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Global Health Cadres: Avian Flu Control and Practical Statecraft in Vietnam
Abstract
Recent scholarship suggests that in areas featuring entrenched poverty and compromised state infrastructures, disease outbreaks prompt multinational interventions that often supplant state institutions in the provision of health services. Ethnographic observation of a multinational avian influenza project in Vietnam permits exploration of the ways in which “global health” operates in a Communist state characterized by an active governmental apparatus. Descriptions of the routine activities of one veterinary cadre illustrate the practical actions through which the Vietnamese state exerts influence over global health processes. In the daily work of bird flu management, global health cadres negotiate an inconstant divide between multinational health agendas and established practices of state-making. The analysis thus begins the crucial task of addressing the ways in which global health interventions operate in nations that, while vulnerable to public health emergencies, are nevertheless characterized by growing economies and influential state apparatuses.
... Anthropological studies of different logics of biosecurity and care have compared the opinions of backyard farmers and commercial farmers in Indonesia (1) and farms and laboratories in Hong Kong (2). Anthropological studies focused on variety of biosecurity have compared corporate, state and systems security with farm biosecurity in Indonesia (3) and how global-state-society relations affect bird flu management in Vietnam (4). Porter also showed how risk perception may vary significantly within a local population in Vietnam, and how divergent risk maps, made by poultry farmers and health workers, represent the wider difficulties in how to define and manage avian influenza risks (5). ...
... Small-scale farms: <500 birds; medium-scale farms: 500-2,000 birds; large-scale farms: >2,000 birds.4 In the commercial live bird sector, all farmers, middlemen, feed dealers, wholesalers and retailers are men and predominantly Muslim. ...
In this paper, we identify behaviours in live bird commodity chains in Chattogram, Bangladesh, which may influence the risk of pathogen emergence and transmission: the nature of poultry trade, value appropriation and selling sick or infected birds. Examining the reasons why actors engage in these behaviours, we emphasise the politics of constraints within a context of real-world decisions, governed by existential and pragmatic agency. Focusing on contact zones and entanglement, analysing patron-client relationships and precarious circumstances, we argue that agency and structure specific to the Bangladeshi context produce a risk environment. Structural constraints may reinforce risky occupational practises and limit individual agency. Structural constraints need to be addressed in order to tackle animal and zoonotic disease risk along live animal commodity chains.
... For example, since 2003, 129 cases of avian influenza (H5N1) have been identified in humans in Viet Nam, leading to 65 deaths (World Health Organization 2024). The ongoing struggle to prevent and respond to diseases such as avian influenza that can quickly spread across borders, means zoonotic disease prevention and oversight has become an international effort with countries collaborating on shared strategies to combat disease risks and limit the impact of outbreaks when they do occur (Porter 2013). In Viet Nam, this includes membership in an international One Health Network with other Association of Southeast Asian Nation (ASEAN) countries, among others (ASEAN 2023). ...
This paper asks what influences farmers’ adherence to national and international zoonotic disease intervention efforts and argues that development and promotion of biosecurity interventions must take into account the economic and social context informing how livestock sectors operate and how those who work in them are making a living. Specifically, we explore how poultry farms in Viet Nam are managed amidst global efforts to combat disease and national ambitions to sustain growth. The growth of Viet Nam’s livestock sector has been accompanied by a range of disease outbreaks that have caused the deaths of animals and humans, threatened businesses, and led to the introduction and ongoing revisions to biosecurity efforts. Despite a strict national (and international) agenda focusing on disease control through biosecurity strategies, on farms disease management is implemented in various ways and to varying degrees. Based on fieldwork in three provinces of Northern Viet Nam and in-depth interviews with actors working on farms and across the commercial poultry sector, we reflect on social, financial and political factors shaping the country’s biosecurity narratives and discuss key practices farming households engage in that influence their disease management efforts. Our findings reveal that strict adherence to biosecurity guidelines is often practically unfeasible for commercial poultry farming households to implement where zoonotic diseases are not a concern related to bird and human health so much as a potential risk to a household’s living, that exists among a range of diverse opportunities and uncertainties shaping farming operations in Viet Nam’s changing livestock sector.
