State retrenchment and informal institutions in Kazakhstan: people's perceptions of informal reciprocity in the healthcare sector

Despite government efforts, post-independence Kazakhstan has largely failed to provide high-quality medical services to its population. State retrenchment in the public healthcare system has led to the deterioration of medical service delivery. It has provided incentives for people to widely use informal reciprocal exchanges – personal connections and informal monetary and non-monetary payments – to gain access to better medical care. In contrast to the existing explanations focusing mostly on the cultural origin of the continuity of informal exchanges, I argue that state retrenchment from the social sphere and under-provision of state goods and services have perpetuated informal exchanges in post-Soviet Kazakhstan. Despite similarities in informal practices between Soviet and post-independence Kazakhstan, some important differences in terms of scope and the nature of informal exchanges are observed. This article draws on data collected from interviews, textual analysis, and original surveys of people's attitudes towards the healthcare system and informal help conducted in Kazakhstan in 2011 and 2013.