Reflections on fluidity and stability: a look at the formality vs informality debate

Olga Zvonareva (Department of Health, Ethics and Society, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands)
Arturs Holavins (Department of Health, Ethics and Society, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands)

International Journal of Sociology and Social Policy

ISSN: 0144-333X

Article publication date: 31 August 2023

Issue publication date: 18 December 2023

405

Abstract

Purpose

The distinction between formality and informality has been a topic central for many scholarly fields. Without rejecting the usefulness of this distinction, the authors argued that instead of analyzing an empirical situation in terms of what is formal and what is informal, it could sometimes be fruitful to focus on what is stable and what is fluid.

Design/methodology/approach

This paper reports the results of review and analysis of secondary sources on the distinction between formality and informality, followed by a conceptualization of an alternative distinction between fluidity and stability. This conceptualization was inspired by a science and technology studies (STS) understanding of relations, and was assessed through applying it to a case of patient organizations’ participation in patient councils in Russia.

Findings

Stability and fluidity do not map neatly into formality and informality; rather, the stability and fluidity cut across these categories. The authors propose a view of both stability and fluidity as kinds of relations between elements of the societal fabric. The distinction proposed here could be especially fruitful when applied to analyses of (1) complex bureaucracies where formal requirements are extensive and potentially in conflict with each other and (2) oppressive situations where significant power imbalances exist.

Originality/value

Instead of providing yet another line of demarcation between formality and informality, this paper proposes a shift in attention to what is stable and what is fluid. This novel distinction can help not only in discerning how things actually work but also in bringing to the fore hitherto unnoticed forms of creativity, responsiveness and inclusion.

Keywords

Citation

Zvonareva, O. and Holavins, A. (2023), "Reflections on fluidity and stability: a look at the formality vs informality debate", International Journal of Sociology and Social Policy, Vol. 43 No. 13/14, pp. 183-193. https://doi.org/10.1108/IJSSP-05-2023-0112

Publisher

:

Emerald Publishing Limited

Copyright © 2023, Olga Zvonareva and Arturs Holavins

License

Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode


Introduction

The distinction between formality and informality is enduring and has been influential in multiple fields of scholarship such as economics, development studies, urban planning, among others (Kanbur, 2021; La Porta and Shleifer, 2014; Laguerre, 2016; Ulyssea, 2020; Williams and Schneider, 2016). At the same time, scholars have noted that despite the pervasive usage of these terms, their definitions tend to be inconsistent. According to Guha-Khasnobis et al. (2006, p. 3), “it turns out that formal and informal are better thought of as metaphors that conjure up a mental picture of whatever the user has in mind at that particular time”. It would not be an overstatement, perhaps, to suggest that current approaches distinguishing formality and informality remain just as diverse.

In this paper, we do not aim to provide yet another line of demarcation. The needs, aspirations and epistemic foundations of various disciplinary fields concerned with informality are so dissimilar that a number of approaches to analyzing informality, formality and their relations may well coexist. What may be needed, though, is a scrutiny of the various grounds for distinguishing informality and formality and an explicit reflection on what they actually allow us to distinguish. Here, we follow this line of inquiry and argue that within the formality vs informality dichotomy; there is at least one line of distinction that does not map neatly into it. This line of distinction separates what is fluid from what is stable or fixed. We propose that some analytical situations require abandoning the focus on informality and formality in favor of fluidity and stability.

Below, we develop this argument in several steps. First, we review a range of conceptualizations of informality vs formality, focusing on the historical continuity between various grounds for demarcating the two. Second, we examine and summarize scholarly arguments that complicate such demarcations. Third, after proposing that at least some of these complications stem from collapsing the two dichotomies onto one another—informality vs formality and fluidity vs stability—we theoretically delineate the latter. Fourth, we illustrate how a distinction between fluidity and stability can be fruitfully applied in analyzing empirical situations. We conclude by delineating the scope of applicability of this distinction and arguing that a focus on fluidity instead of informality can sometimes bring to the fore hitherto unnoticed forms of creativity, responsiveness and inclusion.

