Personal ambivalence and systemic oversight, an entry on the Romanian healthcare system

The nightclub fire that sparked a national fight

In October 2015 the Colectiv nightclub fire in Bucharest not only uncovered the extent of corruption in the public system, but also rallied the population in what seemed to be a nationwide struggle to bring about good governance. While initially the public discontent was centered around the crony contracts and circumventions of health and safety regulations that led to the tragic deaths of thirty two people and the injury of over a hundred others, as events unfolded, Romanian society grew nothing less than enraged at the apparent extent of the issue. Since then, one of the most salient problems of the Romanian public system -inefficient healthcare provision- was brought to the forefront of both the media and public discourse. The discussion was initiated by the inability of hospitals to deal with the aftermath of the fire. In this entry I will argue that the public healthcare system is the ideal lens through which to analyse both corruption and informality in Romania, due to both practices taking place within this context. Moreover, I will argue that as long as corruption persists, regular citizens will continue to employ informal means of procuring medical services due to what has been referred to as moral ambivalence.

Corruption

The Romanian healthcare system is highly centralised and under the aegis of the Ministry of Public Health, which directs policies, funds and management. Not only this, but the institution is also in charge of controlling corruption and fraud within the health system, leading to a vertical centralization model that increases payoffs and decreases welfare (Echazu and Bose, 2008). There are plenty of examples of hospital managers, doctors or just regular employees abusing the system in accordance with the classical definition of corruption: redirecting public funds to line private pockets. The phenomenon manifests in domains ranging from public acquisitions, medical services, hospital budgeting to hiring personnel and distributing medicine, said the former head of the National Anti-corruption Agency (DNA), Laura Codruta Kovesi. One such example is a hospital director that took advantage of the lack of checks and balances in constructing the budget for his unit and managed to embezzle millions of Euros in a span of seven years. Cases like this one appear in the national media frequently and have multidimensional effects. First of all, they contribute to the overall low standard of service. On one hand, fraudulent contracts and misdirection of funds by corrupt officials cause medical school graduates to seek employment abroad, many of them feeling unable to profess their duties in those conditions. This not only affects the quality of services, but also their accessibility, one Romanian news agency reporting that at the beginning of 2017 a third of state hospital jobs were vacant. On the other hand, this often leaves people with few options when accessing services, and while there have been grassroots campaigns meant to address the shortcomings, for many, offering bribes to doctors and nurses often seems like the only option. Second of all, diminished trust in the medical system and inadequate service provision encourage informal practices as a 'coping mechanism'.

Ambivalence

It is hardly surprising then, that while conventional forms of corruption are almost universally frowned upon by the public, informal payments and favours are subject to less scrutiny. The former category is conducted by 'them', the 'corrupt elites', always with malintent. About the latter, over 40% of respondents in an opinion study that admitted to offering money or gifts to various medical staff categories justified their act as to access better service (Farcasanu, 2010). The necessity fulfilling function of informal payments translates into moral justification: even if people tend to be against them in principle, when they are in a situation when it becomes necessary for them to offset official hospital procedure, they will (Moldovan and Van de Walle, 2013, p. 6). Therefore, as service standards remain low, incentives to rely on informal payments will remain high. Moreover, perceptions of on one hand, managerial corruption, and on the other hand, the spread and social norm status of informal payments, also have a positive relation to reliance on informal means. Due to increased media attention to corruption and the general praise of the multitude of convictions by the anti-corruption agency, awareness of the extent of the problem has increased, which can have the unfortunate side effect of enforcing the perception that the system is 'too corrupt' and that it is unlikely to change for the better, therefore people resign themselves to informal payments (Moldovan and Van de Walle, 2013, p. 22). Moreover, the justification of 'everyone is doing it' is prominent in multiple studies analysing informal payments, thus fortifying the role of informality in the health system (Farcasanu, 2010 and Moldovan and Van de Walle, 2013).

Civic failure

While tens of thousands of Romanians gather to protest against increasing levels of corruption, crony politicians and unsatisfactory public services, external opinions of the overall impact are not optimistic. While the fact that at a national level corrupt politicians rely on patronage networks to maintain power and officials subordinate contracts to political interests often results in terrifying situations, such as thirty three victims of the Colectiv fire dying in hospitals due to bacterial infections caused by diluted disinfectant from fraudulent providers; personal responsibility for the bleak state of affairs has been lagging behind. Due to both perceptions and facts of the formal system, people still rely on informal payments to access healthcare, which in turn, perpetuates existing norms and further damages quality of service. Therefore, without efforts to change popular attitudes and norms, lasting social change is unlikely to happen, and better healthcare provision requires effort from both government reform and individual actions.

Word count: 964

Cited sources:

Bose, P. and Echazu, L. (2018). Corruption with Heterogeneous Enforcement Agents in the Shadow Economy. Journal of Institutional and Theoretical Economics, 163(2).

Farcasanu, D. (2010). Population perception on corruption, informal payments and introduction of co-payments in the Public Health System in Romania. Management in Health, xiv(1), pp.8-13.

Moldovan, A. and Van de Walle, S. (2013). Gifts or Bribes?. Public Integrity, 15(4), pp.1-26.