Health Care Transformation in Contemporary China

252 Pages·2019·3.7 MB·English

by  Jiong Tu

Jiong Tu
Health Care
Transformation
in Contemporary
China
Moral Experience in a Socialist
Neoliberal Polity
Health Care Transformation in Contemporary China
Jiong Tu
Health Care Transformation
in Contemporary China
Moral Experience in a Socialist Neoliberal
Polity
123
Jiong Tu
School of Sociology and Anthropology
Sun Yat-sen University
Guangzhou, Guangdong
China
ISBN 978-981-13-0787-4 ISBN 978-981-13-0788-1 (eBook)
https://doi.org/10.1007/978-981-13-0788-1
Library of Congress Control Number: 2018944328
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Acknowledgements
First, I would like to thank Dr. Peggy Watson, my Ph.D. supervisor, for her advice,
encouragement, and support over the years. Her meticulous guidance accompanies
this research from conception to completion.
I owed great gratitude to the people in my field site, who kindly helped me
during the fieldwork and sincerely shared their stories, worries and hopes. Without
them, the work would be impossible.
I am very grateful to Prof. Jan Sundin, who read my Chap. 6 and offered helpful
advice, Prof. Patrick Brown, who read my Chap. 5 and provided useful comments.
I would like to thanks my friends and colleagues, C. Y. Ho, Gong Yidong, and Xiao
Zhimin, who read different parts of my chapters and gave me very useful sug-
gestions. Professor Therese Hesketh and Darin Weinberg gave me many helpful
suggestions on my work, and I really enjoyed the inspirational conversation with
them during the viva.
I would like to express my sincere gratitude to the people who stimulated my
intellectual growth and accompanied my sociology study: Prof. Yuan Tongkai,
Xuan Chaoqing, Peng Huamin, Liu Huaqin, Bai Hongguang, Jan Sundin, Sam
Willner, Marja-Liisa Honkasalo, Isabelle Baszanger, C. Y. Ho, Xiao Zhimin, Gong
Yidong, Alejandro Miranda, Ana Isabel Aranzazu, Mei Xiao, Wang Wei, and
others.
Also, I would like to thank Cambridge University Fieldwork Funds, Department
of Sociology, and Homerton College for funding my field research, the Foundation
for the Sociology of Health and Illness, the Society of Social Medicine, BSA
Medical Sociology Group, Cambridge Philosophical Society for aiding my con-
ference attendance during my Ph.D. study.
Thanks to the Springer team for their work and dedication in making the book
published.
Last, but most importantly, I would like to thank my family, for their support and
encouragement over these years, especially my husband, Bo, who gave innumer-
able support and accompanied me through the ups and downs during the writing up.
The book is also dedicated to my daughter Tutu, who came to my life and opens a
new window for me.
v
Contents
1 Introduction: The Politics and Morality of Health Care
Transformation in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Moral Experience of Health Care Change . . . . . . . . . . . . . . . . . . 1
1.2 Moral Experience in the View of Governmentality . . . . . . . . . . . . 6
1.3 Moral Experience of Health Care in the Transitional Chinese
Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.3.1 Chinese Governance in Transformation: A Socialist
Neoliberal Governmentality? . . . . . . . . . . . . . . . . . . . . . . 9
1.3.2 Moral Economy of the State: Health Care as a Modern
Project and Political Task . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.3.3 Moral Experience of Health Care in Chinese
Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.4 Field Site and Research Methods . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.4.1 The Field Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.4.2 Research Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2 Rescue First or Money First? Commercialised Institutions,
Calculating Professionals, and Neoliberal Governance . . . . . . . . . . . 37
2.1 Rescue First or Money First? . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.1.1 Troubling Emergency Treatment . . . . . . . . . . . . . . . . . . . . 39
2.1.2 Unpaid Debts in the Post-reform Era: The Bankruptcy
of the Credit System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.1.3 To Save or Let Die? The Doctor’s Dilemma . . . . . . . . . . . 42
2.2 Commercialised Institution, Calculative Subjects, and Neoliberal
Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2.1 Ambiguous Characteristics of Public Hospitals . . . . . . . . . 44
2.2.2 Corporatisation of Hospitals . . . . . . . . . . . . . . . . . . . . . . . 46
2.2.3 Doctors as the Calculative Subject . . . . . . . . . . . . . . . . . . 49
2.2.4 Hospital, Government and Neoliberal Governance . . . . . . . 51
vii
viii Contents
2.3 Individualising System Problem. . . . . . . . . . . . . . . . . . . . . . . . . . 52
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
3 From ‘Care of the Self’ to ‘Entrepreneur of the Self’:
Reconfiguration of Health Care Responsibilities, Needs,
and Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3.1 The Individualisation of Health Care Responsibility . . . . . . . . . . . 61
3.1.1 Health Care as a Moral Responsibility of the Family . . . . . 62
3.1.2 The Remaking of Traditional Self-Cultivation and
Socialist Self-Reliance . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
3.2 Patient-Consumer: The Neoliberal Subject? . . . . . . . . . . . . . . . . . 67
3.2.1 Patients as Consumers Negotiate Medical Care . . . . . . . . . 68
3.2.2 Assert Consumer Rights Vis-à-Vis Medical Institutions
and Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.2.3 Differential Consumption and the Reconfiguration of
Neoliberal Subject . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.3 Negotiate Health Care as Basic Needs and Government
Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.3.1 Unmet Health Care Needs and State Legitimacy . . . . . . . . 73
3.3.2 Rights to Basic Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
3.3.3 Need-Based Care as ‘Grace’ from the State, Rather Than
an Inalienable Right . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
4 Health Insurance Regime as Differentiation and Discipline . . . . . . . . 85
4.1 Health Insurance as Segregation: The Exclusion of Migrants . . . . . 87
4.1.1 The Migrant Worker Who Got a Brain Tumour . . . . . . . . . 88
4.1.2 Bureaucratic Regulations, Social Separation and
Exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
4.2 Health Insurance as Regulatory Technology . . . . . . . . . . . . . . . . . 92
4.2.1 The ‘Unqualified’ Patient Under Population Control . . . . . 92
4.2.2 Becoming Qualified Patients: Negotiate Insurance
Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.2.3 Using Guanxi to Gain Benefits: The Unequal Insurance
Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
4.3 Health Insurance for Profit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.3.1 Defraud the State’s Money: A Zero-Sum Competition for
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.3.2 Budget Audits and Counter-Strategies . . . . . . . . . . . . . . . . 100
4.4 Health Insurance for Governance and Legitimacy: The Making
of Governable Subjects and the Consideration for Social
Equality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Contents ix
5 Gift Practice in the Chinese Health Sector: Inequality,
Power and Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
5.1 Gifting: An Individual Technique for Better Care . . . . . . . . . . . . . 113
5.1.1 Changing Gift Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
5.1.2 ‘Compulsory’ Gift-Giving . . . . . . . . . . . . . . . . . . . . . . . . 116
5.1.3 Gifting to Hold Doctors Accountable . . . . . . . . . . . . . . . . 119
5.2 Gift Practice as Profit-Generation and Mutual Vulnerability . . . . . 121
5.2.1 Gift Practice as Profit-Generation . . . . . . . . . . . . . . . . . . . 121
5.2.2 Mutual Vulnerability of Patients and Health
Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
5.3 Gift Complicity and Governance . . . . . . . . . . . . . . . . . . . . . . . . . 126
5.3.1 Gift Practice as Domination, Extraction and Local
Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
5.3.2 Resistance or Complicity? . . . . . . . . . . . . . . . . . . . . . . . . 129
5.3.3 Gift Governance and the Ungovernable Gift Practices . . . . 131
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
6 Power Game of Nao: Violent Disputes in the Chinese Medical
Sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
6.1 The Outbreak of Yinao: From Forgiveness to Revenge . . . . . . . . . 142
