Rethinking problems surrounding access to care: the moral economies shaping health care workforces in Russia and the USA

Abstract

The first conversation excerpted above took place in an era when for-fee provisioning of health care services was first being established as a central feature of Russia’s broader, post-Soviet health care reforms. The second statement took place over a decade and a half later in the United States, just months after the Congress passed and President Obama signed historic legislation mandating comprehensive health care reform aimed at increasing coverage and affordability. Despite their separation in time and space, these excerpts reveal a common cultural contradiction that plays out in contexts of market-oriented health care. These two health professionals simultaneously confirmed and rejected an approach to the exchange of health care as analogous to the exchange of any other consumer service, an approach captured in the aphorism ‘you get what you pay for.’ When the Russian clinic chief backtracked to assert, ‘I can’t do bad work,’ she implicitly contested the widespread assumptions in health policy circles that physicians’ ‘interest’ in the outcomes of their work is derived solely from how well they are paid.1 For Valentina Pavlovna and many Russian doctors, at stake in the issue of whether women who paid actually obtained a superior quality of care was nothing less than their sense of professional pride and dedication. She had spent her entire career in the Soviet socialist model of free and universal health care, which charged physicians with the obligation of providing competent care to all patients for free as a matter of professional integrity. Yet she was reincarnating her clinic based on the popular notion that physicians’ expertise and dedication was only available if bought.2 Still, when asked directly about whether she endorsed inequalities of care based on ability to pay, she found herself unable to condone this practice as ethically acceptable. The US dental student’s statement is telling in that he phrased his perspective through caveats – ‘I’m not saying I’m like that, or anybody else in here is … but [the get-what-you-pay-for mentality is] kinda ingrained in people when they purchase anything.’ Implicitly, he denied that, as a health care professional, he would provide compromised care to the poor – an admission that would seem to violate professional integrity if not also formal ethics. Yet at the same time, he suggested it would be reasonable for health care users to expect to receive worse quality care if they obtained those services for free or through reduced fees. Health policy planners and analysts would do well to contemplate this ambivalence characterizing the relationship between users’ fees, professionals’ integrity, and the presumed unequal quality of medical care. This ambivalence, I will show, stems from mixed cultural messages and uncertain criteria about entitlement, or about what different groups of physicians and patients are seen to deserve. Tacit understandings about entitlement are linked with actors’ expectations of their own and others’ obligation and responsibility; these understandings in turn shape the kinds of claims perceived as legitimate, and the resulting silences that characterize certain kinds of need; they also work as logics shaping the ways providers conceptualize their career choices and daily work practice. Indeed, cultural visions regarding various groups’ legitimate scope of entitlements and their related responsibilities stand in relation to each other in a systematic way and shape daily practice. Anthropologists refer to this interrelated set of concepts and practices as moral economies, or ‘consensual assumptions about reciprocal obligations’ (Minkler and Cole 1997: 40), understanding ‘economies’ here to involve the circulation of goods, both material (such as money and benefits) and non-material (such as dignity, integrity, entitlement, and social standing) – and noting how these various types of goods are often intertwined. We analyze the ways in which moral economies serve as the implicit conceptual backdrop against which certain cultural practices are reproduced without question as ‘the right thing to do,’ while other practices may be protested against as representing betrayals of justice or the violation of fairness (Thompson 1971). My goal in this chapter is to introduce the framework of moral economies to the study of health care policy planning and analysis in Russia and the United States. More specifically, I suggest that efforts to improve access to care by addressing physician workforce issues have not adequately conceptualized the ways health providers’ experiences, aspirations, and strategies are embedded in moral economies that define (if ambivalently and with contradictions) professional and patient entitlement and obligation. Examining the moral economies of health care and professional work through which providers in Russia and the United States make sense of their career decisions and daily practice will bring new and important insights into the challenges of increasing access to underserved populations. Both Russia and the United States have great needs to extend access and improve the quality of health care. The particular characteristics of these two countries’ health care systems and system needs are dramatically different: whereas Russia’s problems of access stem from gaps in what is supposedly a universal model of free health care, the USA’s system of work-based insurance structurally ensures that tens of millions of citizens will face barriers to access because of lack of health care coverage.3 Russian health care reforms have focused on introducing new financing mechanisms while facilitating the emergence of private and semi-privatized services; in the USA, contrastingly, new health care reforms aim to extend insurance coverage and enhance the capacity of community-based, publicly funded clinics for rural and urban residents excluded by the market-based, private health care system. While these differences are immensely important, it is also notable that, in both contexts, workforce issues entail a key part of efforts to address existing needs. In particular, health planners in both countries recognize that access and quality of care are intensely affected by the situations and actions of physicians. Yet in neither context do planners recognize