... Pets in North American settings are formally incorporated into human kin structures by way of titles such as "furbabies" and borrow many cultural features from their owners such as socio-economic status, social media accounts, and designer wardrobes. Meanwhile, a cognitive divide exists between pets and commodified agricultural species such as birds and cows whose large-scale exterminations are considered justifiable to protect human lives (Porter 2013;Rock 2017, 359;Singer 2014Singer , 1287Smart and Smart 2017, 59;Sullivan 2017, 158). Landscapes that possess similar biological properties are represented in different ways; the Amazon is designated a "rainforest" with limitless botanical benefits for humans while Africa is viewed as having "jungles" that present dangerous threats such as Ebola and AIDS (Zerner 2005). ...
A recent trend in public health campaigns has been to include non-human health data to capture all relevant variables related to human well-being. This specific approach is the foundation of the World Health Organization restructuring in the early 2000s as they adopted the “one health” framework. Politically, this movement is influential and draws significant health funding globally. "One health" is characterized by a multi-disciplinary collaboration between medical, veterinary, and health sciences. Similarly, the post-human turn in medical anthropology recognizes that viewing the non-human contributions to the cultural construction of health as symbolic does not adequately address how non-humans and nature independently contribute to human health realities. Ethnographic studies of the non-human perspective shed light on how humans are not the only beings that influence culturally constructed reality, nor are they exclusively in control of cultural phenomena. Theoretical trends in anthropology and public health seemingly converge; however, an artificial academic barrier between the sciences and social sciences remains. As these two disciplines are coming closer together through their data, breaking down structural barriers that prevent the successful integration of knowledge has potential to improve human health outcomes. Methodological concessions will have to occur on all sides to make the inclusion of the social sciences in public health possible. Doing so can bring academia closer to a comprehensive scientific understanding of human health.
... As is the tradition in this literature, qualitative methods were used to answer the research questions (Adato et al. 2011;Basilico et al. 2013;Bell et al. 2011;Brown et al. 2000;Lewis 1999;Markowitz 2001;Porter 2013). Qualitative data provide thick description of NGO operations, and their connections with communities and governments (Devault et al. 2006). ...
This research examines regulatory constraints and uncertain policy implementation on NGO (non-governmental organization) operations in Vietnam, and draws lessons for NGOs, the government, and donors. Research questions were answered through qualitative methods. Twenty semi-structured interviews were conducted, thirteen with the representatives of NGOs, and seven with high-ranking government officers. In addition, documents (decisions, proposals, reports) were reviewed. The government of Vietnam continually impose regulations intended to govern NGO operations through Decree 12/2012/ND-CP, Decision 76/2010/QD-TTg., and Decree 93/2009/ND-CP. Policy implementation is uncertain and unpredictable, making government-NGO relations unhealthy. NGOs should educate the government and donors, increase the effectiveness of implementation, and acquire knowledge about government operations. The government needs to strengthen awareness about NGOs’ operations, and improve the regulatory process. Donor-NGO communications should be strengthened. In summary, the political imposition results in unhealthy government-NGO relations. Government-NGO-donor communication should be improved so that NGOs can benefit society.
From surgical techniques to pharmaceutical treatments, included biological or clinical sciences: what are the specificities and contemporary realities of biomedicine in Southeast Asia? The diversity of its forms invites us to think about the situated character of knowledge and practices that medicalize and transform bodies. This issue examines the dimensions of care when it is produced by actors who mobilize and appropriate the conceptual and empirical tools of Western scientific medicine. It is dealing with providing care for the elderly in North Sulawesi, caregivers of children living with HIV/AIDS in Laos, the healing of a brain tumor among the Dayak Benuaq in East Kalimantan, Cambodian oncologists practices, as well as obstetric violence in Indonesia and Cambodia. All the contributions allow us to analyze how treatment and care are provided in hospitals, private clinics, and health centers to question, more broadly, what it means to be a doctor, a patient, a caregiver or a woman in this region of the world. Far from being exhaustive, these approaches contribute to understanding how biomedicine interferes in the daily life of patients and families by analyzing its current forms, what imaginary and values it carries today in Southeast Asia?
