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Keywords: Morocco; Middle Class; Social social work [faire le social]. Sometimes, Action they want us to charge for consulta- The Politics of tions. But when I see that patients can’t Social Action in Introduction pay, I don’t ask for the fee. They, the ad- About a year before she resigned, the ministrators, want the money but that Morocco head of a paediatric unit at a public teach- isn’t my profession, it is not the way I ing hospital in Rabat told me, “I recognise see things. my limits. I can’t do budget management She added, “We see cases that are dra- or accounting. I am a clinician. I have a way matic. The family has given everything for of working that doesn’t function here. the patient to come here.” They want me to leave, so I st bay. I am not Drawing on qualitative research conduct- good value for money. It’s true—I am a very ed since 2000,1 this paper analyses the at- bad money manager.” She then explained titudes of professionals in the public sec- Shana Cohen that with her specialisation, Type A Diabe- tor toward their work in order to tes, it was very difficult to practice quality understand how a neoliberal policy orien- This paper analyses the attitudes of pub- medicine and be cost effective, so she tation in Morocco has affected the rela- lic sector professionals toward work in or- chose the former over the wishes of hos- tionship between social identity and po- der to understand how a neoliberal policy pital administrators to pursue the latter. litical practice.2 Specifically, the paper orientation in Morocco has affected the It costs a lot for each consultation for suggests that policy reforms since the relationship between social identity and Diabetes. I tell them [the administra- eighties3 have undermined the associa- political practice. The paper suggests that tion] that my meetings with patients are tion between individual social identity and policy reforms have undermined the asso- around preventative care and not con- the nation-based social and political pur- ciation between social identity and the na- sultations, which aren’t free [60 MAD pose of public institutions4 that character- tion-based social and political purpose of at the time of the research in 2009]. ised pre-market reform in Morocco. In- public institutions and instigated new de- Therefore, I don’t bring any money to stead, re-structuring and priorities based pendence in self-identification and politi- the hospital. Moreover, people who on now internationalised principles of in- cal practice on relations with low-income were seeking treatment in the private stitutional reform5 have instigated new de- service users. Professionals no longer act sector come to me instead, and the pendence in self-identification and politi- to preserve a conceptual identification like hospital pays for them too. cal practice on relations with largely the middle class, instead finding political A paediatrician at another hospital echoed low-income service users. and social meaning through demonstrat- the unit head’s comments, stating: Under reforms, particularly over the past ing the capacity to defy institutional rules We hear [from the hospital administra- decade, public institutions have arguably and policy expectations of behaviour. tors] that we are not here to practice changed from signifying national progress

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to serving the “poor.”6 Reflecting on the studying public services has implications ic security and the status of possessing a national education policy of 2009-2012,7 not only for understanding political and skill needed to advance the “nation” (Co- labelled “Programme d’Urgence,” one social change under neoliberalism and in hen), or the bases for a coherent social teacher that I interviewed remarked, “They Morocco specifically but also for linking identity vis-à-vis other social groups. [the Ministry] haven’t talked about the fact academic research with improving the ef- Inversely, the “opacity” of self-identity that most of the students in state schools fectiveness of services. The attitudes and amongst these professional groups today are poor.” behaviour of the professionals inter- is the consequence of a decline in public This change in institutional purpose has in viewed indicate that policy and pro- regard for state institutions like hospitals turn altered the intertwined political grammes should move beyond univer- or schools.9 Self-identification is instead meaning and socio-spatial framework (see salised concepts and related methods like derived from personal insecurity and work Badiou) of working as a professional in “participation” and “empowerment” that increasingly encompassing the complex public services from affirmation of social tend to segregate service users from those needs of low-income service users, setting status to the combined marginalisation of delivering the services, ignoring the real- up the possibility for Butler’s ethical bonds. professionals and service users. Teachers, ity of the front line. Rather, new policy and For instance, one teacher spoke of two of doctors, and nurses no longer situate their programmes could more accurately re- her students who obviously did not have work in relation to a conceptual identifica- frame public services as combined social enough to eat before coming to school. “I tion like middle class within a nation-state and political opportunities situated in rela- can’t expect the