6.2 The Power Game of Nao: Violence, Protest and Inequality . . . . . . 144
6.2.1 Nao in Daily Medical Setting . . . . . . . . . . . . . . . . . . . . . . 144
6.2.2 The Practice of Yinao: A Weapon of the Weak? . . . . . . . . 147
6.2.3 The Pressure of Preserving Stability . . . . . . . . . . . . . . . . . 149
6.2.4 The Inequality of Nao . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
6.2.5 Doctors’ Vulnerability, Defensive Measures, and the
Reversal of Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
6.3 Governing Disputes: Criminalising Nao, Civilising Patients and
Juridifying Conflicts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
6.3.1 Criminalisation of Nao and ‘Civilising’ Patients . . . . . . . . 156
6.3.2 The Insufficiency of Current Dispute Resolutions and the
Limitations of Nao. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
6.3.3 Juridifying Conflicts and System Reforms . . . . . . . . . . . . . 161
6.3.4 Conflicts Within Dispute Governance . . . . . . . . . . . . . . . . 163
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
7 Practice of the Self: ‘Barefoot Doctors’ in Post-reform China . . . . . 169
7.1 Barefoot Doctors in Transition: Self-doubt
and Self-transformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
7.1.1 The Disappearing Collective Clinics . . . . . . . . . . . . . . . . . 171
7.1.2 Self-reinvention and Self-legitimation in Post-reform
China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
7.1.3 Economic Struggle and Moral Responsibility . . . . . . . . . . 176
7.1.4 Moral Reconfiguration in the Market Era: Revolt Against
the Past . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
x Contents
7.2 Moral Economic Struggle for Subsistence . . . . . . . . . . . . . . . . . . 180
7.2.1 Ungoverned Professionals—‘Work Needs Payment’ . . . . . 180
7.2.2 Moral Economic Claim to Pension . . . . . . . . . . . . . . . . . . 184
7.2.3 Action for Pension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
7.3 Governance of the ‘Left-behind’ Doctors . . . . . . . . . . . . . . . . . . . 189
7.3.1 Government Responses . . . . . . . . . . . . . . . . . . . . . . . . . . 189
7.3.2 Moral Economic Struggle, Practice of the Self, and
Governance of the ‘Left-behind’ Doctors . . . . . . . . . . . . . 191
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
8 Conclusion: Moral Experience in a Socialist Neoliberal Polity . . . . . 197
8.1 Making Governable Subjects: Hybrid Moral Experience in a
Socialist Neoliberal Polity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
8.1.1 Self-responsible Patients and Differential Citizenship . . . . . 198
8.1.2 The Self-enterprise, Discipline and Resistance of Health
Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
8.1.3 An Assemblage of Governmental Rationalities and
Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
8.2 Healthcare Reform and the Moral Economy of the State . . . . . . . . 207
8.3 Governance, Conflicts and Limitations . . . . . . . . . . . . . . . . . . . . . 210
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Appendix A: Health Care Transformation in China in the Last
Several Decades . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Appendix B: Interview List of Health Professionals
and Administrators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Appendix C: Interview List of Patients and Local Residents. . . . . . . . . . 231
Appendix D: Other Data Collected and Used . . . . . . . . . . . . . . . . . . . . . . 241
Abbreviations
CASS Chinese Academy of Social Sciences
CCP Chinese Communist Party
CMS Cooperative Medical Scheme
CPG Central People’s Government
DXY Ding Xiang Yuan (a famous Chinese doctor online forum)
EMS Emergency medical service
GDP Gross domestic product
MOH Ministry of Health
MOHRSS Ministry of Human Resources and Social Security
MOPS Ministry of Public Security
MOT Ministry of Transport
NHFPC National Health and Family Planning Commission (since 2013, the
Ministry of Health and the Family Planning Commission were
reorganised to form the NHFPC as a ministry-level organisation)
NPC National People’s Congress
OECD Organisation for Economic Cooperation and Development
PRC People’s Republic of China
TCM Traditional Chinese Medicine
USA United States of America
WHO World Health Organisation
xi