From surgical techniques to pharmaceutical treatments, included biological or clinical sciences: what are the specificities and contemporary realities of biomedicine in Southeast Asia? The diversity of its forms invites us to think about the situated character of knowledge and practices that medicalize and transform bodies. This issue examines the dimensions of care when it is produced by actors who mobilize and appropriate the conceptual and empirical tools of Western scientific medicine. It is dealing with providing care for the elderly in North Sulawesi, caregivers of children living with HIV/AIDS in Laos, the healing of a brain tumor among the Dayak Benuaq in East Kalimantan, Cambodian oncologists practices, as well as obstetric violence in Indonesia and Cambodia. All the contributions allow us to analyze how treatment and care are provided in hospitals, private clinics, and health centers to question, more broadly, what it means to be a doctor, a patient, a caregiver or a woman in this region of the world. Far from being exhaustive, these approaches contribute to understanding how biomedicine interferes in the daily life of patients and families by analyzing its current forms, what imaginary and values it carries today in Southeast Asia?
Global anxieties about avian influenza stem from a growing recognition that highly-virulent, highly-mobile disease vectors infiltrate human spaces in ways that are difficult to perceive, and even more difficult to manage. This article analyses a participatory health intervention in Việt Nam to explore how avian influenza threats challenge long-held understandings of animals’ place in the environment and society. In this intervention, poultry farmers collaborated with health workers to illustrate maps of avian flu risks in their communities. Participant-observation of the risk-mapping exercises shows that health workers treated poultry as commodities, and located these animals in environments that could be transformed and dominated by humans. However, these maps did not sufficiently represent the physical and social landscapes where humans and poultry coexist in Việt Nam. As such, farmers located poultry in environments dominated by risky nonhuman forces such as winds, waterways, and other organisms. I argue that these divergent risk maps demonstrate how ecological factors, interpersonal networks, and global market dynamics combine to engender a variety of interspecies relationships, which in turn shape the location of disease risks in space. I develop the term risky zoographies to signal the emergence of competing descriptions of animals and their habitats in zoonotic disease contexts. This concept suggests that as wild animals, livestock products, and microbial pathogens continue to globalise, place-based health interventions that limit animals to particular locales are proving inadequate. Risky zoographies signal the inextricability of nonhuman animals from human spaces, and reveal interspecies interactions that transect and transcend environments.
Partnerships and participation seem to be the order of the day. Yet, for many community organisations, this way of ordering the social policy space is contradictory, creating practice tensions that increase the complexity of local service systems. Such changes impact community organisations in a politics that needs to be made visible if they are to be able to act in the interests of their members and service users.
We therefore outline the social policy space currently constituted by four major discourses: neo‐liberalism, managerialism, new paternalism and network governance as they intersect and interact chaotically, reshaping participation and partnerships between government, community service organisations and local communities. We then examine how policy as a technology or set of mechanisms is discursively creating contradictions and practice tensions within which community organisations engage for social justice.
Public health in the United States and Western Europe has long been allied with national security and international commerce. During the 1990s, American virologists and public health experts capitalized on this historical association, arguing that 'emerging diseases' presented a threat to American political and economic interests, This paper investigates these arguments, which I call the 'emerging diseases worldview', and compares it to colonial-era ideologies of medicine and public health. Three points of comparison are emphasized: the mapping of space and relative importance of territoriality; the increasing emphasis on information and commodity exchange networks; and the transition from metaphors of conversion and a 'civilizing mission', to integration and international development. Although colonial and postcolonial ideologies of global health remain deeply intertwined, significant differences are becoming apparent.
