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Trading Futures
Sadaqah, social enterprise, and
the polytemporalities of development gifts
Tom Widger and Filippo Osella
Abstract: In this article, we explore what happens when idea(l)s of Islamic charity
(sadaqah) and social enterprise converge within a low-cost public health clinic in
Colombo, Sri Lanka. For both the clinic’s wealthy sponsors and the urban poor
who use it, interpreting the intervention as a pious expression of care toward the
poor or as a for-profit humanitarian venture meant extending different futures to
the poor. The ambiguous temporalities of gifts and commodities anticipated by
benefactors and beneficiaries involved in this challenges anthropological assump-
tions concerning the marketizing effects of neoliberal development interventions.
Our ethnography revealed a hesitancy among the clinic’s sponsors, managers, and
users to endow the intervention with a final interpretation, undermining its stated
goal of promoting health care privatization and “responsibilization” of the poor.
Keywords: Charity, gift, Islam, social enterprise, Sri Lanka, temporality
Tucked away in the backstreets of Slave Island, CommClinic some three years earlier. Insofar as
a bustling but low-income Malay quarter in the CommClinic was able to successfully attract
Sri Lankan capital of Colombo, an unassum- both low- and middle-income patients and
ing medical center provides free health checks change health seeking choices in Slave Island, it
and cut-price prescriptions for local residents.1 had succeeded in its stated mission of “bridg-
CommClinic, a non-profit initiative of a wealthy ing the gap” between public and private health
Muslim family originating in a gift of sadaqah sectors in Sri Lanka. CommClinic proved at-
(voluntary charity) delivered via the corporate tractive to patients, ostensibly at least, because it
social responsibility (CSR) team of the company combined the presumed benefits of public and
they own, was one of three options for medi- private health provision (affordability and cus-
cal treatment available in the area. The other tomer focus, respectively) while solving some of
two, a tax-funded municipal health center and their problems (specifically, waiting times and a
a doctor’s private surgery, had reportedly strug- lack of trust) (see Russell 2005; Russell and Gil-
gled to attract users since the appearance of son 2006).
Focaal—Journal of Global and Historical Anthropology 90 (2021): 106–119
© The Authors
doi:10.3167/fcl.2020.072006Trading Futures | 107
Our opening portrait of health market “di- ity has helped to make social enterprise com-
versification” in Colombo that CommClinic patible with otherwise incompatible models of
represented obscured a complicated set of moves health care delivery—for example, by simultane-
through which actors launched, delivered, and ously embodying charitable and market models.
used the service. We referred to multiple kinds Alongside other “bottom of the pyramid”
of economic, social, and political language and (Prahalad 2005) interventions, social enterprises
practice that imbued the service—from Islamic like CommClinic are rooted in a belief that only
charity2 through CSR to the needs and aspi- once the poor take responsibility for their own
rations that directed patient choices between lives and are provided mechanisms for doing so
private and public services. Underpinning those can they escape the causes of poverty. A grow-
models and modalities of health care was a shift- ing critical literature has shown how such ap-
ing commitment on the part of the program’s proaches can also drive cuts to public services
benefactors to replacing beneficiaries’ exposure and engender new forms of economic, social,
to financial indebtedness caused by high pri- and health marginalization. Taking the shape of
vate health care costs, with a moral obligation what Julia Elyachar calls “empowerment debt”
to taking on responsibility for their own eco- (2005) and Ananya Roy defines as “poverty
nomic well-being. As CommClinic unfolded, capital” (2010), the poor are encouraged to de-
this ambition proved more complicated than velop an ethic of self-care attuned to neoliberal
it originally appeared to be, in terms of how logic (Cross and Street 2009; Dolan and John-
benefactors, managers, and users actually made stone-Louis 2011; Dolan et al. 2012; Elyachar
sense of the program’s stated charitable origins, 2012; Lazzarato 2012; Rajak 2010; Watanabe
compared with what it became at point of de- 2015). By “helping the poor to help themselves”
livery—a fee-based service. The contestations via the transfer of an entrepreneurial spirit via
that arose around aspirations for converting which the poor can adopt an attitude of personal
financial debts into moral obligations via reli- responsibility for their future well-being, some-
gious gifts and commercial relationships reveals thing of the benefactor travels to beneficiaries
some of the practical and conceptual conflicts (Allahyari 2000; Atia 2013; Muehlebach 2007;
that arise when the different temporalities that Osella 2017; Tittensor 2014; Trundle 2014).
