WHAT MEDICAL TOURISM TELLS US ABOUT THE PLURAL SECTOR OF GLOBAL HEALTH DIPLOMACY AND GOVERNANCE: AN ORGANIZATIONAL ANALYSIS OF CIVIL SOCIETY IN RIO DE JANEIRO, BRAZIL
by
FRANCIS JOSEPH MANZELLA
Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy
Department of Anthropology
CASE WESTERN RESERVE UNIVERSITY
May, 2019
CASE WESTERN RESERVE UNIVERSITY
SCHOOL OF GRADUATE STUDIES
We hereby approve the thesis/dissertation of
Francis Joseph Manzella
Candidate for the degree of Doctor of Philosophy*
Committee Chair
Vanessa Hildebrand, PhD
Committee Member
Atwood Gaines, PhD, M.P.H
Committee Member
Lihong Shi, PhD
Committee Member
Eileen Anderson-Fye, Ed.D
Date of Defense
March 27th 2019
*We also certify that written approval has been obtained for any proprietary material contained therein.
2
For My Parents and Grandmother
3 Table of Contents
List of Tables ...... 6 List of Figures ...... 7 Acknowledgments ...... 8 Abstract ...... 11 Chapter 1: Introduction ...... 13 Applicative Value ...... 19 Research Objectives ...... 24 Outline of Chapters ...... 26 Chapter 2: Literature Review and Theoretical Framework ...... 28 Global Health Diplomacy and Governance: Perspectives from Anthropology of Global Health ...... 28 Global Health Diplomacy ...... 31 Global Health Governance ...... 35 Anthropological Contributions to Global Health Diplomacy and Governance ...... 39 Civil Society Organizations ...... 43 Medical Tourism: Perspectives from Anthropology and Global Health ...... 46 Global Health Literature Trends ...... 54 Anthropological Literature Trends ...... 61 Theoretical Framework: Bourdieusian Organizational Analysis of Health Institutions ...... 67 Bourdieusian Practice Theory ...... 67 Bourdieusian Organizational Analysis ...... 69 At the Intersection: Organizational & Medical Anthropology ...... 73 Chapter 3: Methods ...... 76 Data Sources ...... 76 Data Collection ...... 79 Participant-Observation ...... 79 Continuous Monitoring ...... 80 Semi-Structured Interviews ...... 82 Data Analysis ...... 83 Field Notes and Memos ...... 83 Meeting Analysis ...... 84 Semi-Structured Interviews ...... 84 Triangulation of Data ...... 85 Ethics ...... 86 Limitations ...... 87 Chapter 4: Managing Risk With Prospective ...... 89
4 Problem-solving ...... 89 Entering the Field: A City in Transition ...... 90 Meeting the Team ...... 102 Forecasting the Market ...... 107 Organizational Competence ...... 110 Personal Safety ...... 115 Patient Comfort ...... 118 Routine Practice of a Key Strategy: Prospective Problem-Solving ...... 121 Chapter 5: Managing Partnerships by Affirming Amenability ...... 125 Standard Protocol for Selecting, Onboarding, and Dismissing Providers ...... 128 Organizational Review of Service Providers’ Partnership ...... 139 Fixed Preparedness ...... 141 High Supply, Low Demand ...... 147 Insourcing Services ...... 152 Routine Practice of a Key Strategy: Affirming Amenability ...... 155 Chapter 6: Practice in Action: ...... 160 Demarcating the Organizational Field ...... 160 Chapter 7: Conclusion ...... 174 Summary of Main Findings ...... 174 Research Implications ...... 181 Anthropology of Health Organizations ...... 181 Anthropology and Global Health of Medical Tourism ...... 183 Anthropology of Global Health Diplomacy and Governance ...... 184 Bibliography ...... 188
5 List of Tables
Table 1: Reasons Why Patients Travel Abroad for Health Care, as Articulated in the Anthropology and Global Health Literature…………...... 48
Table 2: Perceived Medical Tourism Risks, Solutions, and Requisites, as Determined by Organizational Team Members in Brainstorming Meetings…………………………………………………………………...... 110
Table 3: Perceived Measures of Partnership Selection, Allegiance, and Quality, as Determined by Organizational Team Members in Site Inspection and Negotiation Meetings…………………………………………………………... 141
6 List of Figures
Figure 1: The Process of Prospective Problem-Solving, as Routinely Practiced by Organizational Team Members during Brainstorming Meetings ……………………………………………………………………….. 121
Figure 2: The Process of Affirming Amenability of Service Providers, as Routinely Practiced by Organizational Team Members during Site Inspection and Negotiation Meetings………………………………………….. 156
Figure 3: Theoretical Model From Bourdieusian Organizational Analysis..…. 163
7 Acknowledgments
This dissertation never would have been possible without the generous funding, support, and opportunities bestowed to me by several organizations. I would first like to thank the National Security Education Program (NSEP) for a David L. Boren Fellowship, which provided me the opportunity to conduct pre-dissertation fieldwork in Rio de
Janeiro, as well as learn Portuguese at Middlebury College’s Portuguese School,
Pontifícia Universidade Católica do Rio de Janeiro (PUC-Rio), as well Êxito Curso
Livres. I would like to thank all of my professors and teachers at these institutions for their patience and understanding as I learned Portuguese over the years. Additionally, I am profoundly grateful to have received a Fulbright-Hays Doctoral Dissertation Research
Abroad Fellowship, which supported my doctoral dissertation fieldwork in Rio de
Janeiro. Furthermore, I would like to thank Case Western Reserve University’s Social
Justice Institute for a Graduate Student Fellowship, as well as the Department of
Anthropology for a Research Assistantship. I am also extremely appreciative of the
National Science Foundation for supporting my instruction of research methods at the
Summer Institute for Research Design. The instruction I received there has been indispensible to my academic career.
Words cannot express how fortunate I am to have had such an amazing doctoral committee. My chair, Dr. Vanessa Hildebrand, has been a fierce advocate of my research from day one. She has challenged me to think beyond what I thought I was capable of doing, and has always supported my endeavors. Every step of the way, Dr. Eileen
Anderson-Fye has been an incredible mentor and advisor. Her high expectations of my work have always compelled me to think critically and creatively about my career
8 trajectory, which has been absolutely invaluable. Moreover, I am highly appreciative of the constructive feedback and unique perspectives and insights that Drs. Atwood Gaines and Lihong Shi have provided to me over the years. Thank you all for serving on my committee, and offering such close readings of my work. I would also like to express my sincere gratitude to Drs. Janet McGrath and Katia Almeida. Your guidance has been instrumental in the development of this research project.
I owe my love of anthropology to Dr. Kathryn Oths. She has been such an inspiration to me since my first day as an undergraduate student at the University of
Alabama. I absolutely cannot thank her enough for encouraging and enabling me to be the best scholar I can be. I would also like to thank all of my tutors, instructors, fellow students, and colleagues at the University of Oxford for preparing me to take on a doctorate in anthropology. I would be remiss in not expressing my overwhelming gratitude to Dr. Clarice Rios for her steadfast dedication, determination, will power, and prowess to help me navigate through all of the endless cultural, linguistic, administrative, and bureaucratic barriers I encountered while in Brazil. I so look forward to our future collaboration together.
Lastly, I would like to thank my family and friends for their unwavering support, motivation, and understanding as I completed this doctorate. I am forever indebted to the love, compassion, and patience you all have shown me over the years. My mother, Cindy
Hamlin, and my father, Frank Manzella, have always supported my educational interests and passions, and I am completely grateful to you both for valuing and prioritizing my education above all else. To my step-parents, Craiton Hamlin and Daphne Manzella, you both have provided me with an unshakeable foundational support system I did not know I
9 needed over the years. And lastly, to my grandmother, Pearl Manzella, I will forever be better because of the sacrifices you made. I can only hope to live up to the wonderful example of love you left behind.
10 What Medical Tourism Tells Us about the Plural Sector of Global Health Diplomacy and Governance: An Organizational Analysis of Civil Society in Rio de Janeiro, Brazil
Abstract
by
FRANCIS JOSEPH MANZELLA
Medical tourism, whereby individuals travel outside of their respective country for health care, is a highly unregulated industry. Despite a lack of international health policy and governmental regulation, how is medical tourism formally organized, monitored, and preserved at the local level, and by whom? Based on twelve months of fieldwork with a group of highly influential civic and social entrepreneurs in Rio de
Janeiro, Brazil, this dissertation explores how a private, for-profit civil society organization sought to transform its community economically by formalizing a local medical tourism industry. The author describes how this group of civic and social entrepreneurs directly shaped prospective foreign patients’ medical travel experiences, and successfully formulated and managed a network of medical tourism service providers. This dissertation analyzes how organizational team members consistently practiced two key strategies of risk and partnership management to meet their end goal of establishing Rio de Janeiro as a “leading destination for world-class medical travel.” To meet this goal, team members had to secure a competitive market advantage by continuously redefining their organizational position-taking. In so doing, team members were forced to make impactful decisions regarding standards of patient safety and health care provider assurance and compliance in the absence of strict supervision and precedents from the public sector. With the capacity to retain and convert significant
11 amounts of social and cultural capital into purpose-driven profit (economic capital) to directly influence health care delivery on-the-ground, civic and social entrepreneurs in for-profit civil society organizations warrant greater recognition within global health diplomacy and governance.
12 Chapter 1: Introduction
The growth of medical tourism, whereby individuals travel outside of their respective country for health care, is undeniably exponential (Helble 2011; Cohen 2015;
Borg and Ljungbo 2018). Currently, medical tourism is estimated to be a multi-billion dollar a year industry, and its assembly and practice are expected to skyrocket in the next several decades (Bookman and Bookman 2007; Connell 2011; Adams et al. 2017; Ross et al. 2018). Economically, medical tourism continues to soar as the previous supply-side of health care now incorporates the demand-driven industry characteristics of tourism
(Botterill et al. 2013). This dissertation considers how communities with great infrastructural capacity are able to accommodate a high demand for medical tourism services by formally organizing a local industry. For twelve months, I followed a group of highly influential civic and social entrepreneurs who were establishing a civil society organization in Rio de Janeiro, Brazil. I was interested in understanding how civil society organizations establish, monitor, and preserve new industries and organizational fields to improve their community economically. In this dissertation, I analyze two key strategies of risk and partnership management that civic and social entrepreneurs continuously practiced to establish a formal medical tourism provider network from existing community infrastructure. To be successful, the group of civic and social entrepreneurs I followed had to secure their competitive market advantage by continuously redefining their organizational position-taking.
