THE UNCERTAINTY THAT SHAPES THE OPERATIONS OF HEALTH-FOCUSED NON-GOVERNMENT ORGANIZATIONS IN VIETNAM by Manh Hung Nguyen A thesis presented to the University of Waterloo in fulfilment of the thesis requirement for the degree of Doctor of Philosophy in Public Health and Health Systems Waterloo, Ontario, Canada, 2019 © Manh Hung Nguyen 2019 EXAMINING COMMITTEE MEMBERSHIP The following served on the Examining Committee for this thesis. The decision of the Examining Committee is by majority vote. External Examiner: Zubia Mumtaz, Ph.D. Professor, Program Director Global Health, School of Public Health, University of Alberta Supervisor: Craig Janes, Ph.D. Professor, Director School of Public Health and Health Systems, University of Waterloo Internal Member: Kitty Corbett, Ph.D. Professor, School of Public Health and Health Systems, University of Waterloo Internal Member: Warren Dodd, Ph.D. Assistant Professor, School of Public Health and Health Systems, University of Waterloo Internal Member: Jennifer Liu, Ph.D. Associate Professor, Department of Anthropology, University of Waterloo Internal - External Member: Susan Elliott, Ph.D. Professor, Department of Geography and Environmental Management, University of Waterloo ii AUTHOR’S DECLARATION I hereby declare that I am the sole author of this thesis. This is a true copy of the thesis, including any required final revisions, as accepted by my examiners. I understand that my thesis may be made electronically available to the public. iii ABSTRACT Objective: This research project explores how uncertainty shapes NGOs operating in the health sector in relation to other institutions, and how NGOs strategize to maintain their image and survive under uncertain conditions, while working to improve population well-being. Methods: The research questions were answered through qualitative methods. Twenty semi- structured interviews were conducted, thirteen with the representatives of NGOs, and seven with high-ranking government officers at both central and provincial levels. In addition, documents (decisions, proposals, reports) were reviewed. Results: Numerous uncertainties internal and external to NGOs greatly influence their operations. As a result, they adjust their mandates, roles vis-à-vis government, accountability, and delivery methods to manage these uncertainties. Although relations with government were sometimes difficult, in general NGOs confirmed that they supported government priorities. Several lessons about operations, programming, policy making, and relationship building have been learned through this study, resulting in recommendations being made to the government, to NGOs in Vietnam (including their headquarters), and to donors, aiming to facilitate smooth NGO operations and benefit communities. Conclusion: NGOs have no standing in the local socio-political structure, a problem arising from the government’s restrictive control of the civil society sector. NGOs do their best to avoid notice, “hiding themselves” to avoid attention or scrutiny. As a result, government-NGO relations are highly problematic, and NGOs often struggle to implement sustainable programs at the community level. Further studies are required to identify effective modes of NGO operations under such circumstances, including work to identify methods for strengthening NGO capacity, increasing appropriate donor engagement, and facilitating the localization of foreign NGOs. iv ACKNOWLEDGEMENT I would like to express my sincere gratitude to my supervisor Dr. Craig Janes for his continuous support of my Ph.D. studies and related research, for his patience, motivation, and immense knowledge. His guidance helped me in all the time of research and writing of this thesis, and allowed me to grow as a research scientist. I would like to thank my thesis committee members: Dr. Kitty Corbett, Dr. Jennifer Liu, and Dr. Warren Dodd, for their insightful comments and encouragement, but also for the hard questions which incented me to widen my research from various perspectives. In particular, I am grateful to Dr. Jennifer Liu for enlightening me the first glance of research. My sincere thanks also go to Dr. Susan Elliot and Dr. Zubia Mumtaz, who accepted to be my thesis examiners. Without their support, I will not be able to proceed with the thesis defence. I would like to thank Ms. Mary McPherson for her support editing English language for my thesis, which made me more confident presenting the first draft of the thesis to my supervisor. Words can not express how grateful I am to my wife Thu Vo for encouraging me throughout writing this thesis and my life in general, and to my children Huong Nguyen and Tony Nguyen for being very nice children when I do this thesis. v TABLE OF CONTENTS Examining Committee membership ii Author’s declaration iii Abstract iv Acknowledgement v List of figures x List of tables xi List of abbreviations xii Chapter 1 – Introduction and overview 1 Chapter 2 – Literature review on the role of NGOs in international development 7 2.1.Service