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 © Springer Nature Singapore Pte Ltd. 2019 This work is subject to copyright. 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Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. part of Springer Nature The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore 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