Anthropologists and global health scholars have long conducted ethnographic research into the plural sector by focusing on non-profit civil society organizations
13 (Closser 2011). However, I argue that increased attention should be extended to privately owned for-profit civil society organizations in the plural sector. More specifically, civil society organizations run by civic and social entrepreneurs. Civic and social entrepreneurs often have the capacity to retain and convert significant amounts of social and cultural capital into purpose-driven profit (economic capital) to transform communities in sustainable ways (Mintzberg 2015).
When state actors diplomatically ignore, whether deliberately or unintentionally, governance issues of global health importance, like medical tourism, local communities may be negatively impacted, further motivating civic and social entrepreneurs to take action (Labonte et al. 2018). The group of civic and social entrepreneurs that I followed was tasked with making decisions regarding patient safety and health care provider assurance and compliance without strict oversight and precedents from the public sector.
Decisions on patient safety and provider assurance and compliance were made in an ad hoc manner when designing standard medical travel protocols for prospective foreign patients, and formulating and managing a network of high quality service providers. In this regard, the civic and social entrepreneurs I followed were required to assume diplomatic and governance roles to decide and monitor health care delivery standards by default, when state actors failed to do so. Therefore, this dissertation advocates that civic and social entrepreneurs in for-profit civil society organizations warrant greater recognition within the field of global health diplomacy and governance.
The demand for medical tourism is incontrovertibly expanding in both the Global
North and the Global South (Roberts and Scheper-Hughes 2011). One reason why the demand for medical tourism is mounting is because of epidemiological trends. There is
14 an enormous global prevalence of non-communicable diseases that require expensive care. In light of cost, economic trends help explain why medical tourism is so widespread around the world. As people have either more disposable income for medical travel and elective procedures, or ironically, a dearth of disposable income to afford non-elective procedures and/or health insurance in their home country, people are looking for more cost-effective ways to receive health care outside of their local health care market.
Additionally, global demographic trends further explain why people are traveling abroad for health care. As people are living longer in high- and middle-income countries, people are requiring more health services as they age. Lastly, one could look towards socio- technological trends to explain why medical tourism has taken off so drastically in the last couple of decades. As technology becomes more widely available and accessible, patients are taking advantage of the accelerated ease of international travel and global communication to arrange health services far from home that are cheaper, and perhaps, better than their local health care system can provide (Bookman and Bookman 2007;
Whitaker et al. 2010; Connell 2011; Helble 2011; Cohen 2015).
Given the overwhelming global demand for medical tourism, it is no surprise that many organizations from the private and plural sectors have been established in the past two or three decades (Connell 2013, 2014; Skountridaki 2017; Labonte et al. 2018).
Many organizations are established to capitalize on and competitively influence the quality of the provision of health services made available to foreign patients in the absence of local, national, and transnational regulatory health policy and law (Alvarez et al. 2011; Cortez 2012; Holliday et al. 2014; Cohen 2015). While researchers across disciplines have studied a wide range of topics where medical tourism has become
15 institutionalized, the majority of anthropological studies have focused on experience-near problems encountered by foreign patients, either before, during, or after patients’ medical travel (Whittaker et al. 2010; 2015). Generally, these experience-near problems are grounded on how patient-provider relationships are forged, lived, and maintained
(Kangas 2010; McDonald 2011).
Fewer studies in anthropology, and more broadly in the social sciences, have foregrounded their focus on medical tourism’s successes and short-comings: for-profit civil society organizations. Two leading examples of such for-profit civil society health organizations are entrepreneurial medical tourism facilitator companies and accreditation agencies. A primary reason why researchers have not focused their attention on the internal workings of for-profit civil society health organizations, presumably, is feasibility and access. Finding and recruiting foreign patients present many difficulties in locating such a hidden population (Ackerman 2010; McDonald 2011; Inhorn et al. 2012).
Moreover, it has been well-established in organizational studies that access to elite populations (i.e. high level executives with incredibly busy work schedules) is particularly difficult in live settings versus controlled laboratory ones (Mintzberg et al.1976; O’Reilly 1980; Pinfield 1986; Browne 1993; Hertz and Imber 1995; Nader 1999
[1967]; Langley, et al. 1999; Primo 2009).
By focusing on how organizational stakeholders engage in high-level executive decision-making, this dissertation focuses on one organization’s mobilization of a formal medical tourism industry in Rio de Janeiro, Brazil. As the only city to have ever hosted back-to-back global events (the 2014 FIFA World Cup and 2016 Summer Olympics), Rio de
Janeiro was quickly thrust onto the global center stage. Hosting two global events within two
16 years has forced the city to undergo rapid socio-economic, political, and structural changes to accommodate the enormous influx of tourists and the aftermath that global events invariably produce (Zirin 2016). This dissertation depicts how the aftermath of global events, namely the drastic under-utilization of private medical and hospitality facilities built entirely for mass tourist inflow, primed powerful civic entrepreneurs to opportunistically re-purpose such infrastructure by organizing a local unregulated industry: medical tourism. For this reason, Rio de Janeiro is the optimal site to investigate how civic and social entrepreneurs directly influence the medical tourism process as experienced by foreign patients.
This dissertation argues that civic and social entrepreneurs can formally organize and establish new industries by repurposing community infrastructure during periods of drastic socio-cultural, political, and economic changes. To support this argument, this dissertation documents the establishment of a for-profit medical tourism civil society health organization by a group of prominent civic and social entrepreneurs. This group of civic and social entrepreneurs safeguarded its organization’s competitive market advantage, that is its leverage over future competitors, by practicing two key strategies:
(1) managing risk via prospective problem-solving, and (2) managing partnerships via affirming amenability. Here, prospective problem-solving means predicting what could possibly go wrong in the future, and then inductively developing solutions to curtail such wrongdoings from negatively impacting client experiences, and therefore subsequent generation of referrals. Additionally, affirming amenability signifies regular organizational review of its (candidate) partners’ dedication to successfully support a novel local industrial enterprise, as measured by providers’ demonstration of competence, compliance, flexibility, and enthusiasm. By adjudicating whether (potential) partners
17 continuously demonstrated amenability to negotiation, this organization prescriptively measured the ongoing partnership capacity of its providers. In its consistent practice of both key strategies, this organization further compelled its own competitive trajectory in a novel unregulated marketplace by routinely refining its own intra-organizational position-taking. In this dissertation, the term position-taking refers to the distinguishing features that make an organization truly exceptional in terms of its unique perceived benefits, such as its product and service offerings, constructed goals and identities, or target market and niche specialization. Therefore, it follows that the preservation of an organization’s competitive market advantage depends on the regular refinement of its own position-taking.
The civic and social entrepreneurs that I followed actively pursued a competitive market advantage to weather the aftermath of the rapid socio-economic, cultural, political, and structural changes that the city of Rio de Janeiro experienced from hosting back-back global events. To support this argument, this dissertation presents data gathered from numerous interview responses and meeting observations with organizational stakeholders and their network of partnering service providers over the course of twelve months in 2017-2018. In this dissertation, the presentation of data espouses a situational approach (Boden 1994; Jarzabkowski and Seidl 2008) to understand the “orderly scenes of actions” (Nicolini and Monteiro 2017: 12) that organizational team members routinely practiced with each other and with their
(candidate) service providers throughout this research project. Here, a situational approach refers to “studying organizations in action” (Boden 1994: 199), and is not commensurate to the “situational analysis” of Max Gluckman of the Manchester School
18 (Gluckman 1963; Kapferer 1987).
Applicative Value
This dissertation draws on and contributes to three bodies of literature within medical anthropology and global health: (1) the anthropology of global health diplomacy and governance; (2) the anthropology and global health of medical tourism; and (3) the anthropology of health organizations. By focusing on the globalization of health (Connell
2011) via exploring new linkages and convergences in the global assemblage of flows and networks at the local level, this dissertation further attempts to better understand not only the anthropology of tourism, but also the anthropology of transnationalism and global health (Ong and Collier 2005; Pordie 2013; Holliday et al. 2015). The majority of studies focusing on medical tourism concentrate on either medical systems or key social actors in the medical tourism process, namely how patient-provider-facilitator relationships are forged and maintained. This dissertation seeks to shift analytical focus towards organizations and the people who run them, a focus and opportunity that is rarely accessible in the field.
In so doing, this dissertation aims to contribute to a burgeoning specialization within anthropology and global health, broadly classified as “the anthropology of global health diplomacy and governance.” This dissertation provides an ethnographic account of how private, for-profit civil society health organizations can both directly and indirectly affect “glocal” development of health and tourism industries in developing countries undergoing drastic socio-cultural, political, and economic changes. Taking the for-profit civil society health organization as an object of inquiry, this dissertation provides a better window into what happens “behind-the-scenes” when powerful social
19 actors design, control, and modify the medical tourism process as experienced by foreign patients. By concentrating on private organizations (and the stakeholders that control them) with vested interests in medical tourism, this ethnographic study better illuminates the internal workings of a local-global health system. This dissertation does not focus merely on the unwieldy bureaucratic and operational shortcomings of organizations, as is the most common route taken in anthropology of global health projects. Instead, this dissertation better illuminates the ad hoc processes of constructing organizational
“position-takings,” strategy (re)formulation, and partnership selection required when carving out new industry standards in developing nations.
Also, this dissertation ethnographically foregrounds the construction and maneuvering of a private civil society health organization with resources to organize a lucrative medical tourism industry. This dissertation provides greater insight into the iterative processes of executive decision-making, negotiation, and problem-solving extant in multi-actor and multi-level spaces, the ultimate goal of diplomacy and governance.
Greater knowledge about how for-profit civil society health organizations design service delivery protocols enables the public sector to better improve health policy for medical tourism. Greater health policy is needed in regards to medical tourism, as it is a virtually unrestricted industry worldwide due to an absolute dearth of governing formal health policy (Holliday et al. 2014; Cohen 2015). Moreover, this dissertation seeks to provide an ethnographic account of one of the many types of actors that make up the
“unstructured pluralism,” (Pfeiffer 2003) “open-source anarchy,” (Fidler 2007), and
“unruly mélange” (Adams et al. 2008) that is so rife in global health. This dissertation seeks to expand our understanding of how to better monitor transparency and
20 accountability of private, for-profit civil society organizations that affect global health industry markets.