Informality vs formality: drawing a distinction

It has become an academic tradition of sorts to begin overviews of the evolution of the concept of informality, as opposed to formality, from the work of the anthropologist Keith Hart. In his seminal paper, Hart (1973) reported a study he conducted in a slum area in Accra, Ghana, and used the terms formal and informal to differentiate between labor that was registered by the state bureaucracy and labor that was not, respectively. In his subsequent work, Hart (2006) explained the focus of the original work as follows:

[the main message was] that Accra’s poor were not unemployed. They worked, often casually, for erratic and generally low returns; but they were definitely working. What distinguished these self-employed earnings from wage employment was the degree of rationalization of working conditions. Following Weber (1981), I argued that the ability to stabilize economic activity within a bureaucratic form made returns more calculable and regular for the workers as well as their bosses. That stability was in turn guaranteed by the state’s laws, which only extended so far into the depths of Ghana’s economy. (p. 25)

Nevertheless, this distinction between the regulated (formal) and unregulated (informal) spheres can also be traced to a line of thought that is both older and connected to colonial history. A similar distinction, albeit with no mention of the terms formal and informal, was made by Boeke (1953), a Dutch colonial administrator and academic. Writing about what he called the “dual economy” in Indonesia, Boeke (1953, cited in Kanbur (2017)) contrasted regulated capitalist colonial activities and the unregulated “native economy” and highlighted pronounced differences in how the two operated. This dualism has since repeatedly been cast in scholarship under various terms that have coalesced into two polar opposites, one being modern, capitalist, sometimes industrial and formal and the other being traditional, sometimes agricultural and informal.

This variously articulated duality, however, is uniformly and heavily reliant on the idea that, in the words of Kanbur (2017), “‘formality’ is to do with an activity coming under the purview of the state, in the form of coming under the ambit of a law or a regulation, while informality is that which is outside this domain” (p. 941). Informality emerges here as beyond the reach of official governance mechanisms, concealed from the state by the opaqueness of social practices that overflow regulatory arrangements and explicit organizational structures. The state has little if any impact on the realm of informality because the informal is illegible to the state apparatus and, thus, barely penetrable for state regulation. Building on this understanding, some scholars have distinguished informality from illegality (Polese, 2018). Polese et al. (2019) suggested that while both operate outside of state control, illegal practices contravene legal codes and informal practices may not necessarily be illegal but are concealed from the state, since according to Scott (2020) in his seminal book Seeing Like a State, the state can only “see” what falls within its apparatus of classifications, maps and metrics.

Thus, it is the decisive role of the state in demarcating informality and formality that “stands out as a common strand in a mass of literature that attempts different definitions” (Kanbur, 2017, p. 941; see also Steenberg, 2016). Furthermore, since the state bureaucracy operates “in writing”, in practice and empirical research, the distinction between formal and informal has often taken the simplified shape of a distinction between rules that are written and thus codified and those that are unwritten, respectively.

Informality vs formality: complicating the distinction

There are ample scholarly contributions that attempt to define and differentiate formality and informality. However, the scholarship that attempts to complicate this differentiation is no less abundant. One possible starting point for reviewing arguments advanced by this latter body of scholarship is the nature of the state, which is the hinge of the former body of scholarship. Many analysts have pointed out that the state is not a monolith built and operated entirely within the realm of formality, with the realm of informality being situated on the peripheries. A closer look at the state reveals that its administrative and bureaucratic machinery often operates “‘in the shadow’ of its own regulations, laws and procedural rules and codes” (Polese et al., 2019, p. 15).

First, agents of the state necessarily engage in the interpretation and adaptation of regulations and rules. These interpretations and adaptations do not constitute violations of the law; rather, they stem from the interstices between what is codified and relatively abstract regulations and the messy, diverse contexts that these regulations are meant to apply to. A classic work by Lipsky (1983) demonstrated how civil servants exercised a significant degree of discretion when acting in these interstices and relied on informally established norms and criteria of morality when doing so.

Second, the analytical strategy of divorcing the state from its citizens that is often implicit in conceptualizations that demarcate formality and informality has also been questioned. For example, Caldwell (2004) studied welfare in post-Soviet Russia and suggested that state institutions and structures should not be viewed as autonomous and insulated entities. Rather, they can be viewed productively as “associations composed of independent individuals with the ability to act in their own self-interest” (p. 37). Furthermore, these individuals remain connected by social ties to others and therefore, the actual functioning of the state or narrower the functioning of welfare as studied by Caldwell, is a collective and distributed endeavor where “private citizens and bureaucratic structures alike are complicit partners” (p. 37).

