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Following the collapse of Communism in 1991, Albanians have endeavoured to build a social and democratic state that guarantees fundamental human rights and freedoms, such as the equal right for all citizens to health care provided by the state (Albanian Constitution, Art. 55). However, such endeavour appears to be weakened by inefficient infrastructures and services, and by the approach of members of the medical profession towards different sections of the population. This paper looks at how different Albanians are coping with the inadequacy of the public health service, relying on different systems of exchange. In particular, a traditional system of exchange, based on balanced reciprocity, and a utilitarian form of exchange, which presents itself as a form of negative reciprocity. The analysis is cast in the context of the relationship between citizens and the state, ultimately addressing the impact that such “informal” exchanges have on governance in Albania.