This dissertation provides a thick ethnographic description of a type of civil society organization that makes up the unstructured pluralism in the third sector that is particularly lacking in the anthropology and global health literature: for-profit organizations that are established, managed, and operated by civic and social entrepreneurs. Civic and social entrepreneurs are important links between the private, public, and plural sectors that rarely receive recognition for their power to economically transform communities with their on-the-ground collective venturing. This dissertation endeavors to challenge our understanding of civil society organizations as more than just traditional non-governmental organizations (NGOs) or highly informal associations that exist for voluntary purposes only. Instead, this dissertation aims to reveal that civil society organizations can successfully transform communities by reinstating economic vigor via operating for purpose driven profit (Mintzberg 2015). Moreover, this dissertation reveals that in the absence of local and transnational state regulation, civil society health organizations, particularly ones that are for-profit, are poised to make executive decisions regarding patient welfare and safety (Edwards 2004).
This dissertation also attempts to advance theory on health organizations involved in local industry formation with a focus on inter- and intra-organizational practice. More specifically, this study applies an organizational analytical perspective to Bourdieusian practice theory. This broad theoretical significance is not only beneficial to medical and organizational anthropology, but also to business and health administration, as well as to many of the other social sciences or trans-disciplines (i.e. global health) that use, or could potentially incorporate,
21 organizational analysis and/or practice theory into their critical theoretical repertoire. First, this dissertation provides ethnographic evidence regarding how newly formed health organizations are internally organized, offering further insight into how organizational habitus are methodically and dynamically created and adapted over time according to rapid environmental changes and threats. Second, this project enumerates many types of agents and their practical relation to each other not typical of a single organizational analysis, such as autonomous organization to autonomous organization, internal organizational power dynamics, and autonomous organization to independent agents. Third, this research provides thick ethnographic descriptions of the development of an organizational field’s boundaries. This dissertation highlights the socio-cultural and politico-economic contexts that allowed an organization to borrow, transpose, define, and design the preliminary doxa and respected species of capital of a local organizational field, likely setting a precedent for future (non-)competitive local, national, and potentially international organizational fields.
Also, this dissertation enhances methodological ethnographic techniques in medical and organizational anthropology, and global health. Most notably, this dissertation employs an amended form of content analysis known as “meeting analysis,” and continuous monitoring.
Both methods prove to be particularly useful in gathering data from “elites,” or in this case high power executives, that either lack adequate time for traditional sit-down interviews, or require on-the-go, back-to-back meetings with various institutional representatives or independent agents in multiple locations. Meeting analysis proves to be highly beneficial when coupled with participant-observation and this amended form of continuous monitoring, particularly for ethnographic studies requiring frequent on-site inspections and evaluations. As more anthropologists, social scientists, and/or global health practitioners conduct studies relevant to
22 global health governance and diplomacy, these methodological techniques may prove especially practical when the use of structured interviews are unfeasible with executives and upper management personnel.
Lastly, this dissertation has broad impacts on policy and practice regarding developing nations’ attempts to enter the global market for medical tourism purposes. First, this research has potentially profound implications for informing health policy regarding patient safety and health care provider compliance. Patient safety and health care provider compliance are two areas of health policy research that currently exist within a “data vacuum” in respect to medical tourism
(Alvarez et al. 2011; Cohen 2015). This dissertation provides a window into how private for profit civil society organizations benchmark their selection and management of medical tourism providers, ultimately eliding direct pathways for superior or substandard training of providers with available care options for foreign patients. Understanding the selection and management of medical tourism providers requires knowledge of the internal organizational logics of for-profit civil society health organizations.
In so doing, public and national social security authorities, health ministries, state actors and representatives, and even health insurers will all be better equipped to create formal legislation, policy interventions, and public-private relationships with powerful civil society stakeholders regarding medical tourism, both locally and nationally (Mainil et al. 2012).
Bilateral, or even multi-lateral, agreements require precedents of public-private exchange of both provider networks and on-the-ground industry organization to be truly successful (Closser
2011). This is particularly imperative within the medical tourism industry in respect to follow- up care, as post-surgical complications for foreign patients upon returning home have been shown to be very costly, both in terms of labor and fiscal resources. This is particularly
23 salient for the sending country, as high costs for re-integrating foreign patients back into the domestic health care system after traveling abroad also fall to sending governments and insurance companies (Birch et al. 2007; Ross et al. 2018).
Research Objectives
This dissertation has three main objectives:
Objective 1: evaluate how a newly formed for-profit civil society health organization prepares for and shapes the prospective experiences of its future clients.
a) What are organizational team members’ perceived requisites for or
defining characteristics of an overall good or bad medical tourism
experience for foreign patients traveling to Rio de Janeiro, Brazil for
health care?
b) How are organizational team members’ mitigating the prospective
conflicts that foreign patients will have in a cultural milieu different from
patients’ home countries?
This objective is measured with data collected from participant-observation, continuous monitoring, and semi-structured interviews with organizational team members.
Objective 2: understand how a for-profit civil society health organization establishes partnerships with agents from the health, tourism, and hospitality industries to construct a preferred network of service providers.
a) What criteria do organizational team members’ value in vetting and
selecting their preferred network of medical tourism service providers?
24
b) How are organizational team members finding potential medical tourism
service providers?
c) How do organizational team members reach internal consensus and
manage discord regarding whether or not to partner with medical tourism
service providers?
This objective is addressed with data collected from participant-observation, continuous monitoring, and semi-structured interviews with organizational team members and their chosen service providers.
Objective 3: assess how a for-profit civil society health organization’s interactions with and management of its chosen network of service providers influence the mobilization of a local new industry.
a) What are the most common communicative problems and resolutions
encountered between organizational team members and selected medical
tourism service providers?
b) What provokes organizational team members to enact power over selected
providers, and to dissociate them from the organization’s preferred
medical tourism service provider network?
This objective is assessed with data collected from participant-observation, continuous monitoring, and semi-structured interviews with organizational team members and their chosen service providers.
25 Outline of Chapters
In Chapter 1: Introduction, I propose and enumerate my central research question and specific research objectives, as well as describe the significance of my research project. In Chapter 2: Literature Review and Theoretical Framework, I first provide a general overview of three bodies of literature relevant to this research project, and situate these literatures within a critical theoretical framework. The three literature bodies reviewed in this chapter are the following: (1) the anthropology of global health diplomacy and governance; (2) the anthropology of medical tourism (also referred to as transnational health care); and (3) the anthropology of health organizations. The critical theoretical framework employed in this dissertation is structural constructivism, also better known to as practice theory. In this dissertation, practice theory will be limited to a
Bourdieusian organizational analysis, an analytical framework within institutional theory.
Organizational analysis is an increasingly popular theoretical framework within organizational anthropology, and will best serve as an ethnographic foreground to this dissertation on non-state health care organizations.
In Chapter 3: Methods, I describe the overall methodology and data collection and analysis procedures undertaken in this research project, as well as this study’s strengths and limitations. In Chapter 4: Managing Risk with Prospective Problem-Solving, I first provide a description of my entry into the field, and the current changes in Rio de Janeiro as a result of hosting two global events back-to-back. Next, I argue how a medical tourism start-up organization lowered its risk of failure by inductively creating novel solutions to potential problems likely to plague the foreign patient experience in the future. I also show how this key strategy was consistently practiced by organizational
26 founders, initiating the development of the organization’s position-taking. In Chapter 5:
Managing Partnerships by Affirming Amenability, I argue how organizational team members performed regular reviews of its service provider network in order to test its
(candidate) partners’ competence, compliance, flexibility, enthusiasm, and dedication to successfully support a novel local industrial enterprise. In routinely practicing this key strategy, organizational team members simultaneously fine-tuned their organization’s position-taking, as providers were pressured to finalize their negotiated service offerings.
In Chapter 6: Practice in Action: Demarcating the Organizational Field, I propose and discuss a theoretical model of the key ethnographic findings of this dissertation by applying a Bourdieusian organizational analysis. A Bourdieusian organizational analysis provides the ideal theoretical lens to understand how powerful organizational stakeholders regularly practiced two key strategies that resulted in: (1) the honing of the organization’s position-taking; and (2) the preservation of the organization’s competitive market advantage. As such, this discussion further explains how the iterative refinement of an organization’s position-taking compelled the trajectory of the organization’s competitive market advantage into the future, ultimately preserving the organization’s power to self-regulate the rules, participating agents, and scope of an otherwise legally ungoverned local industry. All in all, team members perceived a competitive market advantage as a compulsory safeguard to repurposing and withstanding the aftermath of the rapid socio-economic, cultural, political, and structural changes recently befallen on the city of Rio de Janeiro from hosting back-to-back global events. Finally, in Chapter 7:
Conclusion, I conclude with a summary of themes transecting the dissertation, its overall findings, implications, and topics and questions that warrant future research.
27 Chapter 2: Literature Review and Theoretical Framework
This dissertation draws upon three bodies of literature: (1) the anthropology of global health diplomacy and governance; (2) the anthropology of medical tourism (also referred to as transnational health care); and (3) the anthropology of health organizations.
Additionally, this dissertation engages with anthropological and sociological literature related to structural constructivism, also known to as practice theory. Practice theory is the critical theoretical framework of this dissertation. More specifically, this dissertation concentrates on a critical application of practice theory: Bourdieusian organizational analysis. Each body of literature presented in this chapter uniquely informs how the local-global health system is comprised of various types of stakeholders with vested interests that may unite under a common good or compete for power and control over capital. In this chapter, I show the importance of expanding the anthropology and global health literature to be more inclusive of for-profit civil society health organizations in the plural sector of global health diplomacy and governance, particularly in respect to medical tourism.
Global Health Diplomacy and Governance: Perspectives from Anthropology of Global Health
The field of global health has been characterized across disciplines as a paradox, a renewed ethic, a goal, a field committed to practice, research, and education, a new paradigmatic vision and action, a mindset, a collective entity that reflects the global good, as well as an expression of human rights support (Velji and Bryant 2011). With all of
28 these descriptive attributes, a definitive, universally accepted definition of what global health actually is, and not necessarily what is should be, has yet to be formulated
(Bozorgmehr 2010). Koplan and colleagues (2009) have rightfully argued that without a generally accepted definition of global health, the term “global health” can ambiguously refer to an objective, a condition, or even a combination of scholarship and practice that attaches inherently different strategies, priorities, philosophies, and skills to accomplish its goals. In accordance with Fried et al. (2010), this dissertation considers global health to be indistinguishable from public health, as both fields operate holistically to address ill-health root causes, as well as possess similar conceptualizations of health and population-level health policies, and individual approaches to health promotion.
However, global health differs from international health in part due to global health’s focus on health promotion advocacy, mainly to improve individuals’ quality of life, health potential, and overall well-being (Velji and Bryant 2011).