Anthropological approaches broaden and deepen our understanding of the finding that high levels of socioeconomic inequality correlate with worsened health outcomes across an entire society. Social scientists have debated whether such societies are unhealthy because of diminished social cohesion, psychobiological pathways, or the material environment. Anthropologists have questioned these mechanisms, emphasizing that fine-grained ethnographic studies reveal that social cohesion is locally and historically produced; psychobiological pathways involve complex, longitudinal biosocial dynamics suggesting causation cannot be viewed in purely biological terms; and material factors in health care need to be firmly situated within a broad geopolitical analysis. As a result, anthropological scholarship argues that this finding should be understood within a theoretical framework that avoids the pitfalls of methodological individualism, assumed universalism, and unidirectional causation. Rather, affliction must be understood as the embodiment of social hierarchy, a form of violence that for modern bodies is increasingly sublimated into differential disease rates and can be measured in terms of variances in morbidity and mortality between social groups. Ethnographies on the terrain of this neoliberal global health economy suggest that the violence of this inequality will continue to spiral as the exclusion of poorer societies from the global economy worsens their health-an illness poverty trap that, with few exceptions, has been greeted by a culture of indifference that is the hallmark of situations of extreme violence and terror. Studies of biocommodities and biomarkets index the processes by which those who are less well off trade in their long-term health for short-term gain, to the benefit of the long-term health of better-off individuals. Paradoxically, new biomedical technologies have served to heighten the commodification of the body, driving this trade in biological futures as well as organs and body parts.
Thirty years since its first public use in 1980, the phrase structural adjustment remains obscure for many anthropologists and public health workers. However, structural adjustment programs (SAPs) are the practical tools used by international financial institutions (IFIs) such as the International Monetary Fund (IMF) and the World Bank to promote the market fundamentalism that constitutes the core of neoliberalism. A robust debate continues on the impact of SAPs on national economies and public health. But the stories that anthropologists tell from the field overwhelmingly speak to a new intensity of immiseration produced by adjustment programs that have undermined public sector services for the poor. This review provides a brief history of structural adjustment, and then presents anthropological analyses of adjustment and public health. The first section reviews studies of health services and the second section examines literature that assesses broader social determinants of health influenced by adjustment.
"In the first quarter of the twentieth century, massive forest fires raged throughout Kumaon in the western Indian Himalaya. Only some of these fires were the usual summer fires. Between 1911 and 1916, the colonial state had reclassified nearly 80 percent of Kumaon's forests into reserves. Villagers found that they had limited or no rights left in the reserves. In response they set fires in the newly classified reserves in a vivid spectacle of challenge to new forms of government over nature. Official reports and surviving accounts of villagers' actions suggest that many fires were deliberate protests against state interventions."
The concept of scale politics offers historians a useful framework for analyzing the connections between environment and health. This essay examines the public health campaign around emerging diseases during the 1990s, particularly the ways in which different actors employed scale in geographic and political representations; how they configured cause, consequence, and intervention at different scales; and the moments at which they shifted between different scales in the presentation of their arguments. Biomedical scientists, the mass media, and public health and national security experts contributed to this campaign, exploiting Americans' ambivalence about globalization and the role of modernity in the production of new risks, framing them in terms that made particular interventions appear necessary, logical, or practical.
Neoliberalism is commonly viewed as an economic doctrine that seeks to limit the scope of government. Some consider it a form of predatory capitalism with adverse effects on the Global South. In this groundbreaking work, Aihwa Ong offers an alternative view of neoliberalism as an extraordinarily malleable technology of governing that is taken up in different ways by different regimes, be they authoritarian, democratic, or communist. Ong shows how East and Southeast Asian states are making exceptions to their usual practices of governing in order to position themselves to compete in the global economy. As she demonstrates, a variety of neoliberal strategies of governing are re-engineering political spaces and populations. Ong’s ethnographic case studies illuminate experiments and developments such as China’s creation of special market zones within its socialist economy; pro-capitalist Islam and women’s rights in Malaysia; Singapore’s repositioning as a hub of scientific expertise; and flexible labor and knowledge regimes that span the Pacific.Ong traces how these and other neoliberal exceptions to business as usual are reconfiguring relationships between governing and the governed, power and knowledge, and sovereignty and territoriality. She argues that an interactive mode of citizenship is emerging, one that organizes people—and distributes rights and benefits to them—according to their marketable skills rather than according to their membership within nation-states. Those whose knowledge and skills are not assigned significant market value—such as migrant women working as domestic maids in many Asian cities—are denied citizenship. Nevertheless, Ong suggests that as the seam between sovereignty and citizenship is pried apart, a new space is emerging for NGOs to advocate for the human rights of those excluded by neoliberal measures of human worthiness.