adhere to gifts and commodities collide within While anthropologists have revealed how
a single organizational setting. such motivations transform ostensibly altruistic
We approach these issues by asking what or pious intentions into a more complicated and
CommClinic meant for the different actors in- interested act, they have rarely discussed the
volved in its design, delivery, and use. Social en- organizational mechanisms of subjectivation
terprises can include charities running money- itself. Anthropologists have also only sparingly
making ventures providing an income stream, to attended to recipients’ own experiences of such
regular businesses that direct profits to human- processes (Copeman 2011; Gregory 1992; Osella
itarian and development activities. The concept and Widger 2018). The metaphors that anthro-
of social enterprise is ambiguous, with legal, pologists have used to describe the “social life”
financial, and organizational form varying be- (Appadurai 1986; Stirrat and Henkel 1997) of
tween historical and social contexts and regula- gifts that “travel” (Ong and Collier 2005; Pet-
tory regimes (Kerlin 2009). They resemble what ryna 2009) from givers to receivers thus reveals
Marianne de Laet and Annemarie Mol (2000: an assumption that programs like CommClinic
225) have called “fluid objects”—unbounded operate in broadly linear terms—with largely
organizational forms that are “adaptable, flexi- unambiguous foundational values transferring
ble and responsive.” Within the context of global more or less unfettered to passive consumers.
health and development where intervention There has been surprisingly little attention paid
models routinely “travel” (Petryna 2009), fluid- to the question of whether benefactors hold true108 | Tom Widger and Filippo Osella
to their own ethical vision, or whether beneficia- and other infrastructure during the nineteenth
ries respond positively toward, let alone care for, century (Hewa 2012; Jones 2009). Following
the subjective transformations of “responsibili- independence from British rule in 1948, the
zation” that such interventions apparently seek post-colonial government launched a “Free
to engender (Trnka and Trundle 2014). In what Health” policy in 1951 that saw the national-
follows, we point to the struggles that benefac- ization of charitable and private hospitals and
tors experience in actually delivering what they the establishment of free-at-point-of-use cura-
set out to achieve in terms of the ethical transfor- tive and preventative services funded through
mation of the poor “other,” and the circulation or general taxation (Alailima 1995; Silva 2009).
counterflow of meaning that emerges from ben- The outcome of sustained public investment
eficiaries’ acceptance, translation, redeployment, across the second half of the twentieth century
or refusal of those benefactors’ aspirations. has been the development of an extremely high
The article draws from ethnographic re- quality health care system, especially in relation
search conducted over a period of 18 months, to preventative services, and excellent perfor-
from February 2012 to July 2013. First, we in- mance on population health indicators (Gupta
terviewed two of CommClinic’s original bene- et al. 2013; Samaratunge and Nyland 2006).
factors, LankaComm’s current and past CEOs, At the ideological level, free public health
Bilal and Esmail, at company headquarters. care remains a central commitment among all
Second, we held four separate meetings with the major political parties—even while pressure
LankaComm’s two-person CSR team, Samuel from international donors including the IMF
and Nimis, over a period of several months as (International Monetary Fund) led to gradual
we conducted longer-term fieldwork in Comm- privatization from the late 1970s (Kumar 2019).
Clinic settings in Slave Island and Grandpass. Today, public health care comprises just 50 per-
Third, we conducted a household survey and cent of outpatient care, although it still accounts
collected case study examples of CommClinic for 90 percent of inpatient care. While private
use among a sample of 66 local residents in both inpatient services remain beyond the reach of
communities. The article begins with a brief in- all but the wealthy middle and upper classes,
troduction to the Sri Lankan health care mar- outpatient services (clinics and dispensaries)
ket and the significance of CommClinic within offering routine health tests, consultations, and
processes of service provider diversification and prescriptions have burgeoned and are, in princi-
privatization that have been taking place over ple at least, accessible to all but the very poorest.
the past few decades. The next three sections Thus, around half (54 percent) of health spend-
follow the design, delivery, and use of Comm- ing in Sri Lanka comes from private sources,
Clinic from the perspectives of LankaComm’s including 85 percent paid out-of-pocket, 5–8
CEO and CSR team, and local people in Slave percent paid via employer benefits, 5 percent
Island and Grandpass. By way of conclusion, we paid via health insurance, and just 2–3 percent
reflect on how the fluid meanings of Comm- covered by the non-profit sector (Kumar 2019).
Clinic and paying closer attention to beneficiaries’ Although Sri Lanka has so far not experi-
responses challenges anthropological assump- enced significant levels of health care “diver-
tions concerning the subjective transformations sification” seen in other countries, the gradual
instigated by philanthropic interventions. expansion of a health care market has worked
to challenge public provision on both practi-
cal and ideological grounds. Publically funded
The Sri Lankan health care “market” curative services have suffered from chronic
underinvestment leading to staff and resource
The origins of the Sri Lankan health care sys- shortages, which has, in turn, led to a grow-
tem lie in philanthropic investment in hospitals ing political acceptance and appetite for theTrading Futures | 109
development of a market model incorporating waiting times were shorter. According to Russell
private and public-private providers (Kumar and Gilson’s interlocutors, private services ben-
2019). The majority of medical practitioners efited from a narrative of convenience, which
employed in the private sector remain public when it came to minor health complaints was
sector employees, and divide their day between valued as more important than trust by their
both sectors—often working in public settings research participants. As our own findings dis-
in the morning and private settings in the eve- cussed below suggest, a confluence of subjective
ning. A much-repeated complaint among the transformations linked with the re-valuation of
public in Sri Lanka is that state services suffer time and status found in narratives of conve-
due to the time constraints this places on medi- nience and waiting helps to explain the growing
cal staff wishing to “get away” to their (lucrative) acceptance in Colombo of the idea that health
private clinics. care can be paid for, as well as being one of the
The relatively high price of private health central messages accompanying CommClinic
care poses a significant risk to the financial se- branding.