Analysts striving to complicate the strict demarcations between formality and informality have also focused on how this seemingly modest distinction feeds into managing and governing societies (MacLeod and Jones, 2011; Roy, 2005). The authors in this stream of research have problematized the picture of formality vs informality as objective and neutral categories. They have shown that the distinction operates as a governmental tool that enables particular interventions, including those in the spheres of resource allocation and service provision (McFarlane, 2012). For example, inhabitants of settlements designated as informal may be denied access to governmental programs. This designation is often made on the basis of a “cut-off” date with people who cannot produce documented proof of living in a settlement before this date no longer being eligible for infrastructure and services. The point about the arbitrariness and instability of the formality vs informality distinction has been made especially strongly in urban planning studies, as illustrated by Roy (2009), who wrote that informality does not “lie beyond [state] planning; rather it is [state] planning that inscribes the informal by designating some activities as authorized and others as unauthorized, by demolishing slums while granting legal status to equally illegal suburban developments” (p. 10). Instead of the picture of informality as lying beyond the reach of official governance mechanisms painted by the scholarship reviewed in the previous section, we see how informal politics are infused in seemingly formal spaces, including those of urban planning and development (McFarlane, 2012, p. 90).

It is not overly surprising that analyses following this line of thinking also highlight how the governance mechanisms themselves entwine what has been split into formality and informality. Cleaver (2002) developed this argument in her study of natural resource management in Tanzania. She questioned the strong focus on “formalisation, transparency, representation, regulation and rights” (p. 13) in conventional scholarship and policy documents on natural resource management, which also tend to ignore or condemn indigenous arrangements. Instead, Cleaver maintained that it is

a false dichotomy to pose a realm of “traditional” informal, culturally and socially embedded institutions against a “modern” domain of rationally designed committees and formal structures, and to suggest that one is likely to be better than the other at resolving conflicts or managing natural resource use. Local resource management arrangements are a complex blend of formal and informal, traditional and modern. (p. 17)

Indeed, according to the authors’ findings, such resource management arrangements have been evolving through a messy process of the piecing together of different mechanisms and formats, borrowed, improvised and adapted for multiple purposes. In the process, bureaucratic procedures may become embedded in networks of social relationships and norms, while “traditional” arrangements may become bureaucratized.

Overall, the scholarship devoted to complicating the clear-cut demarcations between formality and informality has highlighted the co-constitutive and codependent dynamics that inextricably entwine the two (McFarlane, 2019). A number of concepts have been offered to account for these dynamics, including grey zones and hybrid orders (Harboe Knudsen, 2015; Moreno-Martínez and Guerrero-Castro, 2020; Russo, 2016). At the same time, some scholars have cautioned against replacing “a binary view of informality with a conceptualization of their relationship as a continuum or spectrum”, arguing that “the two should be seen as inextricably related but distinct practices” (McFarlane, 2012, p. 103).

Nevertheless, further systematic theoretical elaboration of how exactly formality and informality are inextricably related but distinct has proven difficult. We suggest that this difficulty stems in part from collapsing two related but nonidentical distinctions onto each other: a distinction between formality and informality and a distinction between stability and fluidity. Below, we elaborate on these two distinctions and their relations to each other, and propose an approach for theorizing stability and fluidity, which may be used in some analytical situations in place of the concepts of formality and informality.

Fluidity and stability: introducing an alternative analytical lens

It is often assumed that formality is not only about visibility, accountability and traceability but above all about reliable stability. Correspondingly, even a more widely accepted hallmark of informality is that it is unscripted, unaccountable, shifting and unstable—in other words, fluid. However, even a cursory glance at real-world dynamics shows that formal rules and structures are not always fixed and static. For example, Roy (2009) showed that city planning and governance in India involved rendering “the law itself … open-ended and subject to multiple interpretations and interests”, both idiosyncratic and arbitrary, to enable various urban and industrial development projects. Furthermore, informal arrangements may well be stable and resilient to change. Arguably, the stability of some of these arrangements can be obscured by scholarly and policy tendencies toward “attributing greater value to formalized modes of interaction and codified norms” (Cleaver, p. 14). Moreover, when uncodified stabilities are identified, they tend to be frowned upon as impediments to the functioning of effective and robust regulations and, thus, targets for elimination.