Outbreaks of SARS, swine flu, and avian influenza have prompted a “One Health” effort to control diseases transmitted between species. Using ethnographic observations from Nam, I reveal how avian flu transforms strategies for living in light of human vulnerability to animals. Positing a multispecies approach to biopower, I argue that techniques for safeguarding human–animal collectivities confront heterogeneous moral codes surrounding animals’ role in knowledge hierarchies, village economies, and notions of individual worth. This analysis provides a framework for reconceptualizing biopower in relation to emerging diseases and reenvisions the role of animals in the politics of life itself.
This article draws from fieldwork conducted with the staff, volunteers and recipients of programs run by NGOs in Morrumbala, a rural district in central Mozambique. During the Mozambican conflict in the 1980s and early 1990s, a majority of district residents lived in refugee camps in Malawi. This article explores how recipients and volunteers draw on nostalgic memories of humanitarian experience in Malawi to critique and make claims on the humanitarian regimes that now provide services in Morrumbala. Anthropological literature has shown that refugee experience can be central to processes of political subjectification, becoming the grounds through which claims are articulated on neoliberal regimes of rights and services. These memories, and the nostalgic humanitarian lexicon they deploy, point to the historicity of humanitarian experience. As Morrumbala residents engage new configurations of aid and welfare today, the afterlives of previous interventions also allow for ambivalent and critical engagements with humanitarian practice in the present.
This essay starts from two premises: that, as far as the articulation and mobilization of popular interest in the countryside are concerned, the “best teams won” in the Chinese and the Vietnamese revolutions; but that, after the success of the revolution, the popularity and responsiveness of the regimes to the people became more problematic. Together, these premises imply a shift in the relationship of party to people between the revolutionary and postrevolutionary stages. That such a shift occurred in China and Vietnam is not obvious; there were significant continuities of personnel, policies, and ideology across the revolutionary divide. I shall argue that, despite the continuities, the rational basis of party-mass relations was deeply affected by victory. Indeed, the very continuities helped mask a structural flaw in the new regimes that has induced current political and economic reforms.
This paper was written when one author (LCC) was a scholar-in-residence at the
Why, since 1988, has the Vietnamese government reversed its commitment to collective farming and permitted the revival of family farming? BENEDICT KERKVLIET rejects the obvious explanation-that reversal followed naturally from the post-1986 policy of reform (d oi-moi) or that it merely mimicked Chinese policies. He proposes, as an alternative, that the Vietnamese government has responded with various kinds of accommodations since the mid-1970s to growing popular discontent with its agricultural policies. Borrowing a concept from Brantly Womack, Kerkvliet suggests that Communist parties must be "mass-regarding" both to establish their rule and to maintain it. He links this idea with James Scott's emphasis on the power of everyday peasant resistance to conclude that the Vietnamese Communist Party was responding to popular pressure from below. Thus, Kerkvliet finds that standard characterizations that represent the current regime in Vietnam as a "dominating state" or one that rules through "mobilization authoritarianism" overlook the existence of strong local social pressures that have the capacity for low-level resistance to government policy. Moreover, such characterizations also do not take into account that the Vietnamese state has displayed a long-term concern with ensuring that its policies are acceptable among the peasantry.