Additionally, this dissertation presupposes that global health should not be restricted to health issues that simply transcend national borders, since health threats, determinants, and illness burdens are increasingly in a transnational process of being globalized (Koplan et al. 2009). As such, this dissertation accentuates a defining characteristic of global health that is particularly salient to global health diplomacy and governance: global health’s “supraterritorial” nature. Quite simply, supraterritoriality acknowledges that domestic health issues are always socially linked to health issues anywhere, but not necessarily everywhere, in the world due to transnationalism and globalization (Bozorgmehr 2010). In other words, the supraterritorial tenet of global health allows the local to be re-situated back into “global” health (Bozorgmehr 2010),
29 offering profound implications for diplomacy and governance, which will be elucidated throughout this dissertation.
Throughout the past three decades, anthropologists have contributed significantly to the field of public health, despite relatively little scholarship focusing exclusively on global health diplomacy and governance. Within anthropology, research focusing on global public health issues can be broadly classified under the metadomain of
“anthropology and global health.” Subsumed under this metadomain are two additional epistemologies of anthropological research within global health: (1) the domain of the
“anthropology in global health,” and (2) the domain of the “anthropology of global health” (Closser 2010). Research falling under the anthropology in global health domain generally focuses on the formulation of effective public health interventions for recipient populations. Intervention strategies are normally fashioned after anthropologists assume roles as cultural brokers while working within development agencies. Global inequalities that structure risk for disease, as well as stifle access to and implementation of quality care (particularly in respect to poor institutional response and inadequate infrastructure), are generally ignored in anthropological works in global health (Closser 2010). This domain of research is arguably the most common within anthropology and global health, as seen by the works of Nichter and Nichter (1996), Chapman (2003), and Kamat (2006), among many others.
On the other hand, the anthropology of global health focuses on the internal workings of the global health system, including development organizations and agencies that design, fund, and administer global health projects, either for profit or non-profit.
Here, anthropological research of global health can be seen as ethnographic extensions of
30 Foster’s (1987) interpretation of the bureaucratic aspects of multilateral and bilateral organizations as sociocultural systems, and the health programs they support. In short,
Foster (1987) discusses that international health agencies encounter problems in areas such as rationalizing budgets, failing to learn from prior experience when objectives are not met, and being constrained by agency policy doctrines and Western Values, specifically in leaving Western cultural imprints on non-Western countries where programs are implemented. Therefore, anthropologists of global health have focused on
“uncovering” operational shortcomings within public health organizations.
It is critical to distinguish between these two anthropology and global health domains in order to identify who is to blame when health development projects fail.
Works centered on the anthropology of global health generally attribute project failure to bureaucracy, while research in the anthropology in global health generally credit project failure to poverty or a population’s culture (Closser 2010). I argue that it is in this respect that the anthropology of global health is closely associated with the anthropology of global health governance and diplomacy, with diplomacy partly bleeding into the anthropology in global health domain, insofar as anthropologists assume roles as agency representatives within the private or public sector. However, the anthropology of global health diplomacy and governance is not restricted to cultural brokership or the internal workings of public health organizations, as I will demonstrate in this dissertation.
Global Health Diplomacy
Health has been and continues to be cited as an increasingly powerful tool for improving international relations and political agendas, particularly in respect to development, trade, and the environment (Fidler 2007). As a result, global health
31 diplomacy has been increasingly influenced and informed by changing political and physical environments, failing nation-building efforts, rising biosecurity threats of emerging and re-emerging infections, changing global health governance structures, and widening global economic disparities (Adams et al. 2008). Consequentially, today’s global health diplomacy and foreign policy are no longer managed solely by traditional state diplomats, but now include alongside them non-state and other-state actors
(generally collectively referred to as “civil society”; Janes and Corbett 2009) that may challenge or dictate priorities based on public attention and their ability to raise large financial resources (Kickbusch and Buss 2011). Therefore, in the context of this dissertation, global health diplomacy can be defined as the system of negotiation and decision-making processes that state and non-state actors and stakeholders engage in to potentially create foreign policy centered on global health issues (Kickbusch and Buss
2011; Labonte and Gagnon 2010).
Global health diplomacy can be further divided into subcategories according to its bilateral, multilateral, multi-stakeholder, and semi-official negotiations on health issues internationally (Michaud and Kates 2012). Generally, there are three main types of global health diplomacies and activities: (1) core (high-level, formal treaties developed between bilateral and multilateral institutions and national representatives, i.e. WHO, country-to- country deals); (2) multi-stakeholder (cross-country governmental and organizational partnerships, i.e. national health ministries, USAID, CDC); and (3) informal/ semi- official (also collectively referred to as civil society members, like NGO representatives, private funders, free agents, faith-based organizational representatives, humanitarians, and researchers working on health issues in another country) (Katz et al. 2011; Michaud
32 and Kates 2012). Despite these multiple categories of state and non-state actors, initial findings suggest that decisions regarding foreign health policy are often made with “high politics” in mind, with primary interests in national security, economic materials and trade, and development at the forefront. Although foreign policies typically allude to
“low politics” (i.e. human rights, global public “goods,” and ethical/moral reasoning) as motivating forces behind implementation, findings suggest that low politics do not pervade diplomatic practice (Labonte and Gagnon 2010).
Paramount to global health diplomacy is the art of multi-actor and multi-level negotiation and decision-making for the purpose of improving health policy (Kickbusch
2009). In general, deals are forged between representatives of multi-lateral institutions and/or national agencies, both governmental and non-governmental. The most common deals within global health diplomacy concern specific diseases, the formulation and organization of treaties and conventions, and the perceived betterment of public welfare in individual countries, such as health sector reform and governance. Ancillary to negotiation and decision-making within global health diplomacy are studies of its efficacy throughout time and space. For instance, global health diplomacy requires analyses of: (1) successful and failed attempts to solidify deals and compromises; (2) the political spaces and “enabling environments” where deals take place; (3) the
(mis)leverage of power and leadership among dealmakers; (4) the tools enacted to defend, argue, contradict, and reach compromise; and (5) (the lack of) policy influences on deal structuring, revision, and timing (Kickbusch and Rosskam 2012).
Globalization is often identified as the catalyst for global health diplomacy, which has forced bilateral governments, philanthropic institutions, civil society and non-
33 governmental organizations, and corporations to work together for international health governance like never before (Kelley 2011). In light of globalization, diplomats must extend their service beyond advocating their mere domestic interests, namely security, power, and trade. Instead, diplomats must consider the global effects of their negotiations, while simultaneously promoting health priorities dealing foremost with sustainability in development, environment, food, and water (Kickbusch 2011).
However, Katz et al. (2011) assert that many foreign service diplomats (and global health professionals) have not been systematically taught sufficient legal knowledge, technical expertise (especially in science and technology), and diplomatic skills necessary for not only enacting such negotiations, but also forging partnerships to interact with both governmental and non-governmental stakeholders from developed and developing nations.
Foreign policy and diplomacy have the potential to raise the “global health profile” internationally, while simultaneously creating dialogues that seek to identify common political interests and conflicts between nations and other stakeholders
(Michaud and Kates 2012). Kickbusch (2011) delineates three “global agendas” that have brought health diplomacy to the forefront of foreign policy: (1) security against the
(un)intentional spread of pathogens worldwide; (2) economic investment in the global marketplace via increased development in resource-poor nations; and (3) social justice, which includes upholding “health” as a human right with value. As a “soft power” tool
(as opposed to a “hard power” tool of coercion and payment) for building alliances and improving political relations and reputations, foreign policy must be developed intersectorally with local sociopolitical contexts in mind to be remotely effective,
34 eliciting yet another requirement for health diplomats (Lee and Smith 2011).
Since WWII, the World Health Assembly has traditionally been the main official diplomatic powerhouse proactively focusing on improving foreign health policy. Within the past decade, however, there have been numerous international health ministries that have come together to shape foreign policy with health as their “directing lens,” as seen in the Oslo Ministerial Declaration (Michaud and Kates 2012). Currently, the U.S. is joining other countries in recognizing the importance of health as an avenue to strengthen international relations and national security interests. Even though the U.S. has long supported global health issues, evinced by its many departments and agencies dedicated to address international health issues, the recent implementation of the Global Health
Diplomacy Office in the State Department responds to the urgent need for diplomatic management. Although, without a clear understanding of what global health diplomacy actually is, and more importantly what its responsibilities fully entail, it remains to be seen how effective this Office will be at accomplishing its Global Health Initiative goals, and managing global health’s many stakeholders (Kaiser 2013). Perhaps, the Global
Health Diplomacy Office will improve U.S. efforts to negotiate with key stakeholders multilaterally. However, a decrease in U.S. bilateral negotiations will likely mean shifting primary diplomatic motivations from national security and trade to one that moralizes and re-instantiates health as a humanitarian, and not solely an economic, issue.
Global Health Governance
If global health diplomacy is characterized by the negotiation and decision- making processes required to formulate foreign health policy, than global health governance can be considered the political space in which collective problem-solving on
35 health issues by governmental, intergovernmental, and non-governmental actors takes place (Fidler 2010). Like all political spaces, global health governance consists of rules, regulations, institutions, mechanisms, and processes of creating and prioritizing health goals, as well as determining political organization, such as the restructuring of new-old partnerships. Like global health diplomacy, global health governance relies on the numerous interactions of multiple stakeholders at the international, national, and local levels. These multi-level interactions invariably foster the constant reconfiguration of power within and between levels of authority, making global health governance a persistent political endeavor (Kickbusch 2009).
As with global health diplomacy, global health governance can be further segregated into three different subtle political domains based on direct or indirect involvement with setting, promoting, or implementing global health priorities: (1) global health governance (institutions and processes of governance that are explicitly formulated under or tied to a formal health mandate; i.e. WHO); (2) global governance for health
(institutions and processes of governance that have direct and indirect health impacts typically pending recommendations from global health governance institutions; i.e. UN,
WTO, HRC); and (3) governance for global health (institutions and mechanisms at the national and regional level that contribute to global health governance and/or governance of global health institutions; i.e. local global health strategies). While it is generally assumed that the global governance for health domain will lead progress within global health governance, the governance for global health domain will prove to be critical for successful on-the-ground implementation of domestic and global interests. In response to increased public scrutiny for breaching conflicts of interest, global health governance
36 institutions, like WHO, are now requiring internal re-structuring to account for interactions with non-state actors, both non-profit and for-profit (Kickbusch and Szabo
2014).
Considering that most diplomatic relations are occurring within an increasingly global poly-lateral political space, as seen above with global health diplomacy, global health governance is becoming exceedingly characterized by its “unstructured pluralism.”