Therefore, the distinctions between formality and informality and stability and fluidity do not map neatly onto each other; rather, stability and fluidity may cut across formality and informality. For example, looking at the aforementioned field of natural resource management in Tanzania, we can notice that some of the operating management arrangements are stabilized bureaucratically after they have been agreed upon and spelled out by officially established decision-making bodies, while others derive stability from other sources. One stable arrangement of the latter sort is an unofficial cattle protection militia made responsible by village consensus to, for example, maintain order in seasonal grazing lands. The ways in which this militia operates are based largely on socially embedded principles of reconciliation and conflict minimization. Here, we see that stable natural resource management arrangements entangle both what can be regarded as formal and informal elements. Fluidity, on the other hand, may flow through any kind of stable arrangements and accord flexibility to them. Therefore, at least in some situations, it can be fruitful to understand what is stable and what is fluid in order to disentangle dynamics from different fields.

Before giving an example of how this can be done, we shall spend the remainder of this section outlining a theoretical basis for understanding stability and fluidity. Here, we draw on an STS approach to studying society. This approach allows one to go beyond a number of problematic theoretical assumptions such as a monolithic view of the state, opposing state structures and individual citizens’ agency and viewing the categories of formal and informal as neutral and externally given. As such, it focuses on practices and understands what can be termed as larger scale phenomena-like institutions as composed by and maintained through practices.

For many strands of STS scholarship, objects, organizations and the rest of the societal fabric are made of relations. As long as these relations hold steady, everything is held together. In Law’s (2002) classic work, he provided an example of a Portuguese vessel during times of imperialist expansion to illustrate this point. A vessel can be thought of as a set of relations between the “hull, spars, sails, ropes, guns, food stores, sleeping quarters and crew” (p. 93). On a different level of scale, navigation systems, including charts and stars, can also be understood as components of this set of relations, as can the Portuguese imperial system at large, including ports, other vessels, markets and merchants. Thus, a vessel remains a vessel while “everything stays in place and the relations between it and its neighboring entities hold steady. Navigators, Arab competitors, winds and currents, crew, stores, guns: if this network holds steady then the vessel doesn’t flounder, it doesn’t get seized by pirates and it doesn’t sail on, lost, until the crew are broken by disease and hunger” (Law, 2002, p. 93). For the purposes of this paper, we can call these relations stable relations or stabilities. Following Law and Mol (1998), we can compare these stabilities with grids that can be pinned down and delineated that are mensurable and consistent.

Important for the argument of this paper is that stable relations are not the only type of relations that can be discerned. There are also relations that can be called fluid relations or fluidities for brevity. While understanding the Portuguese vessel as a set of stable relations is certainly fruitful, Law also argued that such an understanding would be incomplete as it effaces “the fluid ad-hocery necessary to keep a vessel at sea and afloat for an 18-month return trip to India” (Law, 2002, p. 101). Ad hoc tweaks, adaptations and adjustments are essential, yet they usually remain invisible behind the secure constancy and consistent functionality of stabilities or otherwise treated as technical failures to be eliminated.

