Expression of interest A cross-country evaluative approach to corruption dynamics in hospitals from Romania and Greece\Poland, and Denmark.

Description of the project: The research aims to use anthropological fieldwork and methods in order to establish a deep comprehension of how corruption practices are constructed and sustained in the medical system. The stakeholders are young resident doctors and patients and the fieldwork will be conducted in hospitals from Romania, Greece and Denmark. It is an evaluative approach because there is a very definite and identifiable intent, both at the national level and at the European Union level, to deter corruption. This has taken the form of anti corruption policies, codes of conduct and the creation of institutions that have prerogatives in controlling and penalizing corruption acts. Post communist Romania and post crisis Greece distribute important resources and efforts into changing their practices in the public sector. The research aim is to evaluate how ethics in the anticorruption policies are reflected at the social interactions level, how different valorization of bribery are mapped and legitimized or stop from being legitimized in the health system. Research questions 60 % of Romanians have said that they are ready to react to corruption and to take some kind of action in stopping it. Having this as an analytical starting point, we would like to explore how the general ethical discourse materializes in peoples actions when they enter in/ interact with the health system. The questions that the research poses are: What are the ways in which corruption alters, disturbs and influences the hospital as an institution, as a functional flow of people and a space where doctor-patient intimacy and trust form? What affects are taking shape in the interplay of fear of disease and dying and the leverage that doctors have when performing a medical procedure. How is corruption a differential characteristic of the organisational culture in the hospitals from the three countries?

Summary of the team research expertize

Summary of the team research expertize The current team members have a background in anthropolgy studies and have gradueted MA in Anthropolgy at the National School of Poltical Science, Bucharest and BA in Jurnalism (Andreea Visan), Literature Studies (Diana Necura), and Sociology (Eliza Lefter). Eliza Lefter is a current Msc student in Anthropology at the University of Copenhagen. Our research interests concern adaptation, vanity, conservation politics, transhumance, nomadism, religiosity, migration Extensive anthropological research in the village of Cajvana, in the North Eastern part of Romania, on patterns of migration and their economic effects on households and social effects on children left behind. Our main focus were the social transformations due to the integration in the European Union and labor force demand in agriculture and construction in Serbia and Italy. The research consisted of participant observation, interviews with family members in the households in which adults were migrant workers, drawings of maps of the houses that were built using the most part of the money produced by migration.

A visual anthropology research on religiosity and secularism adaptation of the evangelical three churches from Copenhagen. The result was the short documentary Someone Elses Church.
Conservation politics and their impact on the peasants traditional practices
Study developed under the tutelage of University of Bucharest and coordinated by Monica Vasile (PostDoc Research Fellow at Max Planck Institute for Social Anthropology). The research was held in two communities in the proximity of two "National Parks" from Romania and its objectives were to establish how the environmental conservation policies affected the community and how the locals perceived National Parks and the respond to the conservation restrictions. (Project participant: Eliza Lefter)

Integration of the Roma minority through the traditional labours Research developed for Romanian Quality of Life Research Institute, Anthropological Research (Project Participant: Eliza Lefter Study of remains of "transhumance" practice among locals from Vaideeni village, Valcea County. Study developed under the tutelage of University of Bucharest and coordinated by Monica Vasile (PostDoc Research Fellow at Max Planck Institute for Social Anthropology). (Project Participant: Eliza Lefter)

Objectives The outcomes of our research are intended to contribute an in-depth understanding of corruption, the rationalities of social actors that enroll in this practice. That can facilitate a future insertion of these rationalities in the design of anti-corruption strategies.

Research context and contribution to the Research field In 2006 a World Bank review stated that anthropological studies covers only 2% of the corruption thematics. This was pointed out by Davide Torsello in his article about the need of ethnographic contributions to the study of corruption (Torsello, 2011), arguing that corruption is a social practice and it demands an ethnographic approach that will complement quantitative studies of this subject from the last two decades. We subscribe to his argumentation and propose a study that goes further than the description of the damages produced by corruption and illustrates better how this is internalized and accepted by social actors. Brief description of the starting context Studying the perception index of corruption in the three countries helped us have some basic understandings about the degree in which corruption permeated the medical system in the three social contexts. Some discrepancies and variations that can be found in some quantitative studies were the starting points in establishing the stakeholders, and the extent to which we could be able to develop a strategy that makes use of qualitative methods. Research published by Transparency International places corruption in the medical system in the EU at a 3,2 level on a scale of 1 to 5, lower than in other segments of public or private sectors At the same time the medical system is seen as the most subjected to bribery, with 12% of European citizens admitting to using bribery in the past year in direct contact with the medical system. The level of bribery in Denmark is almost insignificant, of 1%. In Greece it reaches 23% and in Romania 27%. In 2013 one in five Romanians admitted to having given bribes to hospital staff. The reason that most people gave in Denmark for using bribery was to get a cheaper service, because it is the only way to get a service in Greece and as a gift or as a way to express gratitude in Romania. There is a noticeable variation in corruption perception year by year. Denmarks scoring was 9,94 in 1997 and a perfect 10 in 1998, then fell to 9.5 in 2001, and after a few years, in 2012, even though it was still the highest ranking country in the Index, danish peoples perception had a value of 9.0. Greece started at 5.35 in 1997 but from then on corruption seemed to be seen as more and more present, and in 2012 Greece was one of the most corrupt countries in Europe with an index of 3.9. In the case of Romania in 1998 the rating starts going down from 3.44 to 3.0, even further down in 2001, to 2.8, but an improvement is felt right after the country became a member of the European Union. In 2012 the scoring was better than in Greece, at 4.4. There are worldwide variations, as it happened in 2001, when the report of