same level from them, but rather pursue their own individual ma- tions between the two groups. when they haven’t eaten—or a student who terial security and, for some, existential is being hit at home—from other students.” meaning in their immediate and tangible The Political Significance of Social However, dependence on lower-income support to patients and students subject- Action in Morocco groups for signifying social identity does ed to poverty and discrimination. These Judith Butler writes of subject-formation: not necessarily mean responding ethically professionals identify themselves through Indeed, if it is precisely by virtue of its to their needs. It means that individuals, their ability to succeed, often in collabora- [the subject’s] relations to others that sometimes influenced by their peers or tion with colleagues, in spite of institution- it is opaque to itself, and if those rela- directors, have to make a choice to re- al rules and policy expectations of beha­ tions to others are precisely the venue spond ethically or to refuse, which is mani­ viour.8 for its ethical responsibility, then it may fested at its worst in corruption and absen- This paper first draws on ethnographic re- well follow that it is precisely by virtue teeism. The teacher who observed that the search to examine the current relation be- of the subject’s opacity to itself that it Ministry had “forgotten” about the poverty tween social identity and political practice sustains some of its most important of students said, “Some teachers are very amongst professionals working in public ethical bonds. (22) motivated in their craft. They participate in education and health in Morocco. In the In the past, professions like teaching or clubs after school. I give free supplemen- second section, the paper suggests how medicine offered the promise of econom- tary courses for motivated students dur-

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ing a free period.” She then added, “Oth- py to do a service for patients who don’t he can and then the doctor sends him ers are not motivated at all. They expect have money. It is true that it is medicine to the public sector. rote learning, they don’t show up, they at a basic level. There aren’t enough Amongst the interviewees, responding to insult the students.”10 nurses, technicians or equipment.” An- the demands of patients or students was The obligation to make a decision makes other gastroenterologist, working in a associated explicitly with transcendent the individual practice of their profession teaching hospital, commented, “I like the values—whether universal human rights political, in that this decision acknow­ social side of the public hospital […]. I or the recognition of human dignity in- ledges or rejects personal responsibility could earn three times more in the pri- herent in Islam, rather than nation-based to challenge the poverty and exclusion of vate sector but the mentality is more notions of citizenship. For example, a others. Likewise, it is a choice whether to commercial.” At the end of the conversa- nurse who worked in the same gastroen- maintain the integrity of their profession, tion, she summed up with: “We aren’t terology unit at the teaching hospital re- even if policymakers and administrators here for the conditions [of the hospital]. marked, “It is only humanity as a motiva- are undermining this integrity through We have chairs that are twenty years old, tion here. It is only the humane side and lack of investment and respect. not luxury. We take care of our patients.” our religion that pushes us to do the work One project manager working with state Her unit head also emphasised his human- that we have here.” schools asked: istic regard of the profession, claiming: The most prominent practical effect of Why were teachers so motivated be- Me, I could not work in the private sec- adopting an ethical position in the re- fore versus now? There used to be just tor. When I practice medicine, I see a search was to mobilise resources through one manual, no materials, to teach patient who has need of me to cure social networks, the assistance of former with. And they didn’t have a good sa- him. I cannot profit from that. He does patients, and contact with international lary. Now, they want to add to their everything to come to see me—he NGOs able to offer equipment. The unit salary and that is where they are mo- gathers money from his family, friends head of the gastroenterology unit had tivated. And I say, why have you cho- to come to be treated. I cannot profit built up a bank of medicine through mon- sen this profession? No one imposed from that; I have to practice my trade etary donations from former patients and this path on you. You have to recog- […]. I have done some replacement others to bring medicine via friends in Eu- nise the sacred value of this professi- work but I was not at ease with it. In the rope while several nurses in his unit on, that children are like play dough private sector, they view a patient as a worked around restrictions on equip- in your hands and when the door of client who pays. When they see a pa- ment usage to offer patients tests out of the classroom closes, it is just you with tient, they see how much this person hours. The now retired paediatrician re- the students and no one from the Min­ can pay them. If the person can pay lied upon a former patient to help run a istry. everything, then the patient receives­ support programme for families of chil- On the other hand, a doctor working in a good treatment until the end. If he dren with Type A Diabetes and the retired gastroenterology unit stated, “I am hap- doesn’t have the means, he pays what head of another paediatric unit had