curity of low-income households. Steven Rus- It has been against this background of mar-
sell and Lucy Gilson (2006) showed that for ket diversification on the one side, and grow-
those with the lowest incomes in Colombo, the ing risks of health inequality on the other side,
existence of free health care was an important that recent philanthropic investments in health
social protection measure as even the smallest have played out. Our research in Colombo re-
health expenditure could tip a household into vealed very high levels of voluntary investment
poverty and debt. A study conducted by the in health infrastructure, public health drives,
Catholic development NGO Caritas (2012) community health camps, and patient spon-
provided an indication of the levels of debt in sorship—amounting to what we term a health
Colombo’s low-income communities, much philanthroscape (Osella et al. 2015). Sri Lanka
of which a preference for or being forced to also boasts the highest levels of blood, organ,
choose private health care in the absence of and whole body donation in the world, with the
public health care had created. The researchers supply in corneas outstripping local demand to
found that for the urban poor, the “escalating such a degree that the island exports tissues to
costs of living and the fact that their meagre countries around the world (Simpson 2017).
savings could not meet the expenses related to For many Colomboites we spoke to, health
sudden shocks such as illness . . . in the family” represented a productive field for participation
was a cause of indebtedness (Caritas 2012: 38). as both givers and receivers of gifts and dona-
Similarly, The Women’s Bank of Sri Lanka3 has tions, generating material and spiritual merits
argued that health care costs are a significant and blessings for the healthy wealthy and the
cause of household debt. deserving poor—and for the poor whose gifts
Given the popularity of free health care in Sri of small change and blood and tissue donations
Lanka among the public and its continued im- too offered pathways to social and spiritual
portance in poverty reduction and social pro- satisfaction.
tection, the growing market for private health
care options is perhaps surprising. Russell and
Gilson (Russell 2005; Russell and Gilson 2006) The future uses of sadaqah
have suggested that while public services in Co-
lombo tended to enjoy greater levels of public It was thus into this health philanthroscape of
trust overall (for example, they were seen by re- economic and spiritual economies (Rudnyckyj
spondents to their research as subject to greater 2010) that the owners of LankaComm, one of Sri
levels of accountability and oversight), private Lanka’s biggest conglomerates, decided to en-
services were popular simply because patient ter when they launched CommClinic. Accord-110 | Tom Widger and Filippo Osella
ing to the company website, CommClinic was was to move eventually to South Africa, but
“inspired by the idea of providing free medical “business was good in Colombo, so we stayed
consultation and subsidized drugs to patients.” here,” Bilal told us. “We are Muslim Memons,”
The aim was to appeal to “patients from lower he said with a glistening smile, “business is in
income segments who are unable to afford the our blood!”
usually high-priced private health care system . A successful entrepreneur, Bilal was as keen
. . by giving an affordable solution to the people to talk to us about his charitable endeavors as
without compromising on quality and efficiency he was his family history. He explained how the
of health services.” In 2013, it was company pol- vast majority of what he gave took the form of
icy that no prescription should cost more than zakat, the compulsory monetary alms that all
Rs.200 (ca. £1.00), while the average cost of a Muslims of a certain financial worth must give,
private prescription was Rs.800 (ca. £4.00). and sadaqah, a term that translates as “charity”
We met one of LankaComm’s founding mem- and encompasses any form of spontaneous or
bers in his office at the company headquarters, a planned assistance to others—be it in the form
new three-story building off Colombo’s central of cash, kind, or time. Bilal was keen to stress
Galle Road. Bilal was a cordial and jovial man, that the Islamic laws governing the value and
peppering our conversation with jokes about destination of zakat and sadaqah aside, he gave
himself and his Memon Muslim community. both with equal commitment to ensure he sup-
He was keen to stress that he was a very busy ported only worthy causes for achieving maxi-
man. He had just returned from a business trip mum return. Bilal declined to tell us how much
to Dubai, and when we met he was preparing zakat he gave every year, because “it is a per-
to leave for Singapore and Hong Kong to “inau- sonal matter between God Almighty and me.”
gurate two new companies of the LankaComm “Also,” he grinned, “if I tell you the amount, you
group.” “Our chat will be short,” Bilal told us, will be able to work out my assets, and this is
but we could then talk at length with two of his private too!”
