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Ethnographic Explorations of Health Insurance in Vietnam
By: Amy Dao, PhD, Mailman School of Public Health, Columbia University
It’s 2:00AM in the morning and I am waiting with my friends on the side of the road for a bus that will take us from Vinh Long Province back to Ho Chi Minh City, the largest metropolitan area in Vietnam. This is not a public transit bus, but a privately owned and operated service bus used by the residents of this largely rural province for transport into the city. What’s more intriguing is that passengers use this particular bus to travel directly to the city health facilities for medical treatment.
As headlights direct us through bumpy streets, we stop intermittently to pick up other passengers waiting in the dark with their bags full of clothes and various fruit. Right before sunrise at 4:00AM, I abruptly learn that some have even managed to sneak on two roosters. At the drop off, a female employee of the bus company decides who will continue onto the motorbike taxis first. She groups everyone by destination and tends to give priority to those going to hospitals. My friends leave first and I wait a few minutes before being called up. They pair me with a man who appears to be in his late 40s. The three of us, including the driver, cram onto the back of a motorbike and stop first at hospital where my companion is dropped off.
Zipping through the streets on a motorbike is the best way to experience everything Vietnam has to offer. From the city to the country-side, the unobstructed views of lush gardens, street food vendors, rice paddies, buffalo, tangles of floating electrical cords, karaoke bars, and endless rivers never cease to evoke mixed feelings of harmony and frenzy. My time here this summer was made incredible by the warmth and friendship that I received from both old and new friends as I made my way through an ethnographic exploration of health care reform in Vietnam. I recall one of the many stories told to me by a local café owner as I was scouting out a potential research site in Vinh Long province:
“When you pay the doctor with your own money, he feels that the money is coming from you so he will treat you better. When he is paid by the insurance department, the doctor feels like the money is coming from insurance and he won’t care,” says Dì Nhó* as she explains her reasons for not enrolling in the government sponsored social health insurance program. Her response is indicative of how people are making sense of an expanding health insurance policy in contemporary Vietnam. Dì Nhó’s explanation is only one example of how insurance can open a window onto the ways that these state-wide policies have affected social relationships within the broader culture of care in Vietnam. It also reveals how money comes to have social meaning via the way it is exchanged and represented at a time of increasing social, cultural, and economic change.
In 1986, Vietnam’s economic liberalization policy of Đổi Mới marked a transition from a centrally controlled economy to one that is open to the market flows of global capitalism. Along with the movement of economic capital came the influx of ideas about how a newly privatized health care sector could be improved. With the passing of declaration WHA58.33, the World Health Organization’s endorsement of universal health coverage resulted in a renewed global interest in health care financing. Vietnam, in particular, enacted laws to reform its health insurance program and reach universal coverage by 2020. Current data show that while health insurance has reduced the cost of catastrophic spending, the majority of health spending in Vietnam continues to occur within the private sector in the form of out-of-pocket payments. In my project, I hope to explore the disjuncture between these two phenomena.
Last year, the Weatherhead Sasakawa Young Leaders Fellowship Fund (SYLFF) provided me with the opportunity to collaborate with Hanoi Medical University on social science research on HIV in Vietnam in the summer of 2012, which culminated in an article published here. This summer, SYLFF continues to be instrumental in the development of my scholarship and professional career by enabling me to embark on my own independent research to pilot my ideas and hypotheses about the effect of health insurance on people’s everyday conceptions of managing uncertainty in Vietnam.
During this time, I was able to move forward on my path towards dissertation research. I had two wonderful language teachers who not only improved my Vietnamese, but also fielded all of the naïve questions I was too afraid to ask others. I established scholarly contacts and institutional affiliation by attending a qualitative interviewing training workshop that was supported by the Social Science Research Council (SSRC) and the Southern Institute of Social Sciences (SISS) in Vietnam that specifically examined health care seeking patterns in Vietnam. With the help of SISS, I was put in touch with a fellow anthropologist to help me navigate through Vinh Long province and test out my questions about health insurance by talking to locals about their experiences with the health care system. Obtaining this information in an open-ended fashion allowed me to situate insurance within the wider context of people’s social relationships, thoughts about the future, and concepts of money. More importantly, being there to see and experience the waits at hospitals, how people are divided into those with and without insurance, and the difficulty of traveling to medical facilities during the common summer floods gave me a sense of the social and infrastructural issues that arise when trying to obtain health care. Without the support from SYLFF, I would not have had the means nor the flexibility to think about new questions to ask about insurance.
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