Aploksne (Latvia)

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Aploksne, aploksnīte
Location: Latvia
Latvia map.png
Author: Iveta Kažoka and Valts Kalnins
Affiliation: Centre for Public Policy PROVIDUS, Latvia

Original text by Iveta Kažoka and Valts Kalnins

The literal meaning of the Latvian word aploksne is ‘envelope’ – a common word whose primary meaning is similar in every language. It might therefore seem surprising that, during the years 2005 to 2014, less than half of all mentions of ‘envelope’ in the Latvian print media referred to a flat paper container for letters or documents. Equally often, the word was used to denote the all-too-common problems of tax-avoidance and lack of employment contracts in the context of labour relations (for example, aplokšņu algas – ‘wages in an envelope’). In a fifth of all the articles, the meaning shifted again, this time to refer to corrupt practices in the health service – unofficial, sometimes illegal cash payments to doctors, hospital nurses and other healthcare providers. A similar concept exists in countries bordering Latvia – for example, unofficial payments to doctors in Russia and Lithuania are also associated with the idea of an envelope (конверт in Russian, vokelis in Lithuanian) – and in the Greek language (fakelaki – ‘little envelope’).


Unofficial payments in the healthcare sector are referred to as ‘envelopes’ even in cases when the physical object itself – an envelope – is not present. There is, nonetheless, a common expectation in Latvia that banknotes will be placed in an envelope before they are handed over. This holds true whether what is being made is a gift or bonus payment, or whether cash is being shared outside the context of regular daily transactions. Banknotes do not, therefore, change hands directly, but through an intermediary in the form of an envelope. Such a practice is considered to be both more convenient (banknotes are less likely to get lost) and more polite.


An envelope as a container does not of course discriminate between a legitimate birthday gift and a bribe. Over the years, the meaning of the term ‘envelope’ has undergone a semantic change in the Latvian language. Today, it has the secondary meaning of ‘illegal’ and/or ‘unofficial’ payment. This secondary meaning refers not to the envelope itself as a physical object, but rather to its contents and the purpose those contents are intended to serve (for example, reducing the waiting time for a medical examination or encouraging a more benevolent attitude from medical personnel). A content-analysis of media articles from 2005 to 2014 finds that the term ‘envelope’ may refer not only to bribery in the healthcare system (though healthcare is clearly dominant) but also to bribes paid to judges, journalists, local officials and members of parliament.


Sometimes the term is used in its diminutive form – aploksnīte (‘tiny envelope’). In Latvian, diminutive forms often convey a sense of endearment, and do not necessarily refer merely to the smallness of an object. There might therefore be an even larger amount of cash in an aploksnīte than in an aploksne. However, the choice of the word aploksnīte in the context of unofficial payments is usually sarcastic: it may serve as a means of creating ironic distance and of protecting oneself against the danger of being seen to be engaged in illegal activity. In Latvian, the word for a bribe also has a diminutive form (kukulis, kukulitis – ‘bribe’, ‘little bribe’).

Unofficial payments in the healthcare system are part of the legacy of the Soviet era. In Latvia, just as elsewhere in the Soviet Union, all health workers were state employees, and healthcare was a highly centralised public service, free at the point of delivery. Physicians’ official salaries were deliberately kept low – below the average wage of a factory worker, for example (Barr 1996[1] ). The quality of the care provided was notoriously low. This explains why patients were willing to pay extra to physicians (Barr and Field 1996[2]). Over time, unofficial payments from patients in the form of cash or gifts became the rule and an unofficial system of fees-for-services became common. A survey conducted among physicians in Estonia indicated that, during the Soviet era, unofficial payments by patients for services that were supposedly free were not only the norm, but were not seen as a source of embarrassment (Barr 1996[3]).