The unstructured pluralistic nature of global health governance implies that many social actors and institutions are not only participating within the global political space of solving health challenges worldwide, but they are also imposing their own multifarious agendas, solutions, values, approaches, and roles onto an already shifting sphere of political actors united under the same guise of healthcare problem-solving. As a result of unstructured pluralism, it is extremely challenging to map both the ever-changing networks of actors involved in global health governance, and the shifts in power and authority between institutions and players (Fidler 2007). Despite the difficulty of adequately reticulating governance actors and coalescing their opposing ideologies on global health issues, Kickbusch and Szabo (2014) argue that exchanges between multi- level actors, institutions, and organizations should occur both vertically and horizontally.
To further complicate the problem of global health governance, there is currently not a single governmental body that monitors accountability and cross-checks transparency (two essential characteristics for “good governance”) among participating state, inter-state, and non-state actors (Kickbusch 2009). Efforts to increase accountability and transparency are becoming compulsory within this new multilateral political space, as many resource-rich non-state actors have the power to create their own
37 global health agendas, force other resource-poor organizations to shut down, and entice donor and recipient nations to adopt their global health strategies (Kickbusch and Szabo
2014). The lack of a single transnational governing body charged with the responsibility of ensuring fair accountability and transparency for state and non-state actors results in increased power asymmetry among governance actors. At present, it is up to States to regulate unstructured plurality in order to prevent fragmentation, duplication, and/or competition among actors, as well as to oversee the production and promotion of global public goods (Kickbusch 2009).
The traditional governance space in which state actors are held accountable for health care issue problem-solving is known in the international relations and international law literature as the “old-school anarchy” architecture metaphor. Since old-school anarchy is limited to state governance actors only, the political governance space can be considered a closed-system, allowing state actors to leverage their sovereignty and political interests in the name of their respective national interests without competition from non-state actors. Due to the fact that global health issues are currently transnational and supraterritorial in nature, and thereby are affected by both the private and public sector, old-school anarchy is generally viewed as ineffective, as the metaphor does not account for the contemporary mercurial environment of unstructured pluralism (Fidler
2007).
Fidler (2007) proposes an alternative metaphor for a new governance architecture that opens the closed-system approach to governance by accounting for the governance norms, institutions, and processes developed by both state and non-state actors: “open- source anarchy.” The open-source anarchy metaphor adopts a modern, technologically-
38 informed approach to not only purposefully encourage greater “structured pluralism” within the global health governance space, but also to help explain local governance challenges to health issues within a transnational world. For instance, the open-source anarchy metaphor posits that governance actors invariably (re)create and (re)modify a
“source code” for global health, which evolves through the creative production, expansion, and adaptation of networks, processes, ideas, norms, and values among the diverse types of governance actors (Fidler 2007). This metaphor allows for a more productive ideology than a traditional architecture metaphor because failed governance
(i.e. the neglect of certain health issues due to the self-interests of powerful governance actors) can be attributed to local “hardware failures” (poor public health infrastructure) instead of “bugs in the source code” (Fidler 2007: 13). Many developing and least developed countries simply possess outdated technological hardware to “run global health’s 21st century source code,” thereby further unevening the governance playing field (Fidler 2007: 13). Perhaps unstructured plurality may not be the most challenging problem for global health governance, and instead may be the “plurality of incapacity”
(Fidler 2007: 15).
Anthropological Contributions to Global Health Diplomacy and Governance
Janes and Corbett (2009) enumerate four contributions that anthropology has made to global health: (1) ethnography of health inequities in relation to political-economy; (2) impact of science and technology at the local level (considered to be any small-scale scape where social meanings are informed); (3) analysis and critique of international health programs and policies; and (4) analysis of health consequences on international health’s efforts in configuring social relations. It is in the latter two areas in which
39 anthropologists have only begun to specialize in global health diplomacy and governance.
More recently, there has been a small growth in the number of critical ethnographies focusing on “health policy and systems research,” providing an avenue for anthropologists to highlight aspects of global health diplomacy and governance within their topics of interest. Ethnographies classified under this research domain generally have been limited to the implementation, management, and delivery of health services within weak health care systems (Storeng and Misha 2014). The overall purpose of health policy and systems research has been to bring a heightened socio-political awareness of the multidimensionality of human experience to health policy (Pfeiffer and Nichter 2008;
Storeng and Misha 2014).
In the limited anthropological scholarship focusing on global health diplomacy and governance falling outside of health policy and systems research, there has been a push to expand the role of anthropologists past being mere cultural brokers towards being a polymath of global health practice. For instance, Janes (2004) proposes that in order to be multi-level advocates, a position that is now compulsory for working in the global health
2.0 arena (Gaines 2011), anthropologists must broaden their qualitative and quantitative data collection strategies to re-situate the local back into regional and national programs of research. Expanding our means of data collection also requires anthropologists to cast a critical eye on evolving global policy, and become master synthesizers of multidisciplinary research related to global health in order to positively affect global health governance (Janes 2004). In addition, Justice (1999) claims that anthropologists must consistently present their ethnographic findings in ways that state and non-state actors can use, particularly given the time restrictive conditions under which program
40 planning is done, and the limited alternatives available to decision-makers when trying to adapt policies and programs to local conditions. In his work on how NGOs fragment local health systems in Mozambique, Pfeiffer (2003) suggests that anthropologists should be finely adept in using ethnographic data to create new models of collaboration between foreign technical experts from various funding organizations, national providers, and local communities in order to develop and sustain equitable primary health care.
One of the most exemplary in-depth ethnographic depictions of global health diplomacy and governance is Closser’s (2010) analysis of the Polio Eradication
Campaign in Pakistan. As a multi-sited project, Closser (2010) worked with many state actors, such as Pakistani district bureaucracies, offices of polio eradication officials
(including WHO’s Islamabad office in the Pakistani National Institutes of Health),
WHO’s headquarters in Geneva, and the Centers for Disease Control in Atlanta. In these locations, Closser (2010) conducted structured and semi-structured interviews with
Pakistani officials and bilateral donor agency representatives, assimilated into the role of
“foreign consultant,” participated in planning meetings, analyzed surveillance data and files, acted as a “foreign monitor” on four door-to-door vaccination campaigns that covered all stages from planning to evaluation, performed internal agency participant- observation, and conducted archival research within government agencies (Closser 2010).
This mixed-method and multi-sited approach to understanding local and global diplomacy and governance of polio eradication allowed her to make several noteworthy findings.
Aside from uncovering the fact that government employees consistently used substandard strategies with upper-management, such as lying about complying with
41 foreign consultants’ orders, accepting bribes, small-scale siphoning of money, and routinely falsifying data, Closser (2010) identified very poor communication, leadership, management, and lack of political will and enthusiasm at the district-level. Moreover,
Closser (2010) proposed that confusion among powerful governance actors, namely spearhead organizations and donor agencies, and local governance districts, diplomats, employees, and health project volunteers persists because of the lack of structured political, technical, and operational feasibility. Furthermore, Closser (2010) makes several actionable diplomatic suggestions for paring unrealistic expectations of powerful governance actors to accommodate and improve their working relationships with
“failing” local health infrastructures. Some notable suggestions are having health planners: (1) agree to a pre-commitment analysis of political feasibility with receiving populations; (2) design a program that allows adaptive flexibility in the end-stages of a program to ensure greater success of meeting end goals and objectives; (3) to not readily accept spoken support as actual support; (4) to not incorrectly assume that global health officials can generate political support for a global health goal, as many global health officials are unlikely to be pertinent in many political valences; (5) to not blame individual countries when they encounter a lack of political will, as this normally deflects attention away from poorly formulated health policy, over-optimism of eradication, and assumptions of unified political structures in receiving nations; (6) to recognize, name, and plan around resistance; and (7) to not assign technical experts, like doctors, virologists, and epidemiologists, to be managerial decision-makers (diplomats) at the global level (Closser 2010).
All of the above anthropological scholarship on public and private institutions has
42 significantly contributed to our ethnographic knowledge of global health diplomacy and governance. However, numerous aspects of diplomacy and governance still warrant substantial ethnographic inquiry by anthropologists. One pressing issue that requires anthropological attention is for-profit civil society actors, and their “glocal” influence in global health diplomacy and governance.
Civil Society Organizations
Organizations are broadly classified in the anthropology and global health literature as belonging to one of three sectors: public, private, or third. The public sector refers to non-profit governmental organizations, while the private sector refers to for- profit businesses. The third sector, however, serves as a catch-all category for organizations that are neither purely publicly nor privately owned (Hearn 2001). Some examples of third sector organizations are non-governmental organizations (NGOs), associations, cooperatives, foundations, clubs, think tanks, unions, hospitals, and campaigning groups, to name only a few (Igoe 2005; Fischer 2007).
Third sector organizations do not require the highly defined, formal institutional intra-organization typical of public and private sectors. For example, many grass-roots associations and clubs are loosely organized, while still maintaining a strong sense of collective action (Mintzberg 2015). In the literature, the public sector is synonymous to the political sector in reference to the state, and the private sector is conflated with the economic sector when focusing on market forces. The third sector is associated with the social sector when discussing “civilizing forces” in the literature, hence the term civil society (Bunyan 2014). Moreover, public organizations may be associated with citizenship, private organizations with individual ownership, and third sector
43 organizations with any combination of public-private “communityship.” Like local third sector organizations, global civil society organizations are geographically rooted in and function in benefit of their respective local communities (Mintzberg 2015).
The term third sector is highly problematic in the global health and anthropology literature due to the enormous variation of organizations that are subsumed within this category (Fischer 2007). Researchers are increasingly recognizing that the term civil society is highly ambiguous, as it fails to conjoin the ownership, structural, and hierarchical attributes typical of organizations in the private and public sector. For example, third sector (or civil society) organizations may not be owned entirely by the state or private investors. Instead, they may be partly owned, either privately or publicly, by their respective founding or joining members, or no one at all. Additionally, third sector or civil society organizations may be formally structured as private organizations
(i.e. CEO run), dependent on government control and funding (i.e. state and federal grants), or both. Scholars are increasingly using the term plural sector as a preferred moniker over third sector or civil society, as plural sector accounts for the overall interconnectedness between the three sectors, and the spectrum of varying degrees in which organizations are publicly or privately owned, structured, and managed (Mintzberg
2015).
