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The Social Life of Health Insurance Temporality, Care, and the Politics of Financing Health in Rural Vietnam Amy L. Dao Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy under the Executive Committee of the Graduate School of Arts and Sciences COLUMBIA UNIVERSITY 2018 © 2018 Amy L. Dao All rights reserved ABSTRACT The Social Life of Health Insurance: Temporality, Care, and the Politics of Financing Health in Rural Vietnam Amy L. Dao Health insurance stands at the center of global debates on how nations can ensure equitable access to health care, especially for countries like Vietnam whose integration into the global economy has boosted economic development but intensified social inequality. When health insurance is promoted to low- to middle-income country contexts by development agencies such as the World Health Organization and the World Bank, what embedded cultural values accompany this? How do locally specific historical, political, and ethical concepts for managing vulnerability and uncertainty shape public understanding of insurance? To date, empirical research on health insurance’s impact has tended to examine its relation to health outcomes, service utilization patterns, or health care delivery rather than its cultural effects. As health insurance initiatives have expanded to at least 27 countries within the last decade, the universality of insurance’s value to local populations cannot be assumed. This ethnographic research investigates the cultural mediators and effects as a factor for understanding public responses to health insurance. It documents how this financial technology is transforming knowledge about how to care and manage health vulnerability. With the support of international organizations, the Vietnamese government began its universal health insurance enrollment campaign in 2015. State officials, however, identify the “Vietnamese habit” of purchasing insurance only when ill as both a technical and cultural problem to achieving universal coverage. To better understand this process, I investigated how strategies to “change the mindset of citizens” were deployed by state media and personnel, and then actively resisted, incorporated, or transformed by community members. The study took place in Vinh Long Province, an agricultural area in the Mekong Delta with one of the highest uninsured rates in the country. I conducted twelve months of ethnographic research, including 60 semi-structured interviews with community members, health insurance professionals, and health care professionals; and extended participant observation in government health facilities, insurance offices, and the homes of community members. The study analyzes the social consequences of new health insurance initiatives, the temporality of care, everyday dimensions of health care uncertainty, and their relevance to concerns within medical anthropology. I demonstrate how Vietnam’s insurance reform affected the terms through which people understood their social relations and risk subjectivities. By detailing the dynamic processes of a health insurance campaign aimed at changing health behaviors, the research reveals how financial policies are not value neutral. Rather, they reshape local moral worlds, social relations, and practices for managing uncertainty in late socialist Vietnam. TABLE OF CONTENTS LIST OF CHARTS, GRAPHS AND ILLUSTRATIONS ................................................ ii ACKNOWLEDGMENTS .............................................................................................. iv DEDICATION .............................................................................................................. vii INTRODUCTION: Imagining Health Insurance, Imagining Time and Care ................................................................................................................................ 1 CHAPTER 1: Globalizing Health Insurance and Social Health Insurance in Vietnam .................................................................................................... 42 CHAPTER 2: Stratified Health Care and Living with Uncertainty in Vietnam ........................................................................................................................ 61 CHAPTER 3: Mediating Value for Health Insurance in Vietnam .................................. 89 CHAPTER 4: The Temporality of Illness and Health Insurance ................................. 129 CHAPTER 5: From Familial to Financial Obligation: Insurance and the Moral Economy of Illness ..................................................................................... 160 CHAPTER 6: Precarity Over Risk: Money and Care in Vietnam................................. 189 CONCLUSION: The Social Life of Health Insurance ................................................. 222 REFERENCES ........................................................................................................... 231 i LIST OF CHARTS, GRAPHS AND ILLUSTRATIONS Figures Figure 1: Vietnam's Political and Health System Organization ...................................... 28 Figure 2: Map of Vietnam with major cities and Vinh Long Province ........................... 35 Figure 3 - Map of Vinh Long Province .......................................................................... 37 Figure 4: Evolution of Social Health Insurance in Vietnam (1989-2020) ....................... 52 Figure 5: “Determined to achieve socialist industrialization” (Quyết tâm thực hiện công nghiệp hóa XHCN- xã hội chủ nghĩa). Dogma Collection Online, 1961-1965. ..................................................................................................... 111 Figure 6: “For the future of our children” (Vì tương lai con em chúng ta). Dogma Collection Online, circa 1950-1975. ............................................................... 111 Figure 7: To join health insurance is to protect the health of your family and community (Tham gia bảo hiểm y tế là bảo vệ sức khoẻ cho gia đình và cộng đồng xã hội). .................................................................................................. 115 Figure 8: “Join health insurance, us for everyone and everyone for us” (Tham gia bảo hiểm y tế, mình vì mọi người, mọi ngươi vì mình). .............................. 115 Figure 9: “Participating in social insurance and health insurance is the responsibility and benefit of everyone” (tham gia bảo hiểm xã hội, bảo hiểm y tế là trách nghiệm và quyền lợi của mọi người)................................................ 117 Figure 10: “Health insurance, contribute when well and save when ill” (Bảo hiểm y tế đóng góp khi lành, để dành khi ốm). .................................................... 117 Figure 11: “Health insurance: for the health of the family, friend, please actively join” (Bảo hiểm y tế, vì sức khoẻ của gia đình bạn, hãy tích cực tham gia). .................................................................................................................... 120 Figure 12: “For health of the children and for the future of the nation, please participate in health insurance” (Vì sức khoẻ con em và tương lai đất nước, hãy tham gia bảo hiểm y tế). ........................................................................ 122 ii Figure 13: “For the well-being of society, for the happiness of everyone, please join social insurance and health insurance” (Vì an sinh xã hội vì hạnh phúc mọi người, hãy tham gia bảo hiểm xã hội, bảo hiể y tế). ............................. 122 Figure 14: “Social insurance, health insurance. Ensure the well-being of society (social security), push forward the construction and protection of the country.” (Bảo hiểm xã hội, bảo hiểm y tế, đảm bảo an sinh xã hội, thức đẩy sự nghiệp xây dựng và bảo vệ tổ quốc). ........................................................ 124 Figure 15: Covered Health Insurance Billboard in Town Center. The caption reads, “The Social Insurance Office of Vietnam. Participating in social insurance and health insurance is the responsibility and benefit of everyone’ (Bảo Hiểm Xã Hội Việt Nam. Tham gia bảo hiểm xã hội, bảo hiểm y tế là trách nghiệm và quyền lợi của mọi người)................................................ 126 Figure 17: The Outpatient Waiting Area...................................................................... 129 Figure 16: Patients using their dossiers as place holders in the queue. ......................... 129 Tables Table 1: Sampling Matrix for Community Members of Vinh Long Province ........................................................................................................................ 32 Table 2: Sampling Matrix for Expert Informants ........................................................... 32 Table 3: Time chart comparing the hours of operation for state health facilities, private clinics, and private pharmacies ......................................................... 149 Table 4: Relationships and Moral Debt in Vietnam ..................................................... 176 iii ACKNOWLEDGMENTS I have incurred many debts on the path towards a PhD. First and foremost, I would like to thank my host family in Vinh Long Province for the everyday care and kindness they showed me. They never let me leave the house without a full stomach, a canteen of coconut water, and a piece of advice. There are many people whom I unfortunately cannot acknowledge by name, but who became my teachers and close friends during my time in the field. A special thank you to my research assistants