Cultures of Care and Finance
The year 2008 was a time when fierce debate over the Affordable Care Act (ACA) began. Those who believed stories about ACA’s state-backed death panels clashed with those who advocated for insurance as a human right and brought the politically charged terrain of health insurance into sharp focus. Outside of the U.S., however, the concept of universal health coverage (UHC)—in which people can access quality health services without suffering financial hardship—was taking root on the agendas of international development organizations, nations, NGOs, and donor foundations.
One such country experimenting with implementing UHC is Vietnam—a country whose changing status from a low-income country to a middle-income country has resulted in the urgent need to develop a sustainable health financing system to combat declining funds in development assistance.
The big question in Vietnam—and in debates in global health more generally—how do we operationalize UHC and build health insurance in a country where insurance has not been a popular method for paying for care?
As a medical anthropologist and a doctoral student in Sociomedical Sciences at Mailman, I situated my research in Vietnam because I believe international experience can be a source of profound insight into what is “cultural” about health insurance. If health insurance was so contentious in the U.S., what would implementing it in another country with particular cultural, political, and economic history look like? What could we learn about processes of UHC by focusing on the lives and experiences of those who the policy targets?
I have been passionate about medical anthropology since I stumbled into the subject as an undergraduate student. My finance and accounting books were replaced with ethnographies that used on-the-ground experiences to answer pressing questions about health and the human condition: for example, how does social inequality get “under the skin,” resulting in poor health outcomes for some but not others? How does experience of illness influence how we deal with it? How does political or cultural ideology impact the way societies provide care? Biology and culture matter equally in the human experience of illness and the economic systems and the political structures that support them play a critical role in the health risks people face and the treatments they can access.
What drove me to study at Sociomedical Sciences at Mailman was the School's commitment to understanding public health challenges through the theories of methods of social science, an essential lens for cross-cultural study. Through several preliminary summer trips to Vietnam and a combination of classes in anthropology, sociology, health policy, and health economics, I developed my dissertation project in Vietnam's Mekong Delta region, which had the lowest health insurance enrollment compared to the country’s other regions. I spent a year living in a community where I conducted ethnographic field research, did a homestay with a family of farmers, shared meals with neighbors, accompanied people at hospitals, met with state insurance agents, and later went to Hanoi to interview policymakers and researchers.
Along the way, I got to know the community, and became part of their social networks as I tried to grasp whether or not the promises of UHC had affected their health and economic well-being. I examined how their personal experiences, practices, and values shaped their perception and experiences of government-sponsored health insurance.
The implementation was fraught with many issues the government did not foresee. Those with chronic illnesses benefitted from health insurance, but the majority who were healthy or experienced acute illnesses found no value in health insurance and refused to buy it. Instead, they used their money for other immediate concerns that were morally worthwhile, such as paying for their children’s education, paying off debts, re-investing in their agricultural livelihood, and participating in community-strenghthening rituals such as weddings, funerals, ancestor worship rites, etc.
What the government had to do was to change people’s concepts of risk in order to convince them to purchase insurance. This was done through a combination of economic and discursive tactics, such as raising the price of medical care at public hosptials and tying health insurance participation to civic engagement. Health insurance in this case is not just a financial mechanism for redistributing the cost of care; it requires people to change their knowledge, action, and meanings about how to manage risk and health vulnerability. While UHC as an abstract concept holds promise, policy developers must pay attention to its practice on-the-ground.
I am currently finishing my dissertation manuscript. The interdisciplinary training I received at Mailman helped me approach questions about health care decion-making and responses to new policies affecting health and economics more holistically.
Amy Dao is a PhD candidate in the Department of Sociomedical Sciences. She is supported by the National Science Foundation Graduate Research Fellowship, the Tokyo Foundation, and Columbia's Weatherhead East Asian Institute. In 2008, she received her BS in Anthropology from the University of California, Riverside, where she is now completing her dissertation manuscript as a research fellow in residence at UCR’s Southeast Asia: Text, Ritual, and Performance Program.
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