In anthropology, civil society is often defined in opposition to the state (Hearn
2001; Igoe 2005; Fischer 2007). More specifically, contemporary anthropological understandings and scholarly usage of the term civil society have been greatly shaped by neo-liberalism, partnership, legitimacy, and social justice (Igoe 2005; Fischer 2007;
Bunyan 2014). In reaction to state-led directives, civil society organizations are becoming
44 salient service delivery organizations in their communities. For example, in light of government budget cuts in nations around the world, many civil society organizations are compelled to deliver services that are no longer publically supported (Mintzberg 2015).
This is particularly true for civil society organizations working within global health.
Thus, civil society organizations may be viewed as a social mechanism that makes up for and holds governments accountable for its negligence in addressing pressing social concerns within communities (Fischer 2007; Edwards 2004).
Civil society organizations retain considerable power in converting social and cultural capital into economic capital. Many civil society organizations partner with other organizations in public, private, and plural sectors to establish networks for market cooperation, particularly in regions or industries with weak market regulation from the state (Edwards 2004). Since the state creates legal structures under which all organizations must operate, some civil society organizations are forced to operate outside of the law, especially in regions and industries that are developing quicker than the law can be instantiated (Hearn 2001).
One type of civil society organization that is drastically underrepresented in the anthropology and global health literature is civic and social entrepreneurs. Civic and social entrepreneurs are described as entrepreneurs with “civic virtues” of mobilizing community enhancement and encouraging social momentum during periods of drastic change. Moreover, civic and social entrepreneurs can be viewed as the concatenate among the public, private, and plural sectors. Civic and social entrepreneurs foster, organize, and develop the social and cultural capital required to increase economic assets that mutually benefit local communities. Like business entrepreneurs, they are
45 visionaries who see new economic opportunities within the socio-political realities of struggling communities. As social networkers, motivators, and drivers of economic development, civic and social entrepreneurs make collaborative partnerships across sectors to enhance social responsibility, welfare, and public safety, especially in unregulated or deregulated environments (Henton et al. 1997).
There are several complications that civil and social entrepreneurs face while working within the realm of global health. One challenge is managing convergent and divergent interests from multiple stakeholders, such as health care providers, patients, and payers. Another challenge is formulating health care delivery solutions congruent with government safety regulations (if any) amidst limited infrastructural resources in regions with diverse market dynamics and customs (Denend et al. 2014).
Medical Tourism: Perspectives from Anthropology and Global Health
The term “medical tourism” is highly contested, as it generally conjures four distinct meanings: (1) health care providers traveling to under-resourced settings to provide brief medical care; (2) individuals who travel for free access to medical interventions provided by publicly funded health care systems; (3) individuals traveling for the sole purpose of health care; and (4) individuals who travel for health care and engage in touristic activities and/or side trips (Turner and Hodges 2012). Despite all of these associated meanings, the overall literature on medical tourism enumerate four known specific social actors in the medical tourism industry (Connell 2011): (1) foreign patients; (2) caregiver companions (family and friends who travel abroad with patients to provide support and assistance; Casey et al. 2013); (3) medical tourism facilitators
(individuals who offer comprehensive medical travel services and are contracted to
46 collapse socio-cultural distances between foreign patients, and between foreign patients and providers; Dalstrom 2013); and (4) receiving health care providers. Individuals seeking healthcare in another country travel either for non-elective or elective surgical or non-surgical procedures, which are respectively defined broadly as medical procedures deemed an emergency or not at the time health care services are sought (Ackerman 2010;
McDonald 2011). Regardless of anticipated procedural type(s), foreign patients generally adhere to the following phases of the medical tourism process: (1) patient deliberation and first contact with health care providers, either by word of mouth or online forums and websites; (2) patient follow-up with medical tourism facilitator companies and/or health care providers directly; (3) travel to the receiving nation for health care; (4) the clinical encounter abroad where procedure and treatment are administered; (5) recovery within the receiving nation; and (6) follow-up care upon returning home (McDonald 2011).
Foreign patients form expectations prior to their medical travel, which are strongly influenced by news stories, marketing efforts, and personal needs (Guiry et al. 2013).
Generally, foreign patients decide to engage in medical travel based on a complex calculus of affordability, accessibility, personal networks, and “gut feelings” of safety, sterility, risk, and contamination (McDonald 2011). Table 1 outlines a non-exhaustive list of variables that foreign patients consider when deciding to undergo medical travel.
These variables are divided into five empirical categories that are not mutually exclusive.
The empirical categories and perceived benefits of medical travel in Table 1 were developed from themes extant in the anthropology and global health literature on medical tourism, and will be further described in this section (Bookman and Bookman 2007;
Connell 2011; Smith et al. 2012; Botterill et al. 2013; Turner 2013; Hanson et al. 2015).
47 Table 1: Reasons Why Patients Travel Abroad for Health Care, as Articulated in the Anthropology and Global Health Literature
Empirical Category* Perceived Benefit of Medical Travel Significant cost savings on procedures and treatments in the destination country due to favorable currency exchange rates, market forces and legal structures in owning and operating a local medical practice, rates of medical malpractice insurance, and publicly funded health systems. Affordability Tax exempt incentives Corporate and/or insurance coverage and subsidies Access to cost-effective, non-stigmatized follow-up care upon returning home Ease of travel to and from the destination country Geographic, cultural, religious, and/or linguistic proximity to country of origin Reduced wait times in destination country / ability to evade waiting lists in country of origin Feasibility High availability and accessibility of desired treatment options, interventions, and/or bodily materials (i.e. gametes, organs) Adequate and comfortable recovery in destination country prior to returning home General infrastructural resources of the destination, such as established tourism, transportation, hospitality, and health care industries Specialization of foreign doctors Advanced technology or expertise unavailable in country of origin Quality of Care Proven success rates of experimental treatments not available / illegal in country of origin International reputation and history of destination country’s specialization in desired medical treatment Confidence in facility sterility, as determined by the reputability of the facility’s accreditations (i.e. Joint Commission International) Training and credentials of foreign doctors (i.e. membership of Safety international medical societies, board certifications) Confidentiality and privacy Social, political, and economic stability of the destination country, such as crime and violence Success stories from word-of-mouth, internet testimonials and websites, and before and after photos Personal Connection Professionalism of facilitators and foreign doctors Social support from prospective caregiver companions * Empirical categories are not mutually exclusive.
48 Generally, foreign patients with elective medical conditions are more motivated to not only partake in medical travel, but also touristic activities while abroad. On the other hand, patients with life-threatening conditions are generally more concerned with the economic development of the receiving country, valuing quality of care, safety, and advanced technology over other motivating factors. For foreign patients with prior experiences of traveling abroad for health care, less emphasis is generally placed on travel logistics, cultural aspects, and economic development and safety. Additionally, patients with less confidence in health insurance companies are more likely to consider medical tourism, and consult medical tourism facilitator agencies for medical travel assistance (Hanson et al. 2015). Moreover, as business travel is increasingly intertwined with health travel under employee corporate benefits, some employees-turned-foreign patients are opportunistically deciding to travel to the developing world for cheap health care (Froze et al. 2010). Generally, however, foreign patients tend toward self-selected consumerism over employer- or government-encouraged medical travel (Bies and
Zacharia 2007). For foreign patients living with disabilities, one frequently confronts financial, environmental, interactive, and intrinsic barriers to traveling abroad for care
(Luther 2013). No matter whether the foreign patients’ motivation is based on (the lack of) health insurance coverage, availability, affordability, and/or perceived quality of care, the likelihood of foreign patients returning to medical tourism only increases once one’s familiarity of the receiving health care system is merely experienced positively (Glinos et al. 2010).
It is estimated that over seventy percent of foreign patients use the Internet to find medical tourism information, with the top searched procedures being bariatric surgery,
49 orthopedic surgery, cosmetic surgery, and dentistry (Turner 2008; Froze et al. 2010;
Pollard 2013). With such high volume internet traffic, websites serve as the primary means to elicit and gain trust among potential patients, facilitators, and health care providers. More specifically, medical tourism websites function as a portal or entry point to information on destination infrastructure, health care providers, available treatments, and/or respected brokers, all generally through the use of videos, testimonials, and virtual tours. Some websites are “authoritative” in nature in regards to the media, policies, regulations, legislations, and commerce, while other websites are consumer-generated blogs and discussion boards used for sharing past experiences, recommendations, and community support. Additionally, the majority of foreign patients utilizes social networking and social media before and during their trip not only for community support and information access, but also to document and share their entire journey and experience with others in their social network (Horsfall et al. 2013; Jones et al. 2014).
The majority of foreign patients tend to be “middle class,” since poverty generally precludes individuals from having the expendable income to travel abroad for healthcare, and since the elite can afford health care domestically. However, this demographic profile is changing as insurance companies and employment programs are increasingly choosing to pay to send individuals abroad to save on domestic health care costs (Lee
2012a). Approximately eighty-five percent of foreign patients claim that the level of care received abroad is superior to the care they receive at home, and with over ninety percent claiming that they would recommend their experience to a friend or family member upon returning home (Froze et al. 2010). The most common age range of foreign patients are
30-45 years old. Older, single females generally place greater weight on quality aftercare
50 upon returning home, and normally solicit input from family and friends (Henson et al.
2015). Contrary to popular belief, the current statistics regarding foreign patients suggest that few have completed higher education, possess limited foreign language skills, and generally pay for their medical travel with credit, savings, or small inheritances (Holliday et al. 2014).
In respect to caregiver companions, it is estimated that eighty percent of all medical tourists travel with caregiver companions for timely emotional, cognitive, and material social support (Froze et al. 2010; Jacobson 1986; Jacobson 1987). Caregiver companions may be children, spouses, friends, and/or relatives. In general, caregiver companions influence patients’ decision-making, pose challenges to patients, enhance patients’ experiences of medical travel, and are key to sharing information about the livelihood of patients to health care providers and medical tourism facilitators during their time abroad (Casey et al. 2013). Caregiver companions also represent another demographic in which to sell travel services. In fact, approximately ninety percent of caregiver companions typically participate in touristic activities while caring for foreign patients abroad (Froze et al. 2010).
In respect to medical tourism facilitators, there are generally three types: (1) full service facilitators (FSF), (2) referral services facilitators (RSF), and (3) individual service facilitators (ISF). FSFs offer the most comprehensive services, such as travel visas, transportation within the receiving country, selection and referral of physicians and medical facilities, post-operative care, and translation services. FSFs attempt to collapse cultural and social distances between patients and receiving physicians by reimagining the doctor/patient relationship as a consumer relationship. RSFs, on the other hand, have
51 the sole goal of connecting patients to medical providers directly, rather than dealing with the aforementioned logistical issues for patients that FSFs assume. Generally, RSF services are limited to scheduling appointments, arranging some on-the-ground transportation, and providing information to patients about select health care providers in one country only. Moreover, RSFs generally only recommend medical providers that are familiar with the foreign patient’s nationality. Lastly, as the most common type of facilitator, ISFs are foreign facilitators who directly market medical services to patients without little concern for erasing cultural differences. Generally, these ISFs market the health care services of providers that do not primarily see foreign patients, and typically have little cultural and linguistic knowledge of their patients. Therefore, ISFs generally act as translators for patients, and receive a commission percentage directly from health care providers (Dalstrom 2013).