Transparency International stressed that: There is a worldwide corruption crisis. That is the clear message from the year 2001 Corruption Perception Index. And there are local factors, such as the EU membership mentioned above, that can create a variation. Political and economic factors have an input on perception, if not in actual behaviors and norms related to corruption. These changes have to be correlated with cultural values in the three countries, the cultural reproduction of acts of corruption and their explanation in society, and political and economic stability. Research of the literature Because it is considered one of the major parameters of good governance, corruption is researched and measured constantly, especially in developing countries, where public and private, national and international funding is concerned. National and cross-country surveys have the purpose of indicating the degree of relative success or failure of anti corruption policies applied in specific ares of the public sphere, including the health care system. The World Bank and Transparency International surveys offered very helpful data for assessing the general levels of corruption, general perception and the variations that provided an idea of progress or regress, with explanations and implications that need to be researched further. Other helpful data that we collected comes from a series of articles and working papers on corruption in health care in the developing countries. We will cite some of the observations in the working paper Governance and Corruption in Public Health Care Systems written by Maureen Lewis for the Center for Global Development, a synthesis that confirmed some of the empirical observations that we drew from our experience with a widely spread and widely acknowledged corruption in the Romanian health care system. Lack of management and managers reluctance to confront physicians inspires lower level workers to behave accordingly, leading to high absenteeism and low productivity at all levels (p. 19) Therefore we chose resident doctors as stakeholders in order to capture, through the writing of journals, the process of adaptation to a milieu to which corruption in the form of informal payment was an essential part. Where both large household surveys and smaller studies exist for the same country, the latter always shows higher informal payment. Whether this is due to the greater attention to the issue with dedicated surveys and smaller samples that allow drilling down sufficiently to obtain reliable information on a sensitive subject, or other factors, it suggests that some of the broader surveys

underestimate the extent of patient payment. (p. 27) We hope that the methods and the approach that we will use will prove to be the next step in these efforts of providing a more detailed image, not only of the measurable elements, principles and values of corruption but also of the dynamics involved in its production and reproduction. Using focus groups of patients and providers Sahriari, Belli and Lewis (2001) explain the virtual market for publicly provided care in Poland. Informal payments have become the way to obtain services of specific physicians, with prices reflecting reputation and demand. It is an implicit form of insurance for possible future needs and prices are commonly known. Thus the process of negotiation and payment for health services may be informal but it has become a very sophisticated market in Poland. (p. 30) This sophistication takes into consideration among other things the reputation of the doctors, the complexity of the procedure, the types of care for which payment is demanded, the type of personnel involved. Information flows freely and is available inside and outside the hospital and we believe that using anthropological methods will help the research by collecting and converging as much of this data as possible. Research Methodology The research will gather data using anthropological instruments, and the analysis will be made based on participant observation, journals kept by patients and resident doctors, interviews with other doctors and nurses in the hospitals that will be a part of the fieldwork, and case studies of corruption reported by the media. Participant observation will be used to identify the vocabulary of corruption, where it can be found, and the patterns in formal or informal interactions between patients, between patients and doctors, between young doctors and more experienced ones, and with the nurses, that can be related to corruption in the functioning of the hospital as a public institution. In the countries that have a history of corruption we believe that it is important to go beyond the functional descriptions and the ways in which policies tend to be applied. The research that we propose is concerned with whether localized forms of corruption can be at the same time tools of adjusting social and cultural pressures, or of balancing the high symbolic value that is assigned to the medical profession and the low level of wages in the public sector. Cross country approach

Places in the medical system are perceived, in Romania and Greece especially, and at the European Union more general level as well, as microclimates that integrate corruption practices, most often in the form of direct bribery. The variations in the perception of corruption indes demonstrate that increases and decreases in corruption values are not adherent to a coherent trend or a specific direction. Critical downfalls can occur even in the cases of countries that were seen as part of the developed world, as it happened with Greece, which is now considered a failed state from a wide variety of indicators, including corruption. The purpose of an analogue research in Denmark is to provide a benchmark for the functioning of a hospital in which corruption is seen as almost inexistent, so the influence that it has in the medical system as process, as in the case of in Romania and Greece, is not present.

Challenges and risk mitigation Corruption is a delicate subject, pushing the boundaries of the informal into the illegal and of gratitude into pressure. Access to stakeholders might be hard at the beginning and their selection, dispersion and number is of utmost importance if we want to be able to generalise and conceptualize our findings. Also, because of the methods we are using, we need to be very careful about the triangulation of the information gathered, using multiple sources and/or multiple methods to verify the data. Bibliography Lewis, Maureen 2006, Governance and Corruption in Public Health Care Systems, Working Paper, Center for Global Development, (January) Belli, P., H. Shahriari, and M. Lewis. 2001. Institutional Issues in Informal Health Payments in Poland: Report on the Qualitative Part of the Study. HNP Thematic Group Working Paper, World Bank. (February).