employees who managed LankaComm’s CSR However, Bilal did talk freely about the
(corporate social responsibility) programs. sadaqah (voluntary charity) he gave, much of
Bilal together with his four “cousin-brothers” which he still channeled collectively with his
(father’s brother’s sons) founded LankaComm brothers via the company’s CSR team. Bilal ex-
PLC in the late 1970s with the modest capital plained they ran a number of different schemes
of £1,500. After 35 years, LankaComm had de- to help “the poor, mainly Muslims,” including
veloped into one of Sri Lanka’s most successful help to start a small business, pay for marriage
corporations, and although the cousin-brothers expenses and medical emergencies, and provide
floated the company on the Colombo stock interest free loans. They also gave money to the
exchange in the 1990s, the founding family re- local Memon Association and two well-known
tained a controlling stake. Bilal was extremely Muslim charities, the Ceylon Baitulmal Fund
proud of his business achievements, but it was (established in 1957 by a prominent Colombo
not a rag-to-riches story. The family had its roots Muslim politician; see Osella 2017) and Mercy
in Gujarat where they had run a thriving textile Lanka (a social service organization funded by
business. On the eve of Partition, escalating at- Al-Rahma International of Kuwait). Among
tacks on Muslims convinced Bilal’s grandfather those interventions was CommClinic, Lanka-
to send his two sons to Colombo to set up busi- Comm’s jewel in the crown—the most ambi-
ness there, “just in case conditions worsened.” tious and most expensive program the brothers
The rest of the family stayed put in Gujarat until had supported.
after Independence, but left for Colombo after For Esmail, LankaComm’s former CEO,
anti-Muslim violence that followed Gandhi’s as- CommClinic’s ethos was grounded in the Is-
sassination in January 1948. The original plan lamic commitment to assisting the poor andTrading Futures | 111
needy living in close proximity oneself. During but don’t have money they don’t get help. It’s
an interview, he told us, “[Islam teaches] that if better if they pay something because then they
someone in your neighborhood is starving it’s value what they have and work harder to keep it.”
a sin for you to have proper meals or fill your- Throughout our fieldwork in Colombo, we
self up.” It was for this reason that LankaComm regularly encountered the belief that charity re-
opened the first CommClinic in Slave Island, a cipients failed to appreciate the help they were
short walk from LankaComm’s headquarters off given unless required to “give something back”
Galle Road. Esmail also stressed their involve- (Osella et al. 2015). Middle class interlocutors
ment in the program adhered to the ethic of worried this had the effect of encouraging de-
disinterested giving associated with sadaqah, in pendency, despondency, and lack of self-esteem
that the brothers’ involvement in CommClinic among the poor, and it also signaled their in-
had never been highlighted, and neither had ability to participate in “spiritual economies”
LankaComm’s backing of CommClinic featured (Rudnyckyj 2010) of gifting that provided a key
as part of its branding. Repeating the well-worn means through which blessings and merits could
phrase “the left hand should not know what the be accrued (Haniffa 2017; Osella 2017)—a dis-
right hand is doing,” Esmail insisted that Comm- tinctive feature of the Sri Lankan health philan-
Clinic be run independently from its benefac- throscape. For some organizations, including
tors’ personal or business interests—that the LankaComm, the social enterprise model that
gifts that launched and sustained CommClinic combined a fee-based approach with an ethos
during the first few years of its life were “pure.” of “affordability” and “inclusion” (summed up
Nevertheless, how LankaComm then de- in its motto of “bridging the gap”) provided a
livered the gift to recipients complicated these framework within which those marginalized
claims. The focus on health care itself emerged from economies (spiritual and otherwise) could
from what Esmail had described as a gap in the begin to participate by “think[ing] about debt,
market for private services that was oriented to investment, and loss in statistical terms” (Appa-
the needs of low-income people: durai 2013: 4). The solution that LankaComm
came to, as Esmail explained it, was deceptively
There is severe gap between the service simple: “Two years back our chairman had an
providers—the government hospitals and idea. The consultation will be free, medicines
the private hospitals—there’s a huge gap. sold at cost price.”
The health sector is costly for private pre- To that end, Bilal and Esmail both revealed
scriptions. . . . The government service is aspirations that CommClinic could become a
uncomfortable and not good. . . . And the leading example of “pro-poor” private health
people who go to the government hospi- care in the developing world. In 2014, after just
tals just can’t afford to pay for the services four years of being in business, CommClinic
you get from the private hospitals, so we celebrated its one hundred thousandth “cus-
want to bridge that gap. tomer.” Fees levied that same year exceeded
operational costs, making the program prof-
For Esmail, the gap that existed between public itable for the first time. Recognizing a market
and private health care was not only one created opportunity when he saw one, Esmail described
by the variable standard and cost of service. It how LankaComm was now seeking to consoli-
was also rooted in the challenge that it presented date its foothold in the health care sector. Their
in terms of cultivating an ethic of appreciation strategy would entail opening not only a dozen
and respect among the poor. Such uplift would or so new CommClinic sites outside Colombo,
emerge from the very fact of paying for a service. but also a full inpatient hospital in Colombo. To
As Esmail told us: “People have just become used achieve that goal, Esmail was also wary that they
to getting medicines for free. When they are sick had to move quickly, because the risk of com-112 | Tom Widger and Filippo Osella
petition was rising: “What we feel is, if we get CommClinic. The challenge that Samuel faced
this concept going, we might find a lot of other involved a struggle to reconcile the two sides of
people following suit . . . [A] lot of the corporate CommClinic that Bilal and Esmail had also told
bodies might want to do this as one of their CSR us about: on the one hand, the program origi-
projects. So we might set the trend.” Yet Lanka- nated in a gift of sadaqah; on the other hand, it
Comm’s vision to “bridge the gap” between pub- had adopted a business model. Perhaps because
lic and private health care also transformed the he was a Christian, or perhaps because the gift
nature of the relationship implied in the giving did not originate from him, but for Samuel the
and receiving of sadaqah—a shift that played on difficulty lay less in the possible tensions of
the minds of Bilal and Esmail, who were both marrying religious orthopraxy with market ra-
keen to stress they received no financial return tionality, than it did in the different subject po-
from their donation. However, by charging a sitions that CommClinic “users” or “customers”
nominal fee, LankaComm had also proven that would subsequently occupy in service settings.