Oftentimes, medical tourism facilitators must act not only as commercial arbiters, but as “emotional laborers” as well, particularly if the foreign patient is undergoing drastic, traumatic, and/or transformative medical procedures while abroad (Holliday et al.
2014). This is particularly the case when foreign patients decide to travel without caregiver companions. As such, medical tourism facilitators offer a three-dimensional support system to medical tourists: (1) integrated knowledge of medical services; (2) tourism and travel facilitation services; and (3) concierge services (Mohamad et al. 2012).
Not all foreign patients opt to use medical tourism facilitators as a source for booking services. Instead, some foreign patients consult facilitators as an information source only. There are generally five ethical concerns commonly cited about the roles and responsibilities of medical tourism facilitators: (1) the lack of universal standards of
52 facilitator training and accreditation (problematic for discerning patients, particularly in conjunction with the accreditation schemes of medical facilities); (2) facilitator conflicts of interest (i.e. financial, coercion to do unnecessary procedures, recommending illegal treatments, etc…); (3) marketing transparency and patients’ consent to risks; (4) problems with continuity of care and follow-up care; and (5) legal liability for harms
(facilitators are generally not responsible for adverse outcomes, although they may be held legally accountable for negligent medical referral). In general, more research is needed regarding the patient-facilitator interactions beyond what is known from public facilitator websites. More specifically, more information is needed regarding the degree to which facilitators convey information on the risks of medical tourism, the content and presentation of liability waivers, and discussions of follow-up and continuity of care
(Snyder et al. 2012).
Financial interests appear to influence how information about the risks and benefits of medical care is communicated to prospective medical travelers. More information is needed regarding whether physicians “first do no harm” to patients, even though their efforts to participate in medical tourism appear largely financially motivated at first glance (Guiry et al. 2013). Contrary to popular belief, money is generally not considered the driving force behind whether physicians and surgeons choose to migrate not only from the public to private health care system, but also from international medical systems as well. Rather, the desire to implement an ethic of care perceived to be
“unactualizable” in the public health sector ultimately encourages physicians’ to transition from the public to private health care system (Holliday et al. 2014). Despite financial motivations, it is still unclear what is meant by informed consent within the
53 medical tourism industry. This is compounded by medical tourism websites focusing on relaying the benefits of purchasing treatment abroad, instead of fully disclosing the risks associated with medical tourism, such as post-operative complications (long-term and short-term) and relinquishment of legal recourse for medical malpractice. Facilitators and sales agents are typically not a part of the prior informed consent process between patients and physicians. Ultimately, the financial interests of third parties, then, largely affect patient decision-making (Turner 2012). All indirect or direct providers should be cognizant of foreign patients’ “tolerance zone,” which is the service-performance range that a patient considers satisfactory and the amount of risk a patient is comfortable with mitigating (Guiry et al. 2013).
Global Health Literature Trends
Most of the global health research on medical tourism borrows and expands upon the terminology outlined in the General Agreement on Trade in Services (GATS) developed by the World Trade Organization (WTO) in 1995. This agreement laid the formal legal framework for the liberalization of international trade in health services. In general, four modes of international trade in health services were outlined: cross-border supply (i.e. the outsourcing of the interpretation of diagnostic testing, including telemedicine, teleradiology, and telepathology); consumption abroad (i.e. movement of patients across international borders); commercial presence (i.e. health care institutions providing care outside of their home country); and presence of natural persons (i.e. movements of health care staff to other countries’ health systems; Smith et al., 2009).
Exceeding the boundaries of these aforementioned categories today, medical tourism is perhaps the epitome of the globalization of health, as seen in the dramatic acceleration of
54 transnational: (1) migration of health professionals; (2) trade in pharmaceutical products;
(3) diagnostic laboratory companies; (4) NGOs providing medical assistance; (5) disease- specific international aid programs; (6) hospital corporations; (7) outsourcing of internal
“medical back-office work” (i.e. processing insurance claims, medical transcription, case evaluations, and e-transfers of medical imagery); (8) governmental responses of sustaining revenue and resources for respective health sectors in the face of financial crises, including the exportation of health services to other nations and the importation of tertiary treatments from other countries; (9) expansion of health insurance to cover procedures abroad in efforts to decrease company expenditures; and (10) decline of neoliberal states relying on the provision of public services (Whitaker et al. 2010;
Connell 2011).
To date, the global health literature on medical tourism has been largely evaluative rather than ethnographic, with the majority of studies focusing on Europe and
Asia (Glinos et al. 2010; Bell et al. 2015; Inhorn 2011). There are primarily two nominal typologies of seeking health care outside of one’s primary residence: (1) cross-border health care, and (2) medical tourism. Reserved primarily for European Union contexts, the term “cross-border health care” refers to patients moving between national socialized health care systems, while the term “medical tourism” has been used in intra-regional contexts and discourses of privatized health care systems, such as in the U.S., Latin
America, and Asia (Botterill et al. 2013). For both cross-border health care patients and
“medical tourists,” the crossing of international borders for health care services is requisite. As such, individuals who only cross regional or federal state borders for health care are typically not considered foreign patients in the global health literature. In
55 contrast to “medical tourism,” further distinctions apply to cross-border patient mobility, including the exclusion of: (1) tourists, expatriates, and migrants that access care in a foreign country, as they do not intentionally plan to travel for the purpose of treatment, but instead may make use of health services while abroad; and (2) persons purchasing medical products (i.e. pharmaceuticals and medical devices) or trading medical services via tele-medicine, as travelers do not actually obtain health services abroad, even though borders may be crossed electronically (Glinos et al. 2010). To subsume both categories of foreign patients in the global health literature, a new term, “transnational health care,” has been proposed to encompass a:
“global patient mobility framework, which builds on a logic of transnational health regions (regional development as a vehicle for patient mobility), transnational organisations (such as hospital chains and insurance schemes) and sustainable health destination management (governmental steering of the development of patient mobility).” (Botterill et al. 2013: 3).
Therefore, the term transnational health care is ultimately meant to bridge the supply- demand components of medical tourism and cross-border patient mobility to enable national health systems and their populations combine public health benefits with governmentally controlled market development via health policy (Mainil et al. 2012). In general, the global health literature indicates that transnational health care is not only unevenly regulated and poorly documented, but it sits uncomfortably between health care and consumerism (Holliday et al. 2014). Overall, the global health literature has relied on the following dualities and analytical frameworks to understand transnational health care: (1) supply versus demand; (2) home country deficits versus destination country offerings; (3) patient needs versus provider resources; (4) patient autonomy versus state obligations; (5) commercialization of health care services and technology; (6) globalization; and (7) the evolving nature of medicine and health (Botterill et al. 2013).
56 Also within the global health literature, transnational health care is considered a function of globalization that is constructed of “networks with long-term exchange relationships” (Lunt et al. 2014:19). In short, biomedical platforms provide the opportunity to structure new types of transnational mobilities and practices that are currently in conflict with established regimes confined within nationally defined borders.
These new “biomedical mobilities” of people, knowledge, ideas, and things that travel beyond borders work in tandem with “network topographies” (Beck 2012) and “spaces of connectivity” (Pordie 2013), in which the notions of space and place are not bounded entities, but are rather networks of interactions. As methodological devices to analyze where transnationalism takes place (i.e. international hospitals, clinics, hotels, etc…), how its networks and places are comprised of motionless stabilizing agents (i.e. health care staff), and how these agents foster connectivity among mobile agents (i.e. transnational patients), network topographies and spaces of connectivity are not only fluid and ever-shifting spatio-temporally, but they also oscillate between cultural immersion and insulation of cultural differences (Pordie 2013). Ultimately, the social interactions that occur within these networks are the basis of decision-making within transnational health care (Mainil et al. 2012). To date, global health findings on the social interactions of transnational health care have generally been limited to patients’ social networks. Findings suggest that: (1) patients’ social networks significantly influence treatment itineraries, and the logistical and financial aspects of travel (Bochaton
2015); and (2) destination and provider choices are significantly influenced by informal social networks, including web forums, personal recommendations, and support groups
(Hanefeld et al. 2015). Therefore, research on the social interactions within transnational
57 health care has been restricted to foreign patients’ medical travel itineraries, and to interactions that occur prior to departure from and after arrival in the sending country.
Additionally, transnational health care has been analyzed from the perspective of
Appadurai’s (1990) discussion of global flows and disjuntures, which denote the nonisomorphic, multidirectional, multi-scalar, and complex flows of what happens when all scapes “land” in places, shaping human practices, ideas, and ideals within particular locales (Holliday et al. 2015; Inhorn 2011). For instance, as an “assemblage” of global flows and scapes, transnational health care possesses: (1) ethnoscapes, which refer to the flows of foreign patients, their companions, surgeons, health care staff, facilitators, and other agents; (2) mediascapes, which refer to news media and propaganda for and against transnational health care, including professional and trade publications, travel guides, online forums, and social media; (3) technoscapes, which refer to the flows of medical devices, quality markers (i.e. accreditation schemes), and surgical/procedural techniques;
(4) finanscapes, which suggest the (in)direct payment for health services, favorable global economic incentives for going abroad (i.e. fluctuating exchange rates), growing entrepreneurialism, and “glocal” networks of capital backing for major international hospitals and “medi-cities”; and (5) ideoscapes, which refer to the exchange of ideas about transnational health care through social networks. In such analyses, additional
“meta-scapes” have been introduced to elucidate the contexts specific to particular niche forms of transnational health care, such as Inhorn’s (2011) “reproscape” for reproductive tourism and “beautyscapes” for cosmetic surgery tourism (Holliday et al. 2015).
