system of health care, the new bureaucratic structures of compensation and, more generally, the laws, rules and procedures of the official, Russian state.3
To capture more fully the significance of the moral shifts that have emerged with new, unofficial forms of payment in health care, I turn now to the perspective of physicians. The changes that have occurred in their perspectives and practices reflect substantial reconsiderations of the obligations and rights of a professional, and of the boundaries between ethical exchange and exploitation.
INSTITUTIONAL CONSTRAINTS, PERSONAL RESPONSIBILITIES AND ENTITLEMENTS
It is important to recognize that physicians trained during the Soviet era, more than many educated groups in that regime, considered their professional occupation a calling. This view was inspired by a range of cultural discourses: romantic images in Chekhov stories that portrayed the doctor as a beneficent authority in the community; the legacy of generations of physicians in families; and by the seemingly non-political nature of the work: for those disaffected by Soviet ideology and its imperatives to incorporate political commitments in all aspects of one’s life, medical expertise seemed to be a pure retreat to the objectivity of science and the humane work of relieving suffering.
Physicians’ sense of themselves as called to the healing profession is
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Rethinking Corruption in Post-Soviet Russian Health Care 53 often forgotten in much of the scholarly literature on Russian health care, which has tended to describe the pervasive problem of ‘bribery’
(Cassileth et al. 1995). The notion of bribery in such accounts is used to characterize all informal activities as illicit, corrupting practices, and fails to capture the complex varieties of informal exchange that took place, or the discrete purposes they served. These accounts lead us to imagine that bribery is a clear-cut practice, undertaken directly and with no ambiguity; that health care providers have no ethical quandaries about violating their professional code of ethics and are motivated by economic interests alone – as if the quality of physicians’ interaction with patients has nothing to do with the integrity of their professional identity.
My argument is not that no physician in Russia ever demanded a bribe, but that such acts were the exception rather than the rule. What was more common was the practice of blat – providing special services to patients with connections. Karina, a member of the housekeeping staff at the hospital where I did much of my fieldwork, described the following types of informal relations for accessing special care:
First, of course, is svoi liudi [one’s own people]. That’s not blat at all but my daughter, my close friend. They will be treated as one’s own relative. Then you have blatnyi doktorov – acquaintances of acquaintances of the doctor. Midwives and other personnel won’t feel any obligation to treat them specially. Then you have blatnyi administratsii – acquaintances of the hospital administrators.
They will be given a degree of special treatment, everything will be done officiously and painstakingly, but there will be no warm, caring feelings. Then you have blatnyi for the maternity hospital itself – people who must be cared for well because they have the power to close the hospital down.
This typology and my fieldwork experiences indicate that most physicians undertook informal exchanges with patients not primarily for economic interests, but for social ones: informal exchanges were embedded in larger relational contexts, and thus served to communicate sentiments such as professional respect and dignity, or, on the other hand, suspicion and disdain. The privileges that physicians wanted to offer through informal relations were privileges that they perceived would enhance, rather than threaten, their professional legitimacy. As the free, state system unravelled further in the late 1990s, money became more acceptable in the eyes of providers. Many labelled it expected compensation for their informal services. Yet, even then, money was important for its symbolic no less than its material power.
I begin with ethnographic accounts of interactions I witnessed between providers and patients in 1994 and 1995, when monetary exchange was illegal and ethically taboo. What we see in these examples is that the issue of informal compensation was highly charged and emotionally fraught for providers, who interpreted
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