Good health care by private means? Lessons from the study on private clinics in Russia promoting evidence-based medicine

Against the background of the dissolution of the Soviet Union and the transition from communism and state healthcare to a market economy, the emergence of private clinics in Russia is a fascinating phenomenon. This study aimed to investigate how private clinics in Russia balance profit-making with ideals of reliable knowledge and good care. The study adopted an ethnographic approach, but encountered significant challenges in this regard. Firstly, the outbreak of the pandemic and subsequently the war initiated by Russia against Ukraine rendered it impossible to conduct field research 'on the ground'. Consequently, in-person fieldwork had to be replaced with digital fieldwork: conversations with medical professionals in private clinics continued online, resulting in most interviews being conducted virtually, as well as private clinics' conferences being attended online. While not ideal, this digital workaround still yielded interesting insights. Given the specific nature of the research context, one might question how an ethnographic study of private clinics in contemporary Russia could inform policy recommendations.  How can valuable lessons be drawn from the Russian context and applied elsewhere?

            Before addressing this question, I would like to briefly summarise the key findings of the study. First, the study demonstrated how private clinics promote evidence-based medicine (EBM) in order to establish a niche in the Russian healthcare market. They promote EBM as a guarantee of higher-quality, patient-centred care, setting themselves apart from the dominant medical practices in Russian healthcare. In this context, therefore, profit-making and adherence to evidence-based, quality, person-centred care appear to go hand in hand. Second, the distinction between private and public healthcare has become blurred, as private clinics also participate in state insurance funding schemes. However, this involves navigating significant regulatory uncertainties and ambiguous, often hostile, regulations. Third, the study showed that private clinics perform a great deal of informal knowledge work in order to survive in this landscape; they improvise, anticipate, and establish connections with other medical professionals and healthcare organisations. I consider this to be more than just adaptation to a hostile environment; it is creative and inventive work. Fourth, I demonstrated how these private clinics develop an understanding of evidence-based medicine that enables them to play down commercial interests and distinguish themselves from outdated, paternalistic Soviet-style medical practices, presenting themselves as 'good practices' offering state-of-the-art diagnostics, treatment and personalised care. Fifth, the study demonstrated that private clinics are an important help for cancer patients, helping them to navigate the complex infrastructure of public cancer care, where patients often lose time, become disorientated and receive inadequate treatment. Private clinics help patients by speeding up treatment, helping them to navigate the system, and providing a second opinion on complicated cases. Consequently, they address shortcomings in the Russian public cancer care system and support patients with urgent needs.

Which lessons follow from this study? Analysing the phenomenon of private clinics in Russia promoting evidence-based medicine, this dissertation explored two important questions. The first concerned the interplay between good care and profit-making—whether the two can mutually constitute each other and with what implications. The second addressed the development of novel medical practices in healthcare environments marked by economic and political instability. While I examined these questions within the authoritarian context of Russian healthcare, I believe my research findings contribute to broader social discussions on three key topics: the context of novel medical knowledge practices, the role of informal practices in sustaining malfunctioning healthcare systems, and the intertwinement between private and public healthcare sectors.

First, by exploring how EBM has become entangled with private clinics in Russia, I contributed to a situated understanding of medical knowledge construction practices. While studies in the Euro-American setting have shown that the dominance of EBM was achieved in the context of emerging new disciplines, such as epidemiology, the growing influence of pharmaceutical companies and struggles of medical professionals for authority, this dissertation demonstrated a different dynamic. In the authoritarian context of Russian healthcare, it was not epidemiologists or professional associations that began promoting EBM principles but rather private actors. I analysed how so-called EBM-oriented private clinics in Russia have become secured organisational spaces enabling experimentation with new approaches to medical care, such as EBM. I showed how these clinics interpreted EBM and negotiated their ideals of good care and reliable medical knowledge against the harsh realities of Russian healthcare. By articulating the ideal of EBM, private clinics strived not only to carve out a new niche in the Russian healthcare market but also to practice what they believed to be better care. This entanglement of profit-making with the ideals of good care and reliable knowledge has become a defining feature of how EBM is being constructed in Russia. While commercial interests are historically at odds with the ideals of good care, this dissertation demonstrated that, under specific circumstances, they can mutually constitute each other. Thus, my research highlights the need for a contextual understanding of what counts as good care or reliable medical knowledge.

Second, my research contributes to scholarly and policy discussions about the value of informality for healthcare systems operating in challenging economic and political landscapes. While informality is commonly viewed as a corrupting or subversive activity that should be eradicated, social science scholars have shown that informal practices not only permeate all healthcare systems but, in many instances, are essential for their functioning. My research contributes to this body of literature and aims to rehabilitate informality by seeing it beyond informal payments or the economy of favours. By analysing the practices of three private clinics in Russia, I showed how they relied on multiple informal practices not only to survive as a business but also to secure their novel medical practices. Importantly, I demonstrated that these informal practices also have epistemic value. For private clinics, they served as a mechanism for implementing new medical knowledge practices and navigating several regulatory uncertainties. Consequently, informality not only allowed the clinics to adapt to the challenging healthcare context, as well as assemble new connections and ways of accessing medical care. Recognizing the inventive potential of informality allows for a better understanding of how organisations survive and prosper in challenging economic and political environments.

Finally, my research has called for greater attention to the public-private intertwinement in healthcare. The increasing presence of the private sector in the healthcare provision globally encourages heated discussions among policymakers, businesses and researchers about its potentiality to improve healthcare quality and access, especially in middle- and low-income countries. Within these discussions, the private and public sectors are often understood as predefined and relatively static categories that can be easily differentiated. However, drawing on the case of Russia’s mixed healthcare system, I showed that, in practice, the boundary between the private and public healthcare sectors is increasingly blurred. In my research on private clinics in Russia, I showed their multiple everyday intertwinements with public healthcare and tensions that arise from them. Focusing on these interrelations allowed me to demonstrate the ambivalence of private clinics’ role in Russian healthcare. While private clinics bridged several gaps in public healthcare provision, they also capitalised on the system’s malfunctions, turning their tacit knowledge and expertise into a paid service. I argue that adopting a relational approach to the private-public interplay opens opportunities to rethink the existing private-public dualism and the normativities it entails (e.g. “private is bad, public is good”).