From Informal Exchanges to Dual Practices. The Shadows of the Romanian Health Care Reform

Abstract

The current frailties of the Romanian health care system are often explained by resorting to the previous regime’s institutional framework, rarely accepting that they are also the product of post-1990 reforms and the neoliberal means of system reconfiguration. This paper provides an ethnographic account of the ways in which two “products” of these reforms actively contribute to the augmentation of private medical services and to the diminishing access to quality care in the public system: the bureaucratization of primary medicine and the “dual medical practice”. More specifically, I use the concept of “informal exchanges” in order to explore the variety of transactions that occur between patients and the health care staff and to document the means through which its main social actors understand, reproduce, legitimize or blame the very existence of these practices. Then, I analyze how referrals to private medical units increasingly replace informal payments, simultaneously laying even harder obstacles in the access to health care for those in need.

Global Problem of Physician Dual Practices: A Literature Review

“…Italy (1,3,10,33,37,42,43,45,57,60,63),Kosovo (64),Latvia(65-67),Lithuania (46,47), Macedonia (68)(69)(70)(71),Malta (46,47,72,73), Montenegro (52,70,74),Netherlands (33,42,57,75,76), Norway (1,4,33,37,43,45,57,77,78),Poland (33,46,79),Portugal(1,2,4,33,37,42-45,63), Romania (46,80),Serbia (52),Slovakia (46,(81)(82)(83),Slovenia (33,47,…”

Semantic Ambiguities and Classification Struggles in the Post-Socialist Informal Medical Economy

“…The plethora of articles, old or recent, whose stake is the definition and taxonomy of informal medical payments (Lomnitz, 1988;Ensor & Savelyeva, 1998;Lambertini, 1999;Thompson & Witter, 2000;Balabanova & McKee, 2002;Ensor, 2004;Sharma, 2005;Gaal et al, 2006;Savedoff, 2006;Lewis, 2000;2007;Liaropoulolos, et. al., 2008, Vladescu et al, 2008Stepurko, 2010;Stan, 2012;Baji, 2012;Palaga, 2015;Williams et al, 2016;Najar et al, 2017) avoids questioning the economic strategies and specific political agendas that dictate the use of one meaning to the detriment of another. The importance of the targeted choice of a certain definition of work for those payments made outside the institutionalised channels should not be underestimated, the practical consequences of establishing a discursive order on the informal medical economy being substantial.…”

A five-year (2017–2021) time series evaluation of patient-reported informal healthcare payments in Romania

“…The low public spending on health in Romania has led to the widespread dual practice of physicians working in both the public and private health sectors, allowing doctors to open their private practices for higher income. Palaga describes the dual practice as “triggering power relations that lead to exclusion and layering,” with patients from public institutions redirected to private clinics [ 18 ]. Through dual practice, informal payments are replaced by referrals to the private sector, where the treating physician is either a practitioner or shareholder.…”

“…Through dual practice, informal payments are replaced by referrals to the private sector, where the treating physician is either a practitioner or shareholder. People pay extra in private practices for health services they are entitled to under the public system [ 18 ]. In essence, informal payments are “formalized” via the physicians’ dual practice.…”