the CommClinic program could sustain itself The major advantage of a social enterprise
without further charitable intervention on the model, as Samuel saw it, was the avoidance of
part of the founders. The originating gift of what he called the “charity problem.” In terms
sadaqah was thus temporally sealed off from its echoing Esmail’s, Samuel explained that al-
point of delivery in a fee-based service, retain- though “[medicines] are free from the gov-
ing its character as a “pure” development gift ernment, the problem is that our people don’t
(Stirrat and Henkel 1997). And it was precisely respect things if they are given for free, so we
for this reason that Bilal and Esmail could stress charge a small amount.” By levying a fee for
that although a business, CommClinic offered CommClinic’s services, Samuel wanted to foster
an excellent vehicle for discharging their ob- what he called an ethic of “self-respect” among
ligations to God, by “helping the poor to help the poor. However, in this Samuel also recog-
themselves.” It was through the introduction of nized a potential risk. By requesting payment,
a fee-paying model of health care that Colom- CommClinic also acquired new responsibilities
bo’s urban poor were to be uplifted, simply by toward its patients, whose status transformed
becoming more familiar with the concept of from recipients to customers. With such trans-
“paying their way.” formation came new expectations on the part of
“customers” for a service akin to that provided
in the private sector. Meanwhile, charges of
The risks of commodification and inefficacy or medical negligence could lead to
the protective force of charity negative media reports or claims for compensa-
tion. Ironically, Samuel argued that as a charita-
Operational responsibility for the CommClinic ble service, CommClinic had the right to refuse
program lay with LankaComm’s small CSR treatment to anyone whose ailments exceeded
team, consisting of a director, deputy director, the limited capacity of the clinic. As Samuel
and a couple of administrative staff. Samuel, explained, “There is a risk of litigation and as a
the CSR director, was keen to share the con- CSR project we want to avoid that. We stay away
tributions of his own vision and efforts in the from serious accidents. We’ve told the doctors
success of CommClinic. When we met, Samuel not to admit any patients who are serious but to
had just finished reading a book on social entre- always send them to hospital. We have to protect
preneurship published by Richard Branson, the our brand.” Samuel’s solution was to reempha-
founder of the Virgin business empire. Samuel size LankaComm’s charitable underpinnings,
explained that Branson had recently launched a which he regarded as providing the best defense
website showcasing innovative social enterprise against the predicaments of a market relation-
models, and Samuel was working on submitting ship implied by social enterprise. In so doing,Trading Futures | 113
CommClinic was able to cherry-pick the least both communities. At Slave Island, a munic-
serious medical cases, leaving to public hos- ipal dispensary, open between normal work-
pitals those deemed too costly and time-con- ing hours (8am and 4pm), was located at the
suming, or altogether intractable—a move that end of the road some five hundred yards from
transferred risk from CommClinic back into CommClinic. Samuel had explained that when
the public sector. CommClinic opened, a nearby private dispen-
Samuel’s approach to risk mitigation also sary soon closed because it could not compete
meant resisting a firm categorization of what with CommClinic’s low prices. At Grandpass,
CommClinic was supposed to be—a charity however, a private dispensary close to Comm-
or a social enterprise. If the future that Comm- Clinic remained in business, apparently because
Clinic represented was in the business of low- many residents had not yet been enticed by
cost private health care, then LankaComm CommClinic’s offer of cheaper care.
needed to accept the liabilities and risks that Our research in Slave Island and Grandpass
came with it. However, if LankaComm wanted began with a door-to-door survey, which then
to reduce its exposure to risks, then Comm- provided opportunities for longer interviews.