The flow of international aid from wealthier to poorer countries has increaseddramatically over the last decade. This is attributable in part to the efforts ofhealth activists, including medical anthropologists, who have rendered bare therealities of health disparities and human suffering. We are now facing an unprece-dented moment in the history of global health, in which infectious diseases such asHIV/AIDS, malaria, and tuberculosis are no longer peripheral concerns but primarytargetsofbilateralaidprograms,philanthropy,andresearch.Emergenthealthprob-lems range from antibiotic resistance to tobacco use to SARS and avian flu to theflow of health professionals from developing to developed countries. These prob-lems demand global solutions, challenge the internal sovereignty of nation states,and involve new sets of actors, networks, partnerships, and transnational healthinitiatives.There have been dramatic increases in funding from the U.S. President’s Emer-gency Plan for AIDS Relief (PEPFAR); the Global Fund to Fight AIDS, Tuberculosisand Malaria; the Gates Foundation; the Doris Duke Charitable Foundation; theClinton Foundation; and myriad other philanthropies dedicated to health problemsin the developing world, transforming the way in which high-priority health prob-lems are being addressed, in what has been termed the politics of the possible. Asengaged medical anthropologists, we have fought to keep the health and health careproblems of the world’s poor on the radar screen of wealthier nations by callingattention to issues involving both social justice and enlightened self-interest in theface of these mounting crises. We celebrate the recent emphasis on funding globalhealth initiatives, yet at the same time we remain alert to major concerns related togovernance, oversight, and the impact of high-profile public health efforts on statehealth care systems.As social scientists, we are sensitive to deepening divisions in the global healthcommunity over the way forward, in addition to the manner in which injectingmassive resources into vertical health interventions deflects attention away fromthe management of other health problems. We are also sensitive to recent trendsthat threaten to undermine the remarkable potential of this historic moment. Weare concerned by reports of wasteful spending, poor planning, and uncoordinated
This essay sketches two international, pharmaceutical company—sponsored drug donation programs and assesses this novel integration of corporations into global health. Based on ethnographic interviews with retired and current pharmaceutical executives and scientists, international humanitarian workers, and volunteers and drug recipients in the Morogoro region of Tanzania, this essay develops a concept of "scientific sovereignty," a process through which corporate and biomedical logics supplant the state in the exercise of biopower. I assess these interventions' impact on a local health system and the theoretical implications of the global health orthodoxies on which they rely.
In this article, I analyze the social processes of performance audits in a variety of cases in China, other postsocialist nations, and a U.S. workplace with Chinese immigrant employees. Although the processes share many commonalities, the ideological evaluations of them by the people involved are often diametrically opposed to those by anthropological analysts. For example, the Chinese workers often describe the performance audits as “socialist,” whereas the anthropological analysts tend to see them as a form of “neoliberal” governmentality. I use these contradictory evaluations to develop a critique of Nikolas Rose's conceptualization of “neoliberal governmentality,” especially when it is used as an explanation for contemporary processes of governing. Building on the comparative analysis of the performance audit cases, I conclude with a call for a classic anthropological approach to the study of audit cultures. [governmentality, audit cultures, China, socialism, neoliberalism]
Shenzhen, a city located on the border between Mainland China and Hong Kong, is populated primarily by internal Chinese migrants. After the 2003 SARS epidemic, the pressure in Shenzhen to contain infectious disease has been considerable. By engaging with issues of global biosecurity, migration and citizenship, and intersubjectivity in medicine, I argue that in their attempts to prevent another SARS and protect their own subject positions as modern, urban citizens, Shenzhen's public health professionals worked to maintain precarious boundaries between themselves and their city's majority migrant population. However, by establishing the migrants as dangerous, biological noncitizens, by denying connections between the migrants' experiences and their own experiences of migration, by failing to engage with the migrants as subjects, and by defending structures that institutionalized these exclusions, they undermined both the health of the migrants and the stability of the city they were trying to protect.
The more significant principles of Participatory Rural Appraisal (PRA) concern the behavior and attitudes of outsider facilitators, including not rushing, “handing over the stick,” and being self-critically aware. The power and popularity of PRA are partly explained by the unexpected analytical abilities of local people when catalyzed by relaxed rapport, and expressed through sequences of participatory and especially visual methods. Evidence to date shows high validity and reliability of information shared by local people through PRA compared with data from more traditional methods. Explanations include reversals and shifts of emphasis: from etic to emic, closed to open, individual to group, verbal to visual, and measuring to comparing; and from extracting information to empowering local analysts.