Let us take a look at a more contemporary and detailed example to illustrate how fluidities either remain invisible or appear dangerously sloppy, lax and vague, when noticed. People diagnosed with diabetes need to become a part of the relations that constitute diabetes care. For this purpose, doctors often recommend that they undertake an intense monitoring of their blood glucose levels by using portable devices to feed the results into their care provision and achieve better glucose control. Setting up glucose monitoring seems straightforward: a diabetes nurse meets a new patient and shows them how to prick a finger, squeeze out blood onto a test strip, insert the strip into a monitor, read the results and save them. The patient then goes home, performs this string of actions several times a day and shares the results with the treatment provider. However, Mol (2009) demonstrated that despite appearances, setting up glucose monitoring may require much more adaptations and adjustments—or fluidity—than immediately apparent. She described how glucose monitoring almost failed for a man who worked as a builder, who could not find a private space on a building site to measure his glucose levels several times a day. To keep his diabetes diagnosis secret, he did not want to perform measurements out in the open. Using a toilet was not a suitable option because it was far away, dirty and could not be visited too frequently because his co-workers might have thought that he was dodging work. Possible outcomes of these circumstances could be that this man remained little involved in diabetes care or gave up on attempting to regulate his blood glucose altogether. However, Mol further showed a nurse’s attempt to connect a man and his monitor in a more fluid way. The nurse adapted the monitoring practice to the person’s individual circumstances and offered to measure once a day but at different times. The authors further highlighted that the glucose monitoring was made to work by trying various options to see what was suitable and attuning the different elements to each other. In the example considered, such trying and attuning practices are barely noticeable because they are neither mentioned in clinical guidelines nor reported; if noticed, they may even be frowned upon as dangerous violations of healthcare protocols.

To sum up, stabilities are kinds of relations that connect different—human and nonhuman—elements of the societal fabric in ways that are steady, traceable consistent and can be pinned down, delineated and accounted for. Conversely, fluidities are kinds of relations that are fleeting, inconsistent, uncountable and are hard to pin down, delineate and account for. If stabilities hold everything together, then fluidities make everything work. Coincidentally, making things work is a famous definition of informality given by Ledeneva (2018). However, we suggest that if we differentiate formality vs informality from stability vs fluidity, we will notice that “making things work” is a function of fluidities. Fluidities then flow through grids of stability, so to say, according the latter flexibility, plasticity and allowing some space for the unforeseen.

Importantly and in line with an STS approach to understanding society, focus on stable and fluid relations does not necessarily entail evacuating politics from analytical consideration. Instead, it entails attention to politics as practices of world-making that proceed in the context of (often not immediately apparent) conflict and power. It becomes possible, then, to distinguish a political character of seemingly apolitical practices, for example, of designing and using medical technologies. Looking at the interplay of fluidities and stabilities an analyst could shed a light on who has the power to decide which needs are addressed and how, which alternatives are sidelined and how the resulting arrangements are maintained.

An illustration: participation of patient organizations in patient councils in Russia

Below, we use the case of the participation of Russian patient organizations (POs) in what is called “patient councils” (Rus. patsientskiy sovety, a short for Councils of Non-State Organizations on Rights of Patients), to illustrate our argument about stability and fluidity. We base our account on an analysis of 51 semi-structured interviews and multiple participatory observations. The interviews were conducted with 34 research participants representing 16 nongovernmental POs from 19 Russian regions. All of them were also members of patient councils. The interviews lasted between 30 min and 3 h 30 min, with the average time being slightly over 1 h. The participant observations covered events organized by or with the involvement of several of the largest and most influential POs in Russia, such as patient gatherings, conferences, discussions, roundtables and meetings of patient councils. These data were analyzed using thematic content analysis, which was guided by our interest in how POs manage to participate in healthcare governance in a situation unfavorable to participation. The coding scheme was developed alongside data generation and was adapted in response to the insights emerging from the fieldwork. Regular meetings were held with all members of the project research group to continuously make sense of the generated data, discern patterns, critically discuss alternatives and develop analytical codes and categories.

Russian POs mainly focus on defending patients’ rights to healthcare. They actively interact with state institutions through official requests and complaints, in-person meetings with individual decision-makers and various expert events, such as conferences and roundtables. The key form of interaction between POs and state institutions are nonbinding consultative bodies, established to provide the state with expertise and knowledge about the needs of citizens in otherwise nonparticipatory authoritarian regime settings. Patient councils, which we discuss in this section, are one type of such consultative bodies. They are affiliated with federal and regional ministries of health and branches of the Agency for Surveillance in Healthcare (Roszdravnadzor). Members of the patient councils must represent non-profit organizations, a requirement that has allowed POs to establish a firm presence in patient councils and make this presence work for their purposes.

