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International Medical Travel and the Politics of Therapeutic Place-Making in Malaysia

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International Medical Travel and the Politics of Therapeutic Place-Making in Malaysia INTERNATIONAL MEDICAL TRAVEL AND THE POLITICS OF THERAPEUTIC PLACE-MAKING IN MALAYSIA Meghann Elizabeth Ormond A Thesis Submitted for the Degree of PhD at the University of St. Andrews 2011 Full metadata for this item is available in Research@StAndrews:FullText at: https://research-repository.st-andrews.ac.uk/ Please use this identifier to cite or link to this item: http://hdl.handle.net/10023/1681 This item is protected by original copyright This item is licensed under a Creative Commons License International medical travel and the politics of therapeutic place-making in Malaysia International medical travel and the politics of therapeutic place-making in Malaysia A thesis submitted to the University of St Andrews for the Degree of Doctor of Philosophy Meghann Elizabeth Ormond Department of Geography and Sustainable Development School of Geography and Geosciences University of St Andrews St Andrews, Fife, United Kingdom 31 January 2011 i International medical travel and the politics of therapeutic place-making in Malaysia Declaration I, Meghann Elizabeth Ormond, hereby certify that this thesis, which is approximately 76,902 words in length, has been written by me, that it is the record of work carried out by me and that it has not been submitted in any previous application for a higher degree. I was admitted as a research student in September 2006 and as a candidate for the degree of PhD in Geography in May 2007; the higher study for which this is a record was carried out in the University of St Andrews between 2006 and 2010. Date_________ __ Signature of candidate ______________________________________________ I hereby certify that the candidate has fulfilled the conditions of the Resolution and Regulations appropriate for the degree of PhD in Geography in the University of St Andrews and that the candidate is qualified to submit this thesis in application for that degree. Date_________ __ Signature of candidate ______________________________________________ In submitting this thesis to the University of St Andrews we understand that we are giving permission for it to be made available for use in accordance with the regulations of the University Library for the time being in force, subject to any copyright vested in the work not being affected thereby. We also understand that the title and the abstract will be published, and that a copy of the work may be made and supplied to any bona fide library or research worker, that my thesis will be electronically accessible for personal or research use unless exempt by award of an embargo as requested below, and that the library has the right to migrate my thesis into new electronic forms as required to ensure continued access to the thesis. We have obtained any third-party copyright permissions that may be required in order to allow such access and migration, or have requested the appropriate embargo below. The following is an agreed request by candidate and supervisor regarding the electronic publication of this thesis: Access to printed copy and electronic publication of thesis through the University of St Andrews. Date_________ __ Signature of candidate ______________________________________________ Date_________ __ Signature of candidate ______________________________________________ i International medical travel and the politics of therapeutic place-making in Malaysia Abstract This thesis examines the shifting relationship between the state and its subjects with regard to responsibility for and entitlement to care. Using Malaysia as a case study the research engages with international medical travel (IMT) as an outcome of the neoliberal retrenchment of the welfare state. I offer a critical reading of postcolonial development strategies that negotiate the benefits and challenges of extending care to non-national subjects. The research draws from relevant media, private-sector and governmental documents and 49 semi-structured, in-depth interviews with IMT proponents and critics representing federal, state and urban governmental authorities, professional associations, civil society, private medical facilities and medical travel agencies in Malaysia’s principal IMT regions (Klang Valley, Penang and Malacca). Across four empirical chapters, the thesis demonstrates how ‘Malaysia’ gets positioned as a destination within a range of imagined geographies of care through a strategic-relational logic of care and hospitality. I argue that this positioning places ‘Malaysian’ subjects and spaces into lucrative global networks in ways that underscore particular narratives of postcolonial hybridity that draw from Malaysia’s ‘developing country’, ‘progressive, moderate