ABSTRACT
Until the late 1980s, the Communist Party of Viet Nam (CPV) promoted the development of an entirely state-financed health system designed to eventually provide health services to all Vietnamese as a right of citizenship. But the collapse of Viet Nam’s state-socialist economic institutions in the late 1980s occasioned a dramatic scaling back of these ambitions and necessitated an urgent search for new institutional arrangements to support the provision and payment for health care. In 1987, Viet Nam’s government permitted limited private provision of health care and in 1989 adopted a constitutional provision that permitted public health care providers to charge fees. Low public spending on health in subsequent years appeared to reflect both the fiscal weaknesses of the Vietnamese state and state leaders’ willingness to shift institutional responsibilities for health payments on to households. By the early 1990s, 80 percent of total health expenditure was estimated to be out-of-pocket. Thus, in the span of a few years, institutional responsibilities for health payments in Viet Nam had been largely shifted onto households. Access to health services beyond a basic level were now largely contingent on households’ spending power. The history of health care in Viet Nam since the early 1990s is, however, more complex and interesting than a simple story of “commodification.” Viet Nam during the 1990s did indeed experience catastrophic retrenchment in the health sector, the marketization of many aspects of health care, and the ill effects of these processes. But during the 1990s and especially in the current decade, the Vietnamese state has also reasserted its power in the health sector. In this essay, I explain the character and significance of these reassertions. The analysis is organized in three sections. In the first section, I explain how the erosion of Viet Nam’s planned economy in the late 1980s affected the principles and institutions governing the provision and payment for health care. In the second section I show that, even as Vietnamese political leaders resigned themselves to allowing markets and households a greater role in health sector governance, there was from a very early stage a discernable recursive element in health policy. That is, alongside policies that shifted the costs of health care from the state onto households, the CPV pursued certain redistributive reassertions of the state. Initially, these redistributive reassertions were small and took the form of legitimacy-seeking programs targeting such key constituencies as mothers of
fallen soldiers and certain war veterans. Gradually, these redistributive reassertions have expanded in their scale and scope. Through these redistributive reassertions, the Vietnamese state has sought to renew its commitment to promoting universal access to health services, even as the state’s success in so doing has been decidedly mixed. In the third section, I explain the genesis and outcomes of a quite different kind of reassertion of the state in Viet Nam’s health sector. Specifically, I show how, alongside efforts to protect certain segments of the population from ill-effects of a commodified health system, Viet Nam’s health policies have also promoted accumulative reassertions of the state. By accumulative reassertions, I refer to a variety of formal and informal measures the Vietnamese state has taken that promote state-managed health care facilities as sites of economic accumulation. I explain how, initially, accumulative reassertions of the state amounted to little more than tacit state approval of certain informal practices, such as acceptance of gift payments by health workers and the keeping of double and triple books. Gradually, however, the Vietnamese state more actively promoted economic accumulation in the health sector as a way of reducing state-run health care service providers’ dependence on the central budget. These accumulative reassertions of the state, which the state has now sought to recast as “social mobilization,” has had four major and in some respects contradictory results. They have enabled significant increases in revenues among some state-run health facilities, and state-run hospitals in wealthier regions in particular. They have enabled increases in staff pay, particularly in state-run hospitals in wealthier regions; they have exacerbated health sector inequalities, as service providers in rich regions are able to more easily “cash in” on market opportunities; and finally, promoting economic accumulation has had the practical effect of commercializing health care, reinforcing (perverse) incentives to place private interests of health staff before public health. The government’s recent move to promote further (and weakly regulated) decentralization in the health sector threatens to intensify these perverse incentives. Overall in this essay, I demonstrate that reassertions of the state in Viet Nam’s health sector have responded to the different and sometimes contradictory imperatives of market-Leninism (London 2003, 2009).3 In market-Leninist regimes, Communist Parties adopt market institutions and employ market-based strategies of accumulation while retaining Leninist principles of political organization. In Viet Nam, the subjugation of health care to market principles and outof-pocket payments and the social consequences of these arrangements plainly contradicted the historically rooted, self-legitimating ideologies of the Communist Party and created pressure on the state to provide various forms of social protection through redistribution. On the other hand, public health expenditure remained low and the health sector’s increasing dependence on resources garnered through market-based accumulation reinforced the desire of health service providers to exploit market opportunities, thereby creating pressures toward the further commercialization and commodification of health care. In recent years, the Vietnamese state has continued to increase public spending on health, has extended fees-free health services to all children under age six,
and has promoted the development of a national health insurance scheme that presently counts 37 million beneficiaries. As recently as 2005, however, an estimated 70 percent of total health expenditures were out of pocket and improvements in health status continues to be uneven across regions and different segments of the population.4 Whether reassertions of the state in Viet Nam’s sector will contribute to the development of a health system that meets the needs of most Vietnamese is very much an open question.