We use the case of POs’ participation in patient councils in Russia because of the challenges associated with analyses of this process. These challenges stem from two circumstances. First, healthcare governance in Russia is an extremely bureaucratized process with multiple and often conflicting regulations that coexist, somewhat paradoxically, with the large-scale informality characteristic of many post-Soviet healthcare systems. On one hand, this makes the formality vs informality distinction highly applicable; on the other hand, this distinction is not always capable to grasp the dynamics involved. Second, the participation of POs in patient councils and, thus, healthcare governance in Russia takes place amid an authoritarian climate that does not favor public participation. This situation requires an in-depth explanation of how participation works under such circumstances. Therefore, by relying on this case, we can see the extent to which the notions of stability and fluidity hold in terms of understanding how participation works here.

State institutions are not obligated to create patient councils. Nonetheless, once created, patient councils are an official, state-sanctioned channel for state–civil society communication and, as such, involve multiple stable relations. Some stabilities are more visible than others. One of the more visible sets of stabilities is constituted by the relations that make up the official status of patient councils. Each patient council is attached to a specific ministry of health or Roszdravnadzor; each has a specific structure, including a chair and secretary and an obligatory set of practices, such as chair’s and secretary’s duties and regular meetings; each follows a bureaucratically stabilized mode of action, such as the ways in which a council’s nonbinding decisions have to be written down in protocols so that they can be acceptable to officials. Other stabilities are less noticeable but are still steady, for example, the involvement of state officials in the work of the patient councils. While not required, state officials from a ministry of health or Roszdravnadzor, a specific patient council is attached to, customarily attend patient council meetings in the capacities of either a co-chair and secretary or as a speaker and observer. Officials from other bodies may also be invited as external experts on a specific topic and tend to attend despite other pressing duties.

Another example of stabilities can be gleaned from patient councils’ work formats, which are stabilized not bureaucratically but through something that can be called tradition or custom. For instance, many patient councils have working groups, members of which are selected by voting. Working groups are dedicated to developing solutions for issues in a specific area of (regional) healthcare. Their advice informs subsequent discussions at patient council meetings. Established routines of the working group operations involve individual members collecting and analyzing data on an issue related to the topic that the working group is dedicated to. Not everything is considered suitable and reliable data. Surveys of specific groups of patients, complaints from PO members formulated in an “official” language, analyses of legal documents and compilations of “best practices” of healthcare provision from other regions are admissible, whereas the life histories and experiences of patients that do not fit the conventions of format and style are not admissible. Following discussions about the collected data during a working group meeting, the contents of the discussion are summarized by a group chair in a form reminiscent of a policy note, with statistics, a review of the legislation and possible solutions. A patient council chair then includes the issue in the agenda of one of the upcoming meetings, where a working group representative or invited expert makes a presentation using the respective policy note document as a reference point. A discussion following the presentation leads to a (supposed) consensus on the nature of the issue, possible solutions and actions required, for example, writing an official letter to the Ministry of Health or organizing a joint meeting of a patient council with another state body or organization.

Thus, we can observe a number of stabilities in patient councils’ work routines in understandings of what reliable data are, and in ideas of what output formats and actions are acceptable. Importantly, only some of these stabilities are codified in a similar way as, for instance, the structure of patient councils. Others, such as shared notions of data reliability for a working group to draw on, are not spelled out in any protocol or procedural script. However, both form a set of relations that securely hold together the members of a patient council, its protocols, working groups and their notes. They also secure the position of a council vis-à-vis neighboring entities such as governmental bodies and POs.

At the same time, we can also discern that patient councils, a controlled and approved form of participation, involve multiple spontaneous interactions and situational practices and, therefore rely significantly on fluidities in their operation. These fluidities can be observed in, for instance, how information about the problems experienced by patients reach POs and then patient councils. While a council working group needs such information as statistical data and officially phrased complaints to focus on a particular issue in healthcare provision, the PO representatives involved in councils often bring in patient concerns that are not originally supported by such information. A PO representative may unexpectedly receive a phone call from a frustrated patient, stumble upon some problematic situation shared on a PO’s social media account or hear about a novel malfunction in healthcare provision from a fellow PO representative, during a social gathering. Upon receiving such ad hoc information, the PO representatives may employ various tweaks to adapt it to the patient council’s work, for example, by stripping it of emotional content, including references to regulations and reformulating the problem in such a way that it becomes relevant for more actors than a single specific patient.

