State retrenchment and informal institutions in Kazakhstan: people's perceptions of informal reciprocity in the healthcare sector

Abstract

Despite government efforts, post-independence Kazakhstan has largely failed to provide high-quality medical services to its population. State retrenchment in the public healthcare system has led to the deterioration of medical service delivery. It has provided incentives for people to widely use informal reciprocal exchanges – personal connections and informal monetary and non-monetary payments – to gain access to better medical care. In contrast to the existing explanations focusing mostly on the cultural origin of the continuity of informal exchanges, I argue that state retrenchment from the social sphere and under-provision of state goods and services have perpetuated informal exchanges in post-Soviet Kazakhstan. Despite similarities in informal practices between Soviet and post-independence Kazakhstan, some important differences in terms of scope and the nature of informal exchanges are observed. This article draws on data collected from interviews, textual analysis, and original surveys of people's attitudes towards the healthcare system and informal help conducted in Kazakhstan in 2011 and 2013.

Keywords:

• informal payments
• healthcare
• state retrenchment
• post-Soviet
• Kazakhstan

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. The territorial administration of Kazakhstan is divided into four levels: republic, oblast (region), rayon, and village.

2. For comparison, in the UK it was 13 per 10,000; in the USA, 19 per 10,000; and in Sweden and Denmark, 24 per 10,000.

3. Yevgenii Chazov was a minister of health in the Soviet Union from 1987 to 1990. He was also the chief of the Fourth Directorate of the Soviet Ministry of Health, which was in charge of the system of ‘closed’ clinics and hospitals for Soviet leaders. Y. Chazov was widely regarded as the person responsible for the health of the Soviet leadership.

4. N = 2793.

5. It has been estimated that only 37.5% of rural healthcare organizations have medical equipment.

6. This means that a one doctor has to fulfil the functions of two different medical specialists. For instance, a general physician may also perform the functions of an endocrinologist.

7. N = 700.

8. Author's survey, 2013, Kazakhstan. After devaluation of tenge in February 2013, the amount is $55.

9. Ledeneva defined four different types of needs when Soviet citizens used blat. Regular needs included foodstuffs, clothes and household goods. The second type of needs was travel tickets, health resort stays, and holidays. Housing, hospitals, schools, kindergarten and jobs belonged to lifecycle needs. The fourth type was the needs of others (Ledeneva 1998, 118). In a system of shortages, people had to develop extensive networks with others to get access to rare commodities. In the post-Soviet period, the term blat is not used as often as it was in the Soviet period in Kazakhstan.

10. Author's survey, Sept.–Nov. 2011, Kazakhstan.