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worked with an American NGO to bring Should Policy Account for Motivation? introducing fee payments and expanding equipment to his unit. Likewise, several Tendler and Freedheim, in a study of com- health insurance coverage, encouraging teachers mobilised clothing and school munity nurses working in Ceara, Brazil, competition, improving training and edu- materials for low-income students and a challenge what still remains mainstream cation, and so on.13 Protests against mar- senior teacher had set up classes for deaf thinking that poor performance in the ketisation of services by staff have, none- students through an NGO supported by public sector, whether related to corrup- theless, been rejected as in other Handicap International. The teacher had tion, weak training, or otherwise, requires countries,14 denigrating the motivation of been posted to another school so rushed turning to private sector options and lay- professionals. For example, an article in Le from his new position every afternoon to ing off workers. They write: Matin, the newspaper representing the oversee the project. When agents talked about why they viewpoint of the Palace, dismissed pro- The two extremes of material responses liked their jobs, the subject of respect tests from medical staff in the public sec- to the decline of public services, social from clients and from ‘my community’ tor about encouraging private investment: action and absenteeism/corruption, often dominated their conversation— It is not a secret to anyone that the evoke the need for new policy strategies much more, interestingly, than the sub- health sector is among the most cor- that address how institutional cultures ject of respect from supervisors or other rupt in Morocco (without stigmatising can provoke such different kinds of indi- superiors. The trust that was central to those who are honest). Isn’t the pre- vidual behaviour. Writing about man­ the workings of the health programme ponderance of corruption and bribery aging shared resources, Elinor Ostrom was inspired by quite mundane activi- in the sector proof that a good number states: ties […]. ‘She is a true friend,’ a mother of staff in the public sector (once more, We posit three layers that affect the said of the health agent working in her not to generalise) already do ‘com­ decisions of an individual to cooperate community. ‘She’s done more for us merce’ with the health of our citizens? in a common-pool situation: their own than she’ll ever realise.’ (1784) The author argues that this behaviour is identity, the group context in which de- In fact, the authors found that the trust cul- the result of monopoly, as doctors or cisions are being made, and wheth­er tivated with clients and the larger commu- nurses can charge what they like because the situation is repeated and it is pos­ nity was so significant in inspiring quality they know patients have no other choice. sible to use reciprocity and gain a repu- performance that it was hard to differenti- Yet, if some of the hospital staff members tation for trustworthiness […]. Individu- ate its effects from external performance remain honest, is it appropriate to justify al values are not sufficient, how­ever, to monitoring (1785). privatisation because monopoly encour- solve all common-pool resource prob­ Yet, in Morocco, reform of public services ages exploitative behaviour? I suggest lems. Without institutions that facilit­ate has focused on structural reform rather that the research on professionals in Mo- the building of reciprocity, trust, and than social relations or support,12 high- rocco shows that approaches to reform trustworthiness, citizens face a real lighting now universal themes of cultivat- should consider how policies affect the challenge. (2)11 ing private investment, subcontracting, social role of institutions, and thus the so-

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cial identity of staff. For example, criti­ computer games and painting their nails. agencies like the World Bank, NGOs, and quing teacher unions and administrators Doctors never meet except to talk about a number of national governments, partic- together, a teacher in her early fifties from money, which is all the administrators care ularly India, have integrated rights-based a family of leftist politicians longed for the about.” She openly despised her adminis- legislation17 with widening opportunities state to raise the level of professionalism trative supervisors, whom she claimed for jobs, health, education, among oth- and restore respect to the institution. She “want to increase the number of patients ers. The principle is that building “assets” attributed the absenteeism and inade- for the budget without reflecting on the amongst marginalised groups will—for in- quate performance of her colleagues not quality of work. How are we going to treat stance, specific training, matched by op- only to the lure of profit in extra private all of these people? Do we have the means portunities—lead not only to greater mate- work but also to low morale brought on by to treat them?” She also commented that rial resources but also, as Deepa Narayan issues largely unaddressed by national she and her