Clinic was compelled to reoccupy the ground Some simple numbers generated by the survey
of charity. Just as Bilal and Esmail had left the help to establish patterns of outpatient care in
future of CommClinic open to determination as both communities. Our results suggested that
means of protecting the purity of their original of the 66 (Slave Island, n = 35; Grandpass, n =
gift of sadaqah, Samuel avoided a firm designa- 31) residents we spoke to, 73 percent had used
tion for CommClinic as a means of protecting CommClinic service at least once over the pre-
the CommClinic and LankaComm brands from vious six months. At Slave Island, 46 percent
damage. of respondents said they used the local mu-
nicipal services when not using CommClinic,
compared to just 9 percent who used private
Choosing futures that fit: services and one who used a mix of public or
On using CommClinic or not private. At Grandpass, on the other hand, 36
percent of participants said they used the mu-
Thus far, we have described the kinds of futures nicipal service, 29 percent used a local doctor’s
that CommClinic’s benefactors and managers private surgery, and 19 percent a mix of both. In
imagined they could or should offer the poor, both communities, CommClinic had become
and how such temporal commitments shaped the first option for the majority of residents,
the ways they imagined CommClinic might de- with a slightly larger proportion using fee-based
liver health care. We now move to consider how services in Grandpass than Slave Island—a dif-
those who lived near CommClinic branches ference we suggest reflects the existence of a
in two inner city neighborhoods in Colombo slightly more affluent population in the former
responded to those visions. At Slave Island, compared with the latter.
the clinic was located opposite a government Respondents to our survey gave a range of
housing scheme, to the rear of which were il- reasons for choosing CommClinic above other
legal “encroachments” that over the decades services, including its competitive pricing (97
had developed from slum dwellings into solid, percent), convenience (97 percent), and trust
well-maintained homes.4 At Grandpass, the (92 percent). Respondents weighed the bene-
clinic was located in a maze of multistory en- fit of using free public services that were only
croachments of better quality than those found open during normal working hours and hence
at Slave Island. A range of public and private might incur lost earnings to attend, versus
health care facilities, within walking distance CommClinic that was also free (but charged for
or a short bus or trishaw ride away, served all prescriptions) and was open the evening. In114 | Tom Widger and Filippo Osella
relation to trust, respondents told us they re- health care was thus a real worry. Rizana had to
spected the medical staff for their involvement weigh the savings made by using the free mu-
in a charity project; they also focused on the ef- nicipal service against the time lost waiting for
ficacy of the prescriptions they received, which an appointment at the public dispensary; the
they said were reliable because CommClinic high charges of a private evening clinic would
sourced them directly from the government make a big hole in the family’s meager budget.
pharmaceutical service. By offering what Rizana described as a “conve-
Interestingly, just 20 percent of respondents nient service,” CommClinic provided a realistic
told us they were aware CommClinic was an ini- third option that, despite a small initial outlay,
tiative of LankaComm, and as many thought a worked out cheaper in the longer term.
group of doctors had started it as a charity proj- From LankaComm’s perspective, the com-
ect. However, 60 percent said they did not know. pany had launched CommClinic for people just
Beliefs ranged widely concerning the motives of like Rizana—the Colombo poor who normally
whoever was behind the project, from the idea incurred financial debts to access basic health
that CommClinic was a business run for profit, care but who shied away from resorting to ex-
a social service run for political gain, a form plicit charitable help. Rizana told us she was
of sadaqah offered by LankaComm’s Muslim happy to pay something to access CommClinic’s
owners, or as a “help for the poor people” of- provision; it gave her the chance “to experience
fered by a benevolent corporation. We detected a good lifestyle,” as she put it. Market inclusion
a slight correlation between those who thought allowed Rizana to access (relatively cheaply) pri-
CommClinic was a business and a tendency to vate health care as a consumer, avoiding what
trust the service less than those who thought it she thought of as the shame and stigma of “beg-
was some kind of charitable endeavor. Overall, ging” for health care. Nevertheless, Rizana was
our survey suggested that CommClinic pro- also aware that the clinic originated from the
vided the majority of residents with an option charity of LankaComm’s founders. She told of
that despite a small financial outlay worked out her appreciation of those men, and, as a Mus-
cheaper for people in the longer term. Of the 66 lim herself, hoped that Allah would bless them
residents interviewed, only two told us they did for their kind act in opening the clinic near her
not use CommClinic at all because it was too home. Rizana explained that the company’s own-
expensive. To explore these views further, we ers had created a relationship with, and an obli-
turn now to the experiences of three residents, gation to the community, through their sadaqah.
