“Si Tienes Un Amigo, Tienes Un Central”
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“Si tienes un amigo, tienes un central” A Field Study of the act of informal gift exchanges and social networks between patients and medical staff, in Cuba’s public healthcare system. By: Julia Spaton Goppers Author: Julia Spaton Goppers Word Count: 13.491 Supervisor: Hans Blomkvist Uppsala University, Department of Government Bachelor Thesis, 15 ECTS Political Science, Spring Semester of 2019 Abstract This thesis explores the act of informal reciprocal exchanges and relationships - sometimes referred to as bribes or corruption - within the Cuban healthcare system. The research was conducted in Havana during the autumn of 2018 and was funded by a Minor Field Study scholarship from SIDA. The theoretical framework of Institutionalism is used to answer the research question: For what reasons do patients informally pay for healthcare services, that formally are meant to be free? The study shows through qualitative interview methods, that the perception of informal gift giving varies between the respondents; some consider it to be a way of showing gratitude, while others claim it to be corruption. There was however consensus among the respondents, and also according to previous research, that one’s personal connections within the healthcare system can impact the quality of the services and grant better access to medical resources. The study concludes that gifts can function as a factor creating or strengthening friendships, which may provide better access to healthcare. Resumen Esta tesis explora la acción de intercambios y relaciones recíprocas e informales — a veces llamadas soborno, o corrupción — al interior del sistema de salud en Cuba. La investigación fue desarrollada en La Havana durante el otoño de 2018 y fue financiada mediante una beca del programa de Breves Estudios de Campo de la Agencia Sueca de Cooperación Internacional para el Desarrollo (Asdi). El estudio hace uso del esquema teórico del institucionalismo para responder a la siguiente pregunta: ¿por qué razón los pacientes están dispuestos a pagar informalmente por servicios de salud supuestamente gratuitos? El estudio muestra, mediante el método de entrevistas, que la percepción del presente informal varía entre los entrevistados; algunos lo consideran una manera de mostrar gratitud, mientras que otros lo consideran una forma de corrupción. Sin embargo, existe consenso entre los entrevistados, y también de acuerdo a investigaciones anteriores, en que el acceso a relaciones personales dentro del sistema de salud puede influenciar la calidad del servicio, y asegurar mejor acceso a recursos médicos. El estudio concluye que los obsequios pueden funcionar como una manera de crear o fortalecer amistades — una función importante en la vida de los cubanos — lo que puede resultar en un mejor acceso al servicio de salud. 1 Acknowledgements This Field Study would not have been possible without the cooperation of the Cuban patients, medical employees, and medical students who participated in the interviews. I especially thank my local contact person Sylvia for welcoming me to Havana and assisting me with valuable help, as well as many kind people in Sweden who gave me useful advice and provided me with contacts on Cuba prior to departure. For the generous financial support, I want to thank SIDA for the Minor Field Study Scholarship I was awarded, as well as the preparatory course in Härnösand with dedicated staff where valuable information was provided. Lastly I want to thank my supervisor Hans Blomkvist at the department of government at Uppsala University, for the guidance and support throughout the process. Gracias. Key words: Cuba, Field Study, Healthcare, Gifts, Institutionalism, Sociolismo 2 Table of Contents 1. INTRODUCTION ........................................................................................................................................ 5 1.1. AIM AND RESEARCH QUESTION ..................................................................................................................... 6 1.2. DISPOSITION ................................................................................................................................................. 6 1.3. BACKGROUND AND COUNTRY INFORMATION .............................................................................................. 6 1.3.1. THE HEALTHCARE SYSTEM OF CUBA ......................................................................................................... 7 1.4. PROBLEM DESCRIPTION ................................................................................................................................. 9 2. PREVIOUS RESEARCH AND THEORETICAL FRAMEWORK .......................................................... 10 2.1. PREVIOUS RESEARCH .................................................................................................................................. 10 2.1.1. SOCIOLISMO ............................................................................................................................................. 10 2.2. INSTITUTIONALISM ..................................................................................................................................... 11 2.3. ANALYTICAL FRAMEWORK - IDEAL TYPES ................................................................................................. 12 3. DESIGN AND METHODOLOGY ................................................................................................................ 14 3.1. DESIGN AND MATERIAL .............................................................................................................................. 14 3.2. METHODOLOGY .......................................................................................................................................... 14 3.2.1. RESPONDENT SELECTION ......................................................................................................................... 15 3.2.2. OBSERVATIONS AND HOSPITAL VISITS ..................................................................................................... 16 3.3. ETHICAL CONSIDERATIONS ......................................................................................................................... 16 3.4. DELIMITATIONS .......................................................................................................................................... 17 3.5 SOURCE CRITICISM ...................................................................................................................................... 18 4. RESULT AND ANALYSIS ............................................................................................................................ 20 4.1. GENERAL PERCEPTION OF THE FUNCTIONING OF THE CUBAN HEALTHCARE SYSTEM ................................. 20 4.1.1. PERCEPTION OF THE EXISTENCE OF THE GIFTS ......................................................................................... 22 4.2. GRATITUDE ................................................................................................................................................. 23 4.3. CORRUPTION ............................................................................................................................................... 25 4.4. FRIENDSHIPS ............................................................................................................................................... 27 4.5. OVERLAPPING ............................................................................................................................................. 29 4.6. SANCTIONS ................................................................................................................................................. 31 4.7. DISCUSSION ................................................................................................................................................ 32 5. CONCLUSION ................................................................................................................................................ 34 6. BIBLIOGRAPHY ........................................................................................................................................... 36 7. APPENDIX ...................................................................................................................................................... 40 3 List of Figures and Tables Figure 1: Life expectancy in Cuba and Latin America……………………………….…….....8 Figure 2: Life expectancy in Cuba and High-income countries…………………………...…..8 Figure 3: Illustration suggesting potential effects of the gift………………………….……..33 Table 1: Health Statistics from the World Health Organization ……………………..………8 Table 2: Helmke’s and Levitsky’s typology of informal institutions……………………......12 Table 3: Ideal types and operationalization of gratitude and corruption………………...…...13 Table 4: Ethical requirements………………………………………………………………...17 Table 5: Information about the respondents.…………………………………………….…...20 4 1. Introduction Healthcare policies and their outcomes are shaped differently over the world, and countries have various means and strategies to reach the United Nations’ sustainability goal of ensuring good health and well-being for all at all ages (UN, 2016). Cuba, one of the last communist societies in the world, has since the revolution in 1959 when Fidel Castro seized power, invested in creating a public healthcare system - free and equal for all Cuban citizens, which has continuously