colleagues puts it in a World Bank report, the ability policymakers, from innovations in peda- did their job in spite of increasingly dif- “to make choices and then to transform gogy to greater learning support for stu- ficult working conditions, where human those choices into desired actions and dents. She explained: and material resources are reduced to outcomes” (10).18 The problem in teaching is not just the extreme […]. It is always satisfying As with the Le Matin article, the failure to material. I stopped going on strike when we can note positive results in an deliver “empowerment” is blamed in because the unions only talk about adverse context. Sometimes these re- good part on public sector staff. Remedies money. There is no mention of ped- sults even seem miraculous.15 for this failure include methods like score- agogy. We must take more interest in Discussion of the social dimension of cards on service delivery. Cited in an Asian our craft. For sure, the conditions in public services has overwhelmingly fo- Development Bank study on empower- schools are not good. There are too cused both within development studies ment, a center in Hyderabad collected many students per class. But we need and amongst international aid agencies “the views and perceptions of users about to improve our image and that can be on input from service users. Academics the ability of health services and the per- done through demonstrating that we have argued for greater attention to “par- spectives of the staff of the health centers” care about teaching. ticipation” in governance and designing (29). Once collected, the scorecards re- Moreover, for a few of the professionals programmes (Evans; Wright; Hicky and vealed “dissatisfaction with staff behaviour interviewed the focus on budget manage- Mohan) in order to democratise decision- and working style, hours of operation and ment only heightened a sense of resis- making.16 Perhaps the most holistic ap- availability of medical personnel, and tance. The (now retired) head of the pae- proach to supporting service user input overall weak responsiveness” (29). diatric unit at the teaching hospital thought has been that of “empowerment,” de- Though the scorecards’ leading to better that public health reform meant getting rived from Amartya Sen’s human capabili- attitudes and service quality should cer- rid of doctors while adding managers and ties approach, which attempts to match tainly be regarded as positive, the prob- clerical staff “who spend their time on agency with opportunities. International lem of dissatisfaction with staff points to a

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Shana Cohen more profound issue of neglecting con- collaboration on the front line, similar to tutions would then be represented less by structive social relations between service the mobilisation of resources by doctors, their modes of governance than by collec- is the Deputy Director of the Woolf users and professional staff.19 Scorecards teachers, and sometimes service users. Fi- tive action for shared benefit. Institute in Cambridge. The Institute segregate, labelling one group as prob- nally, the emphasis on the front line im- specialises in the study of relations lematic and giving the other power to “re- plies recognising practical constraints on Conclusion between Jews, Christians, and Muslims form” it. delivering quality services and acting This paper has analysed social action from a multidisciplinary perspective. She If social relations between professional upon them. As one nurse in the gastroen- amongst professional staff in public health is also an affiliate lecturer with the Faculty staff and service users are important to de- terology unit in the teaching hospital com- and education and makes the argument of Asian and Middle Eastern Studies livering quality services, then how should mented: that both constructive and negative be- at the University of Cambridge. Her they be addressed in policy? More funda- You do the work even with the con­ haviour are due to institutions no longer research interests include community mentally, how can the services of public straints in front of you. The patient has linking vocation with collective social pur- activism, public institutions and social institutions be conceptualised so as to en- nothing to do with the salary. You are pose. The paper suggests that policy change, and international social policy. courage constructive behaviour and dis- obliged to do the work necessary. This should respond by reframing the social email: [email protected] courage practices like corruption and ab- is a patient who perhaps came from role of institutions as bringing together senteeism? I suggest three ways of far away. He is far from his family. You different social groups for shared benefit. rethinking public institutions and improv- have to make up for that. And you have This reframing not only addresses the so- ing service quality. First, the language of to be responsible at the same time for cial consequences of neoliberalism as a “public services” should be revised to re- the material side of things, sterilisation, policy approach; it also means offering an flect the mutual participation and benefit and so on […]. The social services here alternative. of different social and economic groups. are negligible. We need a social worker Rather than one social group, i.e. profes- for each ward. But there aren’t any.20 ––› sionals, providing services to another pri- The