delivery as a relief intervention 11 2.2.NGOs’ methods of service delivery 14 2.3.Policy advocacy 16 2.4.Watchdog or monitoring role 19 2.5.Global health research role 20 2.6.Essential elements of government-NGO partnerships in developing countries 22 2.7.Influences internal and external to NGO operations 24 2.7.1. Definitional uncertainty 30 2.7.2. Unclear legitimacy and accountability 32 2.7.3. Vague strategic plans 34 2.7.4. Financial insecurity 35 2.7.5. Local conditions 38 2.7.6. Summary 39 vi Chapter 3 – Research setting 42 Chapter 4 – Research design and methods 58 4.1.Qualitative research approach 58 4.2.Semi-structured interviews 60 4.2.1. The sample 60 4.2.2. The conduct of interviews 65 4.3.Ethics approvals 68 4.4.Document reviews 69 4.5.Data analysis and interpretation 70 4.6.Accuracy and reliability 74 Chapter 5 – Results – External influences on NGO operations 77 5.1.Case example 78 5.2.The issues of defining NGOs 82 5.3. Accountability of NGOs 91 5.4.Vietnam as a “middle income” country 93 5.5.Shifts in funding priorities 95 5.6.Regulatory constraints 105 5.7.Policy gaps 117 5.8.Labour market factors 123 5.9.Local partners, local populations, and field-based challenges 124 5.10. Wider political environment 130 5.11. Sensitivity about faith-based organizations 131 5.12. Summary 133 vii Chapter 6 – Factors internal to NGO operations 141 6.1.Case example 141 6.2.Factors affecting program implementation and effectiveness 144 6.3.Top-down directives from headquarters 159 6.4.Uncertainties related to staffing 161 6.5.Implications for NGO operations 164 6.5.1. Changing mandates 164 6.5.2. Changes to avenues of accountability 165 6.5.3. Changes in delivery strategies 167 6.5.4. NGO alignment with government 171 6.6.Respondents’ recommendations for NGOs 179 6.6.1. Educating government and donors 179 6.6.2. “Collaborating among themselves first” 181 6.6.3. Increasing the effectiveness of NGOs 183 6.6.4. Acquiring knowledge about government 184 6.6.5. Head office’s policies and directions 185 6.7.Recommendations for government 185 6.8.Recommendations for donors 188 Chapter 7 – Discussion 194 7.1.The core problem: Indeterminate social standing 195 7.2.Immediate causes of the indeterminate social standing 197 7.2.1. Issues with program implementation 197 7.2.2. Funding pressures and uncertainties in engagements with donors 205 viii 7.2.3. Key factors of the working environment 207 7.3.Root causes of the indeterminate social standing 209 7.3.1. NGOs hide themselves in a comfort zone 209 7.3.2. Uncertain politics and government control 216 7.4.Consequences 219 7.4.1. Unhealthy government-NGO relations 219 7.4.2. NGOs fail to produce lasting results 222 7.5.Summary 222 Chapter 8 – Conclusions 224 8.1.Summary of research 224 8.2.Contributions to knowledge 229 8.3.Contributions to practice 233 8.4.Recommendations for further research 234 References 238 Appendix 1 – About the author 261 Appendix 2 – University of Waterloo Ethics Clearance 264 Appendix 3 – Hanoi School of Public Health Ethics Clearance 265 Appendix 4 – Interview guides 266 ix LIST OF FIGURES Figure 1: NGO registrations Figure 2: NGO disbursements by sector Figure 3: NGO disbursements by geography Figure 4: Regions of Vietnam Figure 5: NGO financial figure relative to other financial resources Figure 6: NGO financial disbursements by year Figure 7: Organization of the Committee for Foreign NGO Affairs Figure 8: NGOs’ relations in Vietnam Figure 9: Data organized in concrete pieces Figure 10: Problem tree on NGO operations x LIST OF TABLES Table 1: Basic information about participating NGOs Table 2: Interviews by organization, mode of interviewing, and mode of recording data Table 3: Documents by source and type Table 4: Themes and sub-themes xi LIST OF ABBREVIATIONS AIDS Acquired Immuno-Deficiency Syndrome EU European Union GDP Gross Domestic Product HIV Human Immuno-Deficiency Virus HPG Health Partnership Group ILSS Institute for Labour Sciences and Society LMIC Low-Middle-Income Countries MPI Ministry of Planning and Investment NGO Non-Government Organizations ODA Official Development Assistance PACCOM People’s Aid Coordination Committee SDG Sustainable Development Goal SEDP Socio-Economic Development Plan USAID United States Agency for International Development VNR Voluntary National Review VUFO Vietnam Union for Friendship Organizations YAEP Youth Act to End Poverty Network xii CHAPTER 1 - INTRODUCTION AND OVERVIEW Vietnam’s so-called Open-Door policy, which began in 1986, has increased international investment flows to Vietnam. Economically, Vietnam is striving to become a middle-income country, as indicated by the great efforts of the government towards economic growth. United Nation Agencies in Vietnam, the Delegation of the European Union to Vietnam, and the Ministry of Planning and Investment of Vietnam (2014) regard this country as one of the most dynamic economies in the developing world, especially during the period between its initial economic reform and the global financial crisis of 2007-2008.