how physicians’ entanglement in access and quality of care issues is related to the moral economy of health care. This essay highlights the ways Russian and US physicians’ career decisions and daily practices regarding patient access to their services are affected by culturally shaped notions of professional entitlement and patient worth, as well as the perceived symbolic worthiness of particular sectors of health care vis-à-vis the system as a whole. All of these are dimensions of the moral economy of health care. The section that follows examines the ways Russian health policy planners and analysts have defined (and ignored) problems of access as they set about reforming their contemporary health care system. Mainstream discourses emphasize that barriers to access stem from doctors’ demands for illegal payments from patients; and reforms focus on raising physicians’ salaries. I then draw on my fieldwork, and more recent doctors’ blog-postings, to argue that low salaries alone do not explain physicians’ willingness to demand payments from patients – physicians draw on cultural and symbolic understandings of how medical work is and should be valued; they make social assessments of what kinds of persons they are treating, what kinds of care these patients deserve, and what these patients should offer in return for medical treatment. Such culturally embedded calculations, which often remain tacit or discussed through providers’ jokes, stories, and the like, play a significant role in shaping the tenor and character of professional work. In other words, improvements in access and quality do not result mechanistically from increased funding and higher salaries – because material issues alone do not capture the notions of entitlement and responsibility through which physicians make sense of their daily work practices. We need to see material remuneration as part of the broader symbolic messages that the state and patients communicate regarding the value of medical work and different forms of expertise; in turn, the actions of physicians can be seen as commentaries on the varying social worth of different patient groups, the perceived legitimacy of certain kinds of diseases, and their sense of what experts owe to patients, the state, and themselves. I then turn to the US context, where health care reforms aim to promote physicians’ and dentists’ willingness to work in primary care and with underserved populations. Obama’s reforms increase the funding for, and work opportunities in, primary care as a way of recruiting new graduates, while medical and dental schools undertake programs to cultivate students’ commitments to ‘communities’ and ‘service’. Yet public health clinics not only pay less, they also represent lower symbolic value relative to private practice. Market-based health care orients itself to the interests of consumers – those who pay for care – whereas recipients of public welfare services are deemed ‘failed consumers’, expected to be grateful for charity and not entitled to make demands. My fieldwork with dental students reveals how the disparate social worth of private and public clinics, their populations, and the meanings of work in each sphere get conveyed to new practitioners in training. Although committed faculty struggle to insist that under-served populations deserve high quality care, the structural organization of health care often confounds this message. Increased funding and pedagogical attention to the plight of the underserved importantly acknowledge the country’s gaping inequities, but these reform efforts do not substantially subvert the moral economy of market-based medicine; such radical change would require the cultural acceptance of dramatically new calculations of clinician entitlement and the social worth of public health – a vision of clinicians as indebted to society for their training and opportunities, and a notion that all patients, regardless of social background, are entitled to high-quality services and dignity. The issue of health care access – ensuring that all patients who need medical care can receive it – is complexly intertwined with the transitions from a Soviet health care model to a post-Soviet one, whose financing procedures and legal guarantees are still being worked out some two decades after the collapse of the socialist system. Health care reforms are currently an official state priority, one of the 2006 National Projects that Putin established to reform governance and bring legitimacy to the state in the wake of several decades of massive cynicism towards decaying government services. The 1990s had witnessed an unprecedented public health crisis, characterized by skyrocketing rates of premature male mortality, plummeting fertility, the alarming spread of infectious disease, from tuberculosis to HIV, and more. While these indicators reflected the simultaneous confluence of multiple socio-economic disruptions and rapid cultural transformations, the Russian government also attributes part of the health care crisis to the poor funding and poor performance of the health care system itself (Ministerstvo 2009).4 Citing the ongoing declining population numbers and extraordinary high rates of mortality, throughout the 1990s conservative and nationalist critics of market reforms accused the Yeltsin government of causing the ‘genocide’ of the Russian people, which, they claimed, was ‘dying out’ due in part to widespread unemployment, poverty, and a loss of social stability and values. Following this era, Putin built widespread legitimacy for his administration, in part through funneling portions of state revenues from higher oil prices into tangible benefits for citizens, especially through the partial revival of the state’s withered system of social support. In the National Project for health care, these investments included increased funding to improve primary care, raise health care providers’ salaries, build new medical clinics, and develop innovative methods and technologies – all represented as significant initiatives to improve the quality and accessibility of medical care (Antonova 2007: 191). Given the fact that the Soviet health care system had one of the highest ratios of doctors to population in the world and a system of universal coverage, it is somewhat ironic that the country has been and continues to be plagued by serious problems of access at present. My ethnographic research and analysis