recognition of these constraints would marily low-income group, a hospital or logically entail granting more decision- school would be reframed as a means for making power to professionals, like the all stakeholders to achieve social meaning nurse, and service users over the alloca- and political significance as well as better tion of resources. More profoundly, this health and education. shift would make cooperation and raising Secondly, the conceptual and practical fo- the authority of the different front line ac- cus on social relations means shifting away tors a primary objective of institutions in from a vertically-oriented dynamic where- order to improve service quality and “ef- by policymakers and staff respond to ficiency,” for example, greater attention in feedback, like scorecards, from low-in- the front line leading to better after care at come service users, to cooperation and home and less chance of regression. Insti-

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––› Notes 4 A study by Haut- 6 See a White Paper by Dr. 8 Despite his focus on the lack of resources, ramshackle Commissariat au Plan in Alaoui, the Secretary-General motivation of protesters infrastructure and dirty 1 The research consisted of Morocco on the attitudes of the Ministry of Health in across the globe, Zygmunt and dilapidated buildings, several parts: First, I have of youth (“Les jeunes en Morocco for a summary of Bauman’s identification lack of furniture and worked extensively with non- chiffres”) found that for the direction and purpose of of desire for tangible and equipment, classrooms that governmental organisations young men and women health sector reforms, which immediate change as are overcrowded at many since 2000, and a number of (ages 15-24), household was focus largely on governance, the inspiration for action levels, undisciplined, indeed these are run either by former by far the most important decentralisation, insurance could refer both to doctors aggressive students.” or current public sector area (46.2%), followed by coverage, and recruitment manipulating administrators staff or their purpose is to religion (23.9%), work (11.4%), and training. The overriding to avoid low-income patients An article on interns support education or health. and then national progress orientation of his paper, as paying fees or teachers (“Médicin au Maroc”) in the Thus, I have been exposed (10%) (66). well as reforms in education pursuing extra income. public health system, who to some of the challenges and social development, is They both embrace “the were striking at the time for facing public services 5 Writing about the to ensure greater access by locality and press[ing] it medical insurance, echoed in Morocco. Secondly, universalisation of higher low-income populations, close to one’s breast” (16) the pervasive demoralisation I received three grants education policy in a particularly in rural areas. and are spurred on by indicated amongst teachers, (Leverhulme Trust, University comparison of reform in This orientation follows the the “knowledge that the quoting Ayoub Halfya, of Sheffield Internal Grant, Morocco and Egypt, Kohstall World Bank Millennium governments in the form the then president of the and American Institute of remarks, “It is remarkable Development Goals, as well in which they have been association of medical interns Maghrib Studies) to conduct how the discourse on higher as aid agency priorities, squeezed by the ‘global as saying: “We work ninety research over a six-month education has changed but regardless of the merit forces’ are not the protection hours a week, sometimes period in 2009, during which and is now jam-packed of this objective, it leaves against instability but we do forty-eight hours on I ended up focusing on the [with] wording from the out completely the notion instability’s principal cause” call that are not paid, all for a transformation of public international agenda for of public schools and (16). pathetic salary, that doesn’t services under neoliberalism higher education reform, hospitals as serving all of the match the rise in the cost in Morocco. The third is from accreditation to population. 9 Describing the decline of living.” An anonymously ongoing research into how benchmarking and quality of public education in quoted intern was more policy affects the social role assurance to ranking. A Morocco, Rim Battal writes direct, stating: “Our salaries 7 See “Programme d’Urgence of institutions and how, common language has 2009-2012” of Ministère de in the online magazine are […] largely insufficient inversely, front line service emerged that shapes l’Enseignement Supérieur. Yabiladi, “The absenteeism of […]. Over time, I have come delivery can inform policy. university administrators and teachers is only a symptom. to see that you have to be faculty members alike when You have to go further than rich to study medicine. I earn 2 See Koenraad Bogaert for they apply for international that. What can we expect 3,500 MAD a month and my a more general analysis of funding. This is probably from a teacher who earns a parents still have to help me. the relationship between the most important side- miserable wage? Most skip I can’t pay for my rent, a car, neoliberalism and political product of a type of reform their classes between four and all of the daily expenses transformation in the region. that otherwise has not yet and six in the afternoon to with so little. At twenty-eight lead to tangible results in the tutor individual students or years old, one becomes very

