Outside of the U.S., the concept of universal health coverage (UHC) is taking root on the agendas of international development organizations, nations, NGOs, and donor foundations. One such country experimenting with implementing universal coverage is Vietnam—whose changing status from a low-income country to a middle-income country has resulted in an urgent need to develop a sustainable health financing system to combat declining funds in development assistance.
[Photo: Ms. Amy Dao]
Researcher Ms. Amy Dao, a medical anthropologist and PhD candidate in the department of sociomedical sciences at the Columbia University Mailman School of Public Health, studied what implementing health insurance would look like in Vietnam — a country with a particular cultural, political, and economic history — and the processes of universal health coverage, by focusing on the lives and experiences of those who the policy targets.
“The big question in Vietnam—and in debates in global health more generally—is how do we operationalize UHC and build health insurance in a country where insurance has not been a popular method for paying for care,” said Ms. Dao.
To determine how political and cultural ideologies impact the way societies provide care and why some purchased insurance and others did not, Ms. Dao conducted ethnographic field research in Vietnam’s Mekong Delta region, which had the lowest health insurance enrollment compared to the country’s other regions. This included accompanying people at hospitals, meeting with state insurance agents, and interviewing policymakers and researchers in Hanoi.
Ms. Dao got to know the community, and became part of their social networks. “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.”
Those with chronic illnesses benefitted from health insurance, but the majority who were healthy or experienced acute illnesses found little value in health insurance because it was bureaucratically difficult to navigate and the quality of care they would receive was often questionable. Generally, they would only buy it if another family member needed it, or they wouldn’t purchase 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-strengthening rituals such as weddings, funerals, and ancestor worship rites, among others.
Ms. Dao found that the government had 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 hospitals 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,” said Ms. Dao. “While UHC as an abstract concept holds promise, policy developers must pay attention to its practice on-the-ground.”
Dao presented the findings “Three Tales of Health Insurance in Vietnam,” at Neubauer Collegium for Culture & Society, University of Chicago, based on her paper “The Social Life of Health Insurance: An Anthropological Agenda” in Medical Anthropology Quarterly.