Islamic’ and ‘multiethnic’ credentials. In considering the political logics of care-giving, I explore how the extension of care can serve as a place-making technology to re-imagine the state as a provider and protector within a globalising marketplace in which care, increasingly commodified, is tied to the production of new political, social, cultural and economic geographies. ii Table of contents Abstract ii Table of contents iii List of tables v List of figures vi List of appendices vii List of abbreviations viii A note on language x Acknowledgements xi Chapter I. Introduction 1 1.1 Introduction 1 1.2 International medical travel 4 1.3 Cross-border mobility and the social construction of identity-in-place 12 1.4 Care and interdependency 17 1.5 National therapeutic landscapes and selling healing 'in place' 21 1.6 Hospitality 24 1.7 Medical diplomacy 29 1.8 An outline of the study 33 Chapter II. Methodology 37 2.1 Background to the scope of this study and positionality 37 2.2 Data collection and analysis 39 2.2.1 Primary data 39 2.2.1.1 Unstructured non-participant and participant observation 40 2.2.1.2 Interviews 40 2.2.2 Secondary data 46 2.2.2.1 Documentary sources 46 2.2.2.2 Statistics 48 Chapter III. Shifting subjects and territories of healthcare 52 3.1 Introduction 52 3.2 Colonial healthcare - Subjects of the colonial economy 54 3.3 Nation-building and healthcare - Patient-citizens 56 3.4 Neoliberalism and healthcare - Responsibilised healthcare consumers 58 3.5 Globalisation and healthcare - International medical travellers 66 3.6 Conclusion 87 Chapter IV. Plotting Malaysia on the 'flat world base-map' of global healthcare 88 4.1 Introduction 88 4.2 From international to global health governance 90 4.3 Intermediaries and governance over 'flat world' healthcare 96 4.4 Forging landscapes of 'international legitimacy' 103 4.4.1 Hospital accreditation 104 4.4.2 Medical professionals 113 4.5 Conclusion 121 Chapter V. Strategic cosmopolitanism and 'Muslim-friendly care expertise 124 iii International medical travel and the politics of therapeutic place-making in Malaysia 5.1 Introduction 124 5.2 Cultural diversity and 'strategic cosmopolitanism' 125 5.3 Reaching out and linking up with Islamic credentials 134 5.4 Conclusion 153 Chapter VI. 'Complementarities' and regionalised landscapes of medical travel 156 6.1 Introduction 156 6.2 Regionalisation 157 6.3 Experiments in graduated sovereignty 167 6.3.1 Singapore's healthcare hinterland 168 6.3.2 Sumatra's healthcare hub 180 6.4 Conclusion 192 Chapter VII. Conclusion 196 7.1 How far we have come 196 7.1.1 What does this extension of care to non-citizens accomplish? 197 7.1.2 What ‘Malaysia’ is put ‘on the map’ to qualify for ‘world -class’ IMT destination status? 200 7.2 Opportunities for future research 204 7.2.1 Including traditional and contemporary medicine 205 7.2.2 Considering the ‘sending’ context 207 References 210 Appendices 250 iv International medical travel and the politics of therapeutic place-making in Malaysia List of tables Table 1.1 Price comparison among IMT destinations for common surgical procedures in USD (2006-09) 9 Table 2.1 Foreign patient figures among select Asian IMT destination countries (2002 - 2008) 49 Table 2. 2 IMT -endorsed hospitals reporting data to APHM on foreign patients and revenue generated 50 Table 3.1 Growth in GDP per capita and in private hospital beds (1980-2003) 61 Table 3.2 Public-private partnerships in select Asian countries promoting IMT 72 Table 3.3 35 private hospitals endorsed for IMT by the MOH (2010) 74 Table 3 .4 Foreign patient -consumer s treated in Malaysian private hospitals endorsed for IMT (1998-2009) 77 Table 3.5 Patients at three private hospitals endorsed for IMT in Malacca (2001-2006) 81 Table 4.1 International trade in services – the four modes of supply 93 Table 4.2 Medical travel intermediaries 102 Table 4 .5 Publicised accreditation and certification among the 35 endorsed IMT facilities 109 Table 4.6 Prominent international healthcare accreditation schemes 110 Table 4 .7 Expatriation rates for health workers in OECD countries among select sending countries that promote IMT (2000) 120 Table 5.1 Outbound tourism by generating region (millions) (1990-2004) 143 Table 6.1 Prices in GBP of select routine procedures for which Singapore residents might consider receiving care in Malaysia 176 Table 6.2 Economic profile of IMT-GT member-regions 181 Table 6.3 Regional comparison of health performance indicators among select ASEAN countries 184 v International medical travel and the politics of therapeutic place-making in Malaysia List of figures Figure 1.1 A video still from Patients Beyond Borders - Malaysia Edition launch ceremony on 23 July 2009 1 Figure 1.2 Imagery used in campaigns promoting countries as IMT destinations 25 Figure 1.3 IMT imaginaries 30 Figure 1.4 Symbolic gestures of ‘Malaysian’ hospitality
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