3 Structural adjustment and improvement of teaching to teach in the private sector. angry. One starts to want to market liberalisation began in and research.” (107) The teachers diagnose a Morocco in 1983. number of problems like ––›

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16 ––› set up in the private sector, collective disengagement 14 For example, teacher Participation has also been 18 Citing Sen and others, the where, with my specialisation, from the public school as a strikes in 2011 in the UK over criticised within development Asian Development Bank I can earn much better than space of empowerment and pensions were criticised by studies for only superficially study on empowerment in the public sector. But the integration, I emphatically Michael Gove, the Minister acknowledging service defines the approach as: set up costs a lot, and there reorient our attention for Education. He said of users while carrying on with “People should be free to too, the assumption is you away from the technical the strikers (which included, pre-determined policies and choose what they want to do, have the means to do this.” diagnostics of international unusually, head teachers): specific projects (Cooke and have the functional ability policymakers and toward “They want mothers to give Kothari). to put those choices into 10 Boutieri views the the political nature of all up a day’s work, or pay for action, and have an enabling dichotomies and hierarchies learning.” (445) expensive childcare, because 17 The Asian Development environment that allows them in public education, schools will be closed. They Bank report provides more to actually perform those exemplified in language 11 For more information see want teachers and other detail on the practice of actions.” (20) skills (French and Arabic Ostrom. public sector workers to lose empowerment: “A common primarily), as a precursor to a day’s pay in the run-up to form of empowerment 19 For more information see the disaffection expressed 12 A World Bank article Christmas. They want scenes is through rights-based Oxfam Briefing Paper 125. across North Africa during on educational reform in of industrial strife on our entitlements, which the Arab Spring, because the Morocco lists as the priorities TV screens. They want to are enforceable rights 20 The same anonymous school is an original source governance, decentralisation, make economic recovery enshrined in the legal intern quoted in the article of limiting opportunities and infrastructure. harder—they want to provide framework or national (“Médicin au Maroc”) about and establishing socio- Management of human a platform for confrontation constitutions with specific the interns’ strike in Morocco economic difference. She resources are regarded just when we all need to pull roles and responsibilities of made similar comments: “The writes that in Morocco as key to ‘effectiveness’ together” (“Gove Appeals to implementing authorities as public hospital in Morocco today, “educational anxiety “because they exercise a Teachers”). The heads of the well as criteria for beneficiary lacks resources. Like myself, emerges as socio-cultural considerable influence on teaching unions responded eligibility and procedures many of my intern or resident critique. The circumvention the performance overall of to government criticism by for identification. There are colleagues are obligated to of public education through schools. The minister has remarking how much they two types of rights-based do the tasks of the nurse or privatisation, parallel launched a massive strategy would prefer to be practising entitlements: First, the right nurse’s aide because of a lack schooling, corruption, or to promote the career plans their profession. The head of eligible citizens to specific of personnel. It is up to us charity—all responses to and mobility of teachers with of the university lecturers services; and second, the to change the sheets, clean this anxiety—is telling of a the aim of directing them union (UCU) remarked, right to information, which the sick who are immobile, radical uncertainty about to where their competence “Our members are unlikely is an instrument to ensure push the guerneys. In some how to plan the future of will be the most useful.” The militants and would much that citizens can influence services, there is a nurse the next generation” (445). language is notably and not rather be in the classroom the fulfillment of their rights for ten sick people, which She adds that this anxiety surprisingly utilitarian and than on the picket line” (“UK to services. In both cases, is [simply] not enough, and cannot be remedied through individualist, again obscuring Schools Disrupted by Pension it is the binding obligation suddenly it is the doctors conventional reforms, the necessarily social Strikes”). of the state to ensure that who have to contribute to stating: “By claiming that dimension of teaching. eligible citizens receive the remedying the situation, and what appears as a sudden 15 She eventually retired in specific entitlement being this isn’t OK. Above all, it tires move to the streets [the 13 See Royaume du Maroc, frustration in 2012. guaranteed.” (22) us out and takes over the Arab Spring] may in part “Stratégie Sectorielle de time when we are supposed be a gradual result of a Santé 2012-2016.” to be curing patients.”

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