With the collapse of the USSR in 1991, the newly independent states, Latvia included, were forced to reform their healthcare systems. This was not an easy task, given the shortage of public resources and the prevalence of the Soviet tradition of unofficial payments to physicians. The World Bank and other institutions identified informal, unreported and sometimes illegal payments to doctors as characteristic of healthcare systems in both Eastern Europe and Central Asia (Lewis 2000[4]). The problem was aggravated by another legacy of the Soviet era: generally lenient public attitudes towards petty corruption. Such attitudes have persisted into the present. In 2015, for example, approximately one third of Latvians questioned said that they considered corruption to be justified in cases where there was no other way of solving a legitimate problem. A similar proportion of Latvians said they did not object to someone defrauding the state, given that the state did not provide any service of value (KNAB 2015[5]). In 2013, 72 percent of Latvians said they considered it acceptable to make a gift to a civil servant in order to get a needed service from public administration. Latvia scored more highly in this respect than any other European Union member-state (Special Eurobarometer 2013)


The general confusion associated with changes in values and institutions that followed the break-up of the USSR makes an ‘envelope’ a particularly fitting symbol of the times. The amount of cash placed in an envelope is not immediately apparent; neither is the nature of the transaction. Is it a gift? Is it an undisclosed payment? A tip? A bribe? If it is a bribe, has it been extorted? The term aploksne covers all such eventualities, thereby conceptually placing each individual case in a grey zone of semi-legality and semi-legitimacy. When asked in 2002 whether an envelope was a form of corruption, almost one half of Latvians surveyed denied that this was the case (CIET International 2002[6]).


In the early 2000s, however, informal payments to doctors did begin to be generally perceived in Latvia as a serious problem. Media coverage of aploksne peaked in 2007, when a former doctor who had admitted having received envelopes throughout his career was elected as President of Latvia. By then, a consensus had emerged as to what forms of envelopes were unacceptable, and doctors were prohibited from demanding unofficial payments. There still remained a grey zone in cases where no such demand had been made: the so-called ‘gratitude’ or’ thank-you’ money (Latvian – pateicība). Such ‘gratitudes’ were frequently given to doctors or nurses before a service, which cast doubt on their fully voluntary nature. A patient who made no such up-front payment might reasonably expect to get worse treatment than a patient who had already expressed his or her ‘gratitude’ in the form of an envelope.


Analysis of media usage of the term aploksne indicates a steep decline in recent years. In 2006-2007, for example, the term had been found four times more frequently than was the case in 2015. The resultant decline in media attention has been so rapid that it even seems that the term may be on the verge of obsolescence.


Improvements in living standards in general and the healthcare system in particular have led to a situation where fewer people in Latvia now say that they feel the need to bribe their doctors. The number of respondents who say they expect to pay a bribe to healthcare workers (3 percent) is now only slightly above the EU average (2 percent), and considerably lower than in neighboring Lithuania (21 percent) (Special Eurobarometer 2013). Recent public-awareness raising campaigns have spread the message that all kinds of unofficial payments to public-sector healthcare workers are unacceptable, even when they are intended as an expression of gratitude for a job well done.


It might therefore not be surprisingly if in the not-so-distant future there is again just one meaning for aploksne – the Latvian term for an envelope.


Notes

  1. Barr, D. 1996. ‘The ethics of Soviet medical practice: Behaviours and attitudes of physicians in Soviet Estonia,’ Journal of Medical Ethics 22: 33-40
  2. Barr, D. and Field, M. 1996. ‘The Current State of Health Care in the Former Soviet Union: Implications for Health Care Policy and Reform,’ American Journal of Public Health86(3)
  3. Barr, D. 1996. ‘The ethics of Soviet medical practice: Behaviours and attitudes of physicians in Soviet Estonia,’ Journal of Medical Ethics 22: 33-40
  4. Lewis, M. 2000. ‘Who is Paying for Health Care in Eastern Europe and Central Asia?’ The International Bank for Reconstruction and Development/The World Bank http://web.worldbank.org/archive/website00504/WEB/PDF/WHO_IS_P.PDF
  5. KNAB. 2015. Attieksme pret korupciju Latvija. Sabiedriskas domas aptauja http://www.knab.gov.lv/uploads/free/aptaujas/soc_aptauja_par_2015.pdf
  6. CIET International. 2002. Ka likvidet suci sistema:Veselibas aprupes sektors un licencu izsniegsana Latvija http://www.knab.gov.lv/uploads/free/aptaujas/ciet_latviski_2002.pdf