Rizana, Ibrahim, and Farrar. Because of this, Rizana said, no one would com-
Rizana, 43 years of age, lived in Slave Island plain about the service; she and her neighbors
with her husband and three children in a first expressed gratitude for the project. As a Comm-
floor municipal flat directly opposite Comm- Clinic user, Rizana had developed a complex
Clinic. Rizana explained the benefits of Comm- relationship with the clinic. She was neither an
Clinic in terms of the three key issues also empowered consumer nor a meek recipient of
important to our survey respondents—compet- charity. Rather, Rizana’s statements implied that
itive pricing, convenience, and trust. Rizana’s she had come to embody elements of both.
household managed on her husband’s meager Grandpass resident Ibrahim, 52 years of age,
income as a server in a local restaurant, where was a retired policeman who worked in the
he earned around Rs.400 (£2.00) per day. Like Colombo constabulary for some 25 years. He
most low-income families in Colombo, Rizana’s now survived on a government pension, and
household also depended on loans to meet both was the most financially secure person we in-
short and long-term contingencies, obtained terviewed in Grandpass or Slave Island. Ibra-
by either pawning jewelry or borrowing cash him lived with his wife in a three-story home
from local moneylenders. How best to deal with that his parents had originally built, extendingTrading Futures | 115
their once simple two-room encroachment into the CommClinic surgery. To earn a living she
a substantial house replete with middle-class sold roti to a local teashop for Rs.10 (£0.05)
lifestyle furnishings—a tiled floor, widescreen each, making around Rs.200 (£1.00) a day. Her
television, and washing machine. One of Ibra- husband, a three-wheel driver, earned another
him’s sons worked as a driver in the Gulf, while Rs.300 to Rs.500 (£1.50 to £2.50) daily. With no
the other was a government clerk. Both sent wealthy relatives to call on and most of the fam-
money home, and rather than depending upon ily’s moveable assets pawned years ago, Farrar
the charity of others when things became tight, and her husband struggled under heavy debt.
Ibrahim talked of how at Ramadan he liked As such, when taken ill, they had little option
to give zakat to “poor people in the area.” For but to use the free municipal health clinic. This
outpatient medical care, for the past ten years did mean, however, losing time and income
Ibrahim and his wife had used a doctor’s private waiting for an appointment, extending their
surgery located a short walk from their home. economic predicament further still. There was
When CommClinic opened, Ibrahim decided thus little in Farrar’s responses to our questions
to stay with his existing doctor. According to about CommClinic that expressed any enthusi-
Ibrahim, this was partly out of loyalty, as the asm whatsoever about the benefits of subsidized
doctor had always provided good care in the private health care. While she spoke about the
past, but also because he viewed CommClinic inadequacy of the municipal service, Farrar still
as extending charity, which was something he had no doubt it remained a better option than
was not in the habit of taking. CommClinic’s subsidized yet still expensive
Contrasted with Rizana, Ibrahim spoke as private service. “Municipal health service costs
a person secure in his ability to pay for private nothing, why should I pay CommClinic for it?!”
medical care. More than this, however, Ibrahim she asked with notable derision.
regarded the prospect of using even subsidized For Farrar, CommClinic either attracted fel-
private care as something beneath him and low residents who had forgotten their right to
demeaning. When asked under what circum- free medical care or were far too preoccupied
stances he might use CommClinic, Ibrahim about their status to accept charity. Farrar’s
suggested that only if he could not afford to opinion was crucial in exposing something that
visit his regular doctor would he consider doing others we interviewed did fear—that Comm-
so. On the possibility of using a free municipal Clinic would ultimately undermine free munic-
service, there was no question—“my sons will ipal services, leaving them only with fee-based
always take care of us,” he assured us. Thus, for outpatient health services. Thus, whether or not
Ibrahim using a fully private outpatient service people could or should use CommClinic, de-
was an important mark of status, while using spite its short-term benefits, was for Farrar tem-
CommClinic (or worse, a free municipal ser- pered by a longer-term and very real worry that
vice) would have damaged his status. Similarly, health care funded through general taxation
Ibrahim stated that he would never countenance would ultimately suffer, leaving the poorest like
the prospect of taking loans for medical care, her with no options at all.
even though he once did when he was younger The majority of respondents to our survey
and still struggling to raise children and pay for framed CommClinic just as Bilal, Esmail, and
a household on a single wage. The avoidance of Samuel might have hoped—as an affordable op-
both debt and charity was for Ibrahim an im- tion that emulated the benefits of public health
portant dimension of his ability to retain his care and the ease of private health care. How-
self-ascribed middle class identity. ever, the meanings and values they attached to
Back in Slave Island, we encountered Farrar, CommClinic scattered according to the diverse
a Muslim woman in her late forties living in a economic, social, and political positions of local
two-room encroachment in a small lane behind residents. CommClinic resonated the strongest116 | Tom Widger and Filippo Osella
for Rizana, who passed back and forth between For CommClinic’s founders and managers,
liquidity and debt, finding opportunities for economic and social transformation of the poor
self-advancement through the consumption really appeared to be achievable—if users suc-
of CommClinic yet always worrying about its cessfully habituated the underpinning ethos of
loss. Ibrahim, meanwhile, focused on main- rejecting “handouts” and “paying one’s way.” For
taining his more secure position in the world some local residents this did appear attractive,
of fully private health care. Farrar, struggling while for others it was insulting and politically
with debt, found CommClinic an unaffordable unpalatable. Such a trade in futures articulated
luxury. How and why people conceived of and by the ambiguous semantics of service provi-
understood those possibilities had important sions constituted at the interstices of Islamic
implications for service take-up and satisfac- charity and health consumerism challenged
tion, and ultimately for the longer-term outlook any straightforward reading of what Comm-
of the CommClinic program. It was far from Clinic might be or do for its sponsors and us-
clear whether CommClinic was achieving sub- ers alike. The idea(l) of CommClinic not only
jective transformations among beneficiaries of failed to travel unfettered from boardroom to
the kind imagined by Bilal and Esmail. beneficiary, at times it did not travel at all. The
consequence was an inevitable—and produc-
tive—ambiguity over what kind of program
Conclusion CommClinic was “really” supposed to be.