This article analyses how the 'securitization' of highly pathogenic avian influenza (H5N1) contributed to the rise of a protracted international virus-sharing dispute between developing and developed countries. As fear about the threat of a possible human H5N1 pandemic spread across the world, many governments scrambled to stockpile anti-viral medications and vaccines, albeit in a context where there was insufficient global supply to meet such a rapid surge in demand. Realizing that they were the likely 'losers' in this international race, some developing countries began to openly question the benefits of maintaining existing forms of international health cooperation, especially the common practice of sharing national virus samples with the rest of the international community. Given that such virus samples were also crucial to the high-level pandemic preparedness efforts of the West, the Indonesian government in particular felt emboldened to use international access to its H5N1 virus samples as a diplomatic 'bargaining chip' for negotiating better access to vaccines and other benefits for developing countries. The securitized global response to H5N1 thus ended up unexpectedly entangling the long-standing international virus-sharing mechanism within a wider set of political disputes, as well as prompting governments to subject existing virus-sharing arrangements to much narrower calculations of national interest. In the years ahead, those risks to international health cooperation must be balanced with the policy attractions of the global health security agenda.
Thesis (Ph. D.)--University of Washington, 2007. This dissertation explores the fascinating ways the concept of civil society is understood in Vietnam, its place in Vietnamese political ideology, the conflicts around its deployment by international donors, and particularly its daily manifestations through local, non-profit, non-government development organizations, the so-called Vietnamese NGOs. My goal is to challenge the dominant definitions in current civil society theory, particularly those definitions used by international development actors. By challenging these dominant definitions, I look for understandings and insights that better explain the empirical data I collected in my fieldwork. In the process, I argue for a new manner of characterizing civil society based on activities and roles of both state and non-state actors instead of on institutions such as "autonomous associations." By looking at what each actor does---using a "logic of actions"---rather than what each actor is---using a "logic of domains"---we can begin to see forms of civil society that are obscured by structural definitions. This new manner of approaching civil society can help overcome much of the Euro-centric bias in both mainstream theories of civil society and in the application of civil society through international development projects, allowing for a broader understanding of state-society relations in Vietnam and other places in the world.
The past two decades have witnessed an upsurge in the number of external agencies involved in the health sectors of developing countries. Concomitantly, there has been an increase in the volume of resources transferred through multilateral, bilateral and non-governmental organizations to these health systems. Notwithstanding the beneficial impact of increased resources, recipients and donors are increasingly concerned about the effects of this trend. This is particularly pertinent where the effort lacks adequate coordination. Recipients despair of an unruly mélange of external ideas and initiatives, that too often results in project proliferation and duplication, unrealistic demands, and ultimately a loss of control over the health development process. Donors on the contrary, are concerned about aid efficiency and effectiveness, two areas it is assumed will gain from increased attention to coordination. Both recipients and donors are looking for ways of better managing the aid relationship. Although there has been considerable experience with coordination strategies, most writing has considered external assistance in general, rather than the health sector in particular. The literature is striking in its bias towards the needs and perspectives of the donor community. There has been little analysis of the manner in which recipient ministries of health manage donors and the influx of resources. This review begins to fill this gap. Its focus is country-level, where most direct gains from coordination are to be reaped. The paper begins with an enumeration of the many and diverse trends which have raised the salience of aid coordination. A definition of coordination, a term used ambiguously in the existing literature, is then developed and the principles of aid coordination outlined. Finally, attention is directed to the initiatives of recipients and donors to improve the coordination of health sector aid.
Developing countries that were early, enthusiastic adopters of primary health care often developed an extensive - but eventually dilapidated and under utilized - network of public clinics at the grassroots. As paradigms and investment patterns of health sector reform have shifted, the question of what role these public clinics can meaningfully play, and how best to revitalize them, has become important in a number of countries. This paper evaluates the strategy taken by, and outcomes of, a major attempt in Vietnam to revitalize the grassroots infrastructure of primary health care against the backdrop of the country's economic transition. The project's substantial supply-side investments in infrastructure led to marginal increases in utilization and the quality of preventive health services provided by the centers. But because the project failed to take adequate stock of broader, public sector-wide trends and reforms over the transition, the investments had little impact on the incentives, accountability patterns and capacities of clinic staff and the local authorities. Such institutional factors are heavily implicated, in Vietnam as elsewhere, in the substantial and often increasing disparities in service access and quality that continue to afflict transitional health sectors.
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Adjustment, Transition and the Provision of Health Care: Vietnam's Experience
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The Emergence of a Nonprofit Sector and Philanthropy in the Socialist Republic of Vietnam
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