of health policy debates in the 1990s found that barriers to access were created not only by financial need, but by pervasive cultural dynamics too: providers evaluated patients’ social worth by assessing their apparent education and ‘cultural level’, as well as the type of condition patients had. Even at present, patients with HIV and other STIs face shaming and prefer to seek care at specialized AIDS centers rather than mainstream clinics (Bendina 2009). Exclusionary tactics against those deemed to have a ‘low level of culture’ are common, with the result that patients who felt berated distrusted the medical professionals and were reluctant to use their services (Rivkin-Fish 2005). Rusinova and Brown (2003) found that access to care depended on the networks and social skills that patients were able to deploy to maneuver around bureaucratic obstacles and pervasive mistrust. Patients’ strategies, and their success in obtaining high quality services, differed according to their social strata and the related social and cultural capital they could mobilize. My research further explored the specific ways in which patients’ strategies and networking affected providers’ sense of personal obligations to provide especially attentive care. Close acquaintance relations facilitated access not merely to medical services, but even more importantly, to trustworthy, satisfying relations with providers. The acquaintance relationship in turn helped physicians, as they were more likely to have their expertise acknowledged and valued when they shared a personal connection with patients (Rivkin-Fish 2005). Certainly, personalized relations compromised the possibility of equity in health care; yet the perceived ethical character of these relationships, and the kinds of (inadequate) solutions they achieved to the problems of mutual distrust and enmity between doctors and patients, have not been addressed in policy debates, which often caricature these relations as simply exploitative and extortionist. Until the late 1990s, many Russian health providers expressed great ambivalence about the introduction of fee-based health care, seeing required monetary payments as unethical and creating compromises in professional integrity. Physicians trained during the Soviet era described entering medicine as a calling, an arena in which scientific knowledge could be applied in an apolitical career that provided humanitarian-oriented workers with the satisfaction of saving lives. The financial remuneration was less than in other professional fields, but the sense of mission was invaluable. Yet, as Russian society underwent broader shifts driven by the profoundly transformative ubiquity of consumer culture, professionals began to redefine cultural expressions of self-respect, and their expectations for a dignified middle-class lifestyle transformed: markers of success (or failure) now became read in the clothing one wears, the mode of transportation one takes, the holiday destinations one chooses, the state of disrepair or remodeling of one’s apartment. The significance of one’s professional occupation became increasingly interpreted on the basis of whether it enabled culturally emerging aspirations to consume expensive goods. Male physicians told me their marriages were threatened because they were committed to practicing medicine in public hospitals and not demanding money from the poor; women physicians described being able to continue with their career only because they had ‘rich’ husbands who agreed to support their ‘uncompensated’ calling. Many worried about how they would fund their children’s higher education as tuition payments were becoming more common. The economic crisis that medical professionals confronted was thus experienced as at the same time a piercingly unjust material deprivation, a traumatic source of life-altering interpersonal loss, and a cruel attack on the social value of their professional role. The focus of health care reforms as early as 1993 centered on creating new financing models that would decentralize and shift the flow of resources away from the state as a monolithic funder. Policy makers roundly celebrated ideas of competition, fee-for-service, and salary differentiation for performance as solutions to the problems created by the Soviet system, almost never considering how market mechanisms in health care would affect access to care for the poor and socially marginalized or providers’ own well-being. A brief examination of the actual realities wrought by this new financing model reveals both the ideological character of these reforms, and their narrow, mechanistic understanding of the social dynamics that shape access to care. In the new financing system, employers and municipal governments were required to make contributions to quasi-governmental health insurance funds (OMC). Each of Russia’s eighty-nine regions (except Chechnya) has its own fund, a situation that contributed to decentralized policies and significant variation across the country. The employer payroll tax for medical insurance of workers was set at 3.6 percent, an amount that both insurance fund directors and chief doctors decried as severely low, as reported in Judyth Twigg’s survey conducted in 2000 (2002: 2260). Municipal governments made contributions on behalf of the non-working population. They determined their payments on a per capita basis, with the amount decided by each individual region (Twigg 2001: 204). The federal government was also to continue payments to health care, but the amount was small and expected to gradually diminish as an overall percentage of health care financing (Curtis et al. 1995: 760). In the year following Russia’s financial crisis of 1998, the funding for health care as a proportion of GDP dropped by 30 in to in by it had to of GDP (Ministerstvo the per capita paid by regions was the actual throughout the Russian from a low of per capita paid in the of to a high of per capita in (Ministerstvo In the early that, in many the funds were with private insurance is to the of patients and quality (Twigg Even at that time, doctors and other critics the of insurance funds and private insurance which represent an of have been expressed that these were payments for the health care system for personal in In somewhat that insurance to be facilitating the of insurance but the mechanisms and that employers were not the amount they Indeed, to reforms as early as et al.