Placing the information received on the agendas of a patient council and a wider range of stakeholders involves fluidity that is no less extensive. In order to make it happen, the PO representatives may mingle with other patient council members before council meetings and engage in a casual conversation about the topic of interest, call in-person meetings with experts or state officials “friendly” to that PO to obtain oral or written support for the main points of their presentation at an upcoming patient council meeting or send requests to multiple state institutions at once to learn of the positions of different decision-makers before choosing whom to send the recommendations from the patient council meeting. Whom to contact, when, with which words and how to convince other patient council members that an issue also concerns them are decisions taken by specific PO representatives based on their experience, “gut feeling” and some insights about other POs’ work or state officials’ agenda and interests. More generally, PO representatives in patient councils rely significantly on interpersonal relations with experts and state officials beyond patient councils to facilitate change. The development and maintenance of such relations is a very flexible process full of improvisations, such as inviting the Deputy Minister of Health for an after-meeting New Year celebration or a public acknowledgment in media and social networks of a medical professor backing the message of the patient council resolution.

The fluidities described above are much more unstable and inconsistent relations than stabilities. Nevertheless, they enable new concerns to enter the patient council’s apparatus to be taken seriously and to be engaged with by a range of stakeholders. They dilute the rigidity of stabilities, opening up some opportunities for responsiveness and adaptability. Thus, we can observe that in their participation in patient councils, POs rely both on the stabilities of the councils’ operation and the flow of fluidities through these stabilities. POs adhere to such stabilities as the structure of patient councils, formats for council output and conceptions of reliable data to be able to participate in healthcare governance in a setting largely unfriendly to participation. POs also rely on fluidities such as ad hoc information about patients’ problems and improvised tactics for ensuring support for powerful actors to make the patient councils work for them.

Conclusion

The distinction between formality and informality has been important for many scholarly fields. Without rejecting the usefulness of this distinction in this paper, we argued that instead of analyzing an empirical situation in terms of what is formal and what is informal, it could sometimes be fruitful to focus on what is stable and what is fluid.

The conceptual pair of stability and fluidity has hitherto been either overlooked or implicitly assumed to be identical to formality and informality. However, as we have shown, stability and fluidity do not map neatly into formality and informality; rather, they cut across these categories. We propose that both stability and fluidity be viewed as kinds of relations between different elements of the societal fabric. Relations of the first kind are steady, traceable and consistent and can be pinned down, delineated and accounted for, while relations of the second kind are fleeting, inconsistent, uncountable and hard to pin down, delineate and account for. Both are intertwined: stabilities that hold everything together and fluidities that make things work by according flexibility, adaptiveness and some space for ad hoc improvisations to stable grids.

We used the example of patient organizations’ participation in patient councils in Russia, to illustrate how this distinction can be applied analytically. Given the presence of firmly established uncodified stabilities exemplified by the routines and authority relations involved in patient councils, it is prudent to take them into account in the analysis alongside more explicitly formalized structures and modes of action. It then becomes noticeable that fluidities, exemplified by ad hoc channels of information about patients’ problems and POs’ improvised tactics of building relations with other stakeholders, flow through both, tweaking, bending and slightly blurring stable relations.

This example highlights that understanding change in different sectors of societal life, including health care, one of the most complex contemporary fields, may benefit from the application of the distinction proposed here. Perhaps it could be especially fruitful when applied to analyzing (1) complex bureaucracies where formal requirements are extensive and in potential conflict and (2) oppressive situations where significant power imbalances exist.

Importantly, focus on stabilities and fluidities makes noticeable political character of seemingly apolitical situations. By adopting it, it becomes possible to discern how power is exercised in apparently technical decision-making, how certain priorities and needs become sidelined and how particular arrangements are maintained. But drawing on the notions of stability and fluidity, analysts may not only be able to discern how things actually work. They may also be able to bring to the fore hitherto unnoticed forms of creativity, responsiveness and participation that feed, unassumingly, into shaping to a certain extent even situations characterized by exclusion.

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Acknowledgements

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 948073). The content of this article reflects only the authors’ views and the ERC Executive Agency and the European Commission are not responsible for any use that may be made of the information it contains.

Corresponding author

Olga Zvonareva can be contacted at: o.zvonareva@maastrichtuniversity.nl

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