Thus the “heterochrony” (Ssorin-Chaikov
At the heart of our story has been a reflection 2006) of CommClinic—the presence of multi-
on the problem of definitional consensus un- ple temporalities at work in one location—for
der conditions of market diversification and us recalls arguments made by both Maurice
fluidity. As private health providers have gained Bloch (1973) and Pierre Bourdieu (1991), more
more ground in a landscape still dominated by recently rearticulated vis-à-vis the operations of
publicly funded providers, their “unique selling microfinance by Chika Watanabe (2015), that
point” (USP), as it were, has been an ability to sell gifts require specific amounts of time to be actu-
a narrative of convenience (short or no waiting alized as such. Reciprocated immediately, a gift
times) that has, at least for routine health checks, takes the shape of a commodity; reciprocated
trumped trust, which remains the strength of never at all, and it becomes a true debt. As David
public and charitable provision. Behind this USP, Graeber (2011) argues, loans and the obligation
and underpinning interventions like Comm- to pay one’s debts and charity and the commit-
Clinic, were shifting and often contradictory ment to reciprocate givers’ wishes are under-
ethical stances, aspirations, and practices, from girded by the same moral foundations—the
Islamic charity through CSR and social enter- responsibility to honor a return. CommClinic’s
prise, to the needs and ambitions informing pa- operational model engendered concomitant
tient choices within and between private, public, cycles of debt and return that sought to allure,
and charitable provisions. What traveled with if not bind, the Colombo poor to a project of
CommClinic as it passed from LankaComm’s spiritual and economic renewal. At stake was
boardroom to beneficiaries in Slave Island and not simply the delivery of health services to a
Grandpass were the different possible futures population of the urban poor, but the (re)imag-
that our informants themselves saw in the orga- ination of the subject of development and the
nizational and ideational forms taken by the pro- relational and moral obligations between givers
gram. Those forms were never stable and varied and recipients.
according to the aspirations and realities that Yet as we have shown, this endeavor was not
people held and faced as they sought to make the straightforward. Aside from “success stories”
program a viable health care alternative. like Rizana’s, LankaComm’s wider mission wasTrading Futures | 117
failing—struggling to find footing in the poly- his research has focused on social mobility
temporalities of the health philanthroscape. Bi- among ex-untouchable communities, migra-
lal and Esmail’s hoped-for future for the poor tion and mobility, masculinity, popular reli-
ran up against Samuel’s risk management strat- gion—Hinduism and Islam, in particular—and
egy that found corporate safety in the charity socio-religious reform movements, charity and
model. Most of those we spoke to at the com- philanthropy, and trade.
munity level were happy to pay for the service https://orcid.org/0000–0001–7054–9275.
but did not share a common understanding of Email: f.osella@sussex.ac.uk.
who was responsible for the intervention, its
funding model, or its social mission. Our eth-
nography revealed a hesitancy among the clin- Notes
ic’s sponsors, managers, and users to endow the
intervention with a final interpretation, leav- 1. The names of respondents and organizations in
ing open to question its potential or efficacy this article are all pseudonyms.
as a vehicle for promoting the privatization of 2. Rather the seeking to define Muslims’ almsgiv-
ing with reference to Islamic canon, we focus
healthcare.
on lived ideas and practices as we found them
during fieldwork. In this article, we mention
zakat, which is central to Islamic orthopraxis,
Acknowledgments and sadaqah, a routine and daily expression.
Zakat, a form of worship, is a religious obli-
This research was carried out in collaboration gation performed by giving a percentage of
with the Centre for Poverty Analysis (CEPA), one’s wealth to specific categories of (Muslim)
Colombo, and was supported by a generous deserving recipients. It is distinguished from
grant from ESRC/DfID (ES/I033890/1) for voluntary almsgiving, sadaqah, which is not
which we are grateful. We thank Sarah Kabir for regulated by normative rules and can be given
her valuable help with fieldwork, and Jock Stir- by anyone to Muslims and non-Muslims alike
rat for his insightful comments on earlier drafts (Benthall 1999; Bonner et al. 2003; Singer 2006).
of this article. 3. “The Women’s Bank in Sri Lanka.” http://www
.gdrc.org/icm/inspire/womenbank.html (acces-
sed 1 August 2020).
4. For a recent study of precarious housing in Slave
Tom Widger’s research spans social, health, and Island, see Harini Amarasuriya and Jonathan
environmental anthropology. He has conducted Spencer (2015).
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