WHAT MEDICAL TOURISM TELLS US ABOUT THE PLURAL SECTOR OF GLOBAL HEALTH DIPLOMACY AND GOVERNANCE: AN ORGANIZATIONAL ANALYSIS OF CIVIL SOCIETY IN RIO DE JANEIRO, BRAZIL by FRANCIS JOSEPH MANZELLA Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Anthropology CASE WESTERN RESERVE UNIVERSITY May, 2019 CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES We hereby approve the thesis/dissertation of Francis Joseph Manzella Candidate for the degree of Doctor of Philosophy* Committee Chair Vanessa Hildebrand, PhD Committee Member Atwood Gaines, PhD, M.P.H Committee Member Lihong Shi, PhD Committee Member Eileen Anderson-Fye, Ed.D Date of Defense March 27th 2019 *We also certify that written approval has been obtained for any proprietary material contained therein. 2 For My Parents and Grandmother 3 Table of Contents List of Tables .......................................................................................... 6 List of Figures ......................................................................................... 7 Acknowledgments .................................................................................. 8 Abstract ................................................................................................. 11 Chapter 1: Introduction ........................................................................ 13 Applicative Value ............................................................................................... 19 Research Objectives ........................................................................................... 24 Outline of Chapters ............................................................................................. 26 Chapter 2: Literature Review and Theoretical Framework .................. 28 Global Health Diplomacy and Governance: Perspectives from Anthropology of Global Health ...................................................................................................... 28 Global Health Diplomacy ........................................................................................................................... 31 Global Health Governance ......................................................................................................................... 35 Anthropological Contributions to Global Health Diplomacy and Governance ....................... 39 Civil Society Organizations ........................................................................................................................ 43 Medical Tourism: Perspectives from Anthropology and Global Health ............ 46 Global Health Literature Trends .............................................................................................................. 54 Anthropological Literature Trends .......................................................................................................... 61 Theoretical Framework: Bourdieusian Organizational Analysis of Health Institutions .......................................................................................................... 67 Bourdieusian Practice Theory ................................................................................................................... 67 Bourdieusian Organizational Analysis ................................................................................................... 69 At the Intersection: Organizational & Medical Anthropology ....................................................... 73 Chapter 3: Methods ............................................................................... 76 Data Sources ....................................................................................................... 76 Data Collection ................................................................................................... 79 Participant-Observation .............................................................................................................................. 79 Continuous Monitoring ................................................................................................................................ 80 Semi-Structured Interviews ......................................................................................................................... 82 Data Analysis ...................................................................................................... 83 Field Notes and Memos ................................................................................................................................ 83 Meeting Analysis ............................................................................................................................................ 84 Semi-Structured Interviews ......................................................................................................................... 84 Triangulation of Data ................................................................................................................................... 85 Ethics .................................................................................................................. 86 Limitations .......................................................................................................... 87 Chapter 4: Managing Risk With Prospective ....................................... 89 4 Problem-solving .................................................................................... 89 Entering the Field: A City in Transition ............................................................. 90 Meeting the Team ............................................................................................. 102 Forecasting the Market ..................................................................................... 107 Organizational Competence ..................................................................................................................... 110 Personal Safety ............................................................................................................................................. 115 Patient Comfort ............................................................................................................................................ 118 Routine Practice of a Key Strategy: Prospective Problem-Solving ................. 121 Chapter 5: Managing Partnerships by Affirming Amenability .......... 125 Standard Protocol for Selecting, Onboarding, and Dismissing Providers ........ 128 Organizational Review of Service Providers’ Partnership ............................... 139 Fixed Preparedness ..................................................................................................................................... 141 High Supply, Low Demand ....................................................................................................................... 147 Insourcing Services ..................................................................................................................................... 152 Routine Practice of a Key Strategy: Affirming Amenability ........................... 155 Chapter 6: Practice in Action: ............................................................. 160 Demarcating the Organizational Field ................................................ 160 Chapter 7: Conclusion ....................................................................... 174 Summary of Main Findings .............................................................................. 174 Research Implications ...................................................................................... 181 Anthropology of Health Organizations ................................................................................................. 181 Anthropology and Global Health of Medical Tourism .................................................................... 183 Anthropology of Global Health Diplomacy and Governance ....................................................... 184 Bibliography ....................................................................................... 188 5 List of Tables Table 1: Reasons Why Patients Travel Abroad for Health Care, as Articulated in the Anthropology and Global Health Literature…………......... 48 Table 2: Perceived Medical Tourism Risks, Solutions, and Requisites, as Determined by Organizational Team Members in Brainstorming Meetings…………………………………………………………………........... 110 Table 3: Perceived Measures of Partnership Selection, Allegiance, and Quality, as Determined by Organizational Team Members in Site Inspection and Negotiation Meetings…………………………………………………………... 141 6 List of Figures Figure 1: The Process of Prospective Problem-Solving, as Routinely Practiced by Organizational Team Members during Brainstorming Meetings ……………………………………………………………………….. 121 Figure 2: The Process of Affirming Amenability of Service Providers, as Routinely Practiced by Organizational Team Members during Site Inspection and Negotiation Meetings………………………………………….. 156 Figure 3: Theoretical Model From Bourdieusian Organizational Analysis..…. 163 7 Acknowledgments This dissertation never would have been possible without the generous funding, support, and opportunities bestowed to me by several organizations. I would first like to thank the National Security Education Program (NSEP) for a David L. Boren Fellowship, which provided me the opportunity to conduct pre-dissertation fieldwork in Rio de Janeiro, as well as learn Portuguese