Transnational health care continues to affect the production, alteration, and reinforcement of borders and nation-states, as well as public health’s response to
58 changing notions of health (Roberts and Scheper-Hughes 2011). Currently, the majority of people seeking health services abroad are flowing from the Global North to the Global
South. However, not all medical migrations should presume the sole exploitation of the
Global South by the Global North, simply because individuals move consistently around the world, and that some exploitation is internal and based on local economies of body trade (Cohen 2011). Patient mobility is not just limited to the bi-directionality of the
Global North to the Global South, however, as mobility between the Global South is now made possible with world-class health care and international transportation at economical prices (Glinos et al. 2010). Even though the global transnational health care industry is becoming more globalized and standardized, one cannot assume that there is a homogenous effect across all destination countries (2012b).
In any case, low- and middle-income countries benefit greatly by attracting foreign patients and establishing a national medical tourism industry of their own. Some potential benefits of developing nations seeking to expand their offering of health services to foreigners are: (1) generating foreign exchange; (2) attracting and retaining health professionals, including extension of specialists to the entire local population; (3) building new and improved health care facilities; (4) job creation; and (5) production of tax revenue from food, hotel, tourism, and insurance businesses; and (6) utilization of excess capacity of private hospitals (Whitaker et al. 2010; Alvarez et al. 2013). Of course, the benefits of establishing transnational health care are merely theoretical, as actualizing these benefits requires the formulation and subsequent adoption of formal policies
(Kanchanachitra et al. 2012). However, the following are considered perceived negative drawbacks for developing countries to engage in building a national medical tourism
59 industry: (1) the under-staffing of the public health sector will be exacerbated, as skilled practitioners will migrate to the private sector (also known to as the brain drain effect);
(2) the cost for public services will increase, further reducing public access to, availability, and quality of health services to individuals utilizing the public health care system; (3) wages will be lowered for unskilled workers, directly affecting wage inequality in destination countries; (4) new ethical concerns will arise if health is treated as a commodity, such as the creation of a two-tiered medical care system; and (5) development of an inequitable two-tiered health system, where elite, technologically advanced hospitals sit alongside poorly resourced public hospitals (Kanchanachitra et al.
2012; Beladi et al. 2015). The fact that countries may both send and receive patients, professionals, and products, and that medical facilities may be foreign owned or managed, further complicate these (dis)advantageous implications on health systems
(Whitaker et al. 2010). For developing nations seeking to enter the transnational health care market, it is generally recommended that nations engage in bilateral agreements, and not multilateral or regional trade agreements, between sending and receiving nations, since bilateral agreements are the most effective trade agreements for capitalizing on the aforementioned benefits, while simultaneously reducing such risks (Alvarez et al. 2013).
For instance, in their study of both state and non-state medical tourism stakeholders,
Alvarez et al. (2011) found that stakeholders’ perceived main barriers to creating bilateral agreements for the purpose of fostering medical tourism exchanges between two countries are linked to: (1) the perception of quality of care offered in receiving countries;
(2) reliable accreditation of health care organizations; and (3) the “political cost” of litigation issues, in which the public health system of the sending country would be
60 responsible. Despite all of this, one thing is certain: sending countries will only continue to lose revenue to foreign health care providers if they do not eliminate domestic waste and inefficiency, and do not curb rising health care and other related costs (Kumar et al.
2012).
Anthropological Literature Trends
The anthropology of tourism has recasted the phenomenon of tourism as not merely an economic activity that people engage in, but as a form of cultural commoditization and/or cultural commercialism. With the establishment of the anthropology of tourism, ethnographies have been able to focus not only on the people who work in the tourism sector, but also on such topics as cultural authenticity, protection, dependency, and insecurity (Burns 2004). In contrast to the global health literature on transnational health care, which focuses heavily on receiving nations’ health care resources and geographic attributes (i.e. salubrious climate for travel and convalescence), the anthropological literature on medical tourism has concentrated on foreign patients’ lived experiences of medical travel (Kangas 2010). In the limited number of ethnographic studies on transnational health care, it has been repeatedly shown that the lived experiences of foreign patients are often fraught with considerable amounts of anxiety, frustration, hopelessness, sacrifice, tribulation, uncertainty, and discomfort
(Kangas 2010; Inhorn 2011; Nairandos and Bastos 2011). Distressing experiences are customary for patients traveling for either non-elective or elective surgical or non- surgical procedures (Ackerman 2010; McDonald 2011). Few anthropologists have focused on how traveling from or to specific places and geocultural locations mediate patients’ experiences with transnational health care. For instance, Gessler (1992)
61 proposes the notion of “therapeutic landscapes” as a geographic metaphor for understanding how the process of healing is carried out in places by paying particular attention to physical attributes, intentions, and ideas of social actors and structural forces underlying relationships among patients and health care providers. Therefore, transnational medical travel does not produce a single universal patient experience.
Instead, multiple experiences exist within transnational “neutrally cultural spaces” (i.e. transnational hospital-hotel hybrids), all dependent on the patient’s diverse demographics, expectations, experiences, subjectivities, and sensibilities (Whitaker and
Chee 2015).
Anthropologists have only started to explore how “medical tourism” is structured, lived, and embodied, since emphasis has been on defining what the phenomenon is and restructuring it into typologies (Cook 2010). Within anthropology, terms such as
“medical quests” (Cook 2010), “medical travel” (Sobo 2009), “medical migration,”
(Roberts and Scheper-Hughes 2011), “medical exile” (Inhorn et al. 2012), and
“biomedical pilgrimage” (Kangas 2010) have all been proposed as alternative monikers for medical tourism. These terms have stemmed from and are reflective of the frequently divergent embodied experiences of medical travelers in different medical tourism niches, like organ transplant, reproductive, and cancer treatment tourism (Roberts and Scheper-
Hughes 2011). These aforementioned examples are considered means of circumvention tourism, which comprises travel for access to services that are legal in the receiving country, but are illegal in the patient’s sending country, thereby circumventing the domestic prohibition on the health care service sought (Cohen 2015). Some other examples of circumvention tourism are pharmaceutical, abortion, assisted suicide, female
62 genital cutting (FGC) of minors, and other types of reproductive technologies (Cohen
2012; Van Hoof and Pennings 2013). Moreover, such alternative medical tourism terms are meant to dissociate tourists from the previously held notion that patients are merely savvy consumers who operate exclusively within an unsocial, depoliticized valence of leisure. Since travel is a political process imbued in historical and economic contexts, this dissertation presupposes that medical tourists are politically and socially embedded beings that actively seek out ways to transform, modify, and intervene on their physical bodies through health care (McDonald 2011).
Additional terms for medical tourism within anthropology are also meant to highlight, delineate, and foreground medical travel that is not necessarily biomedically centric. Some foreign patients may travel abroad for “alternative and complementary” medical procedures unique to the history and specialization of the destination country.
Generally, non-biomedical tourism is grouped under the catch-all moniker of “health and wellness tourism” (Sobo 2009). It is important to note that biomedicine is in fact only one type of ethnomedicine (Gaines 1992, 1998, 2006; Gaines and Davis-Floyd 2003), and to presume that patients would travel only for biomedical procedures would ignore the
(combination of) desired treatment modalities that make up foreign patients’ medical travel itineraries. In fact, some global health experts now advocate for a separation between “illness-centered” and “wellness centered” tourism; however, this distinction only further conflates the aforementioned duality of social exclusion versus luxury travel
(Voigt and Lang 2013).
Ethnographic accounts of cosmetic surgery tourism, which include both cosmetic and reconstructive plastic surgery (Connell 2011), are drastically underrepresented in the
63 anthropological literature. The vast majority of cosmetic surgery tourism research has been overly simplistic in its analyses by downplaying patients’ medical experiences, trivializing the electiveness of cosmetic surgery procedures and the luxury of tourism
(Holliday et al. 2015). Moreover, the ethnographic research that has been conducted on cosmetic surgery tourism has only begun to explore the following themes: the globalization and embodiment of local gendered beauty ideals, as well as tourists’ appropriations of local rituals and cultural practices (Aizura 2010); healing landscapes, embodied subjectivities, and post-surgical liminality and nostalgia (Ackerman 2010;
Cook 2010); embodiment of the “momentum” of the cosmetic surgery tourism process
(McDonald 2011); and national biotypes, place myths, and “beautyscapes” (Edmonds
2012; Holliday et al. 2015). In the limited ethnographic accounts of cosmetic surgery tourism, the only variables that have been identified for positive cosmetic surgery tourism experiences are the following: (1) sense of place, as determined by cultural and physical proximity/distance to one’s home country; (2) discursive and physical characteristics of the destination as a “friendly resort”; and (3) the presence of “willing” staff (i.e. healthcare providers, tour guides, interpreters, etc…) to engage in emotional and aesthetic labor for tourists (Bell et al. 2011). In addition to the above themes, ethnographic analyses of cosmetic surgery tourism require further research into: (1) understanding how relationships are forged and maintained during the cosmetic surgery tourism process
(Holliday et al. 2015); as well as (2) conducting “deep immersion” into the influential practices of all social actors involved in cosmetic surgery tourism and their effects on patients’ decision-making (Bell et al. 2015).
Only a few ethnographic accounts have begun to discuss medical tourism as a
64 catalyst for nation-making and national identity politics, further exacerbating the need to link micro-level individual experiences to public conversations of nation-building (De
Cassanova and Sutton 2013). One such example is Ackerman’s (2010) ethnographic account of Costa Rica’s cosmetic surgery tourism industry as a form of medicalized leisure for North Americans, in which she describes how Costa Rica’s international plastic surgery recognition is inextricably linked to Costa Rica’s project of nation-making and social inclusion. Ackerman (2010) claims that not only are cosmetic surgery tourists and local caretakers actively re-making and re-structuring Costa Rica’s medical practices, institutions, and national identity politics, but they are also providing the means for attracting clinicians (either from the local public sector or returning ex-patriots, otherwise referred to as the brain drain and reverse brain drain effect, respectively) with the neoliberal promise of prosperity and autonomy. Currently, Costa Rica is caught between two competing visions of national development: one that adheres to principles of socialized medicine, and one that emphasizes neoliberal growth and establishing itself within the global marketplace (Lee 2012b). Lee (2012b) claims that there should be an ethnographic focus on the “local worlds” of the populace of the destination countries’ nationals, whose voices are often overshadowed by powerful stakeholders in the medical tourism industry.
Additionally, De Cassanova and Sutton (2013) note that media representations of cosmetic surgery tourism are portrayed differently in countries with different position- takings in the global political economy, ultimately highlighting the discrepancies between nation-building efforts in receiving developing countries versus rhetorics of national- disrepair in sending countries. For example, De Cassanova and Sutton (2013) claim that
65 U.S. media representations assert warnings or horror stories of receiving cosmetic surgery abroad in order to maintain and assert their global hegemony over the Global
South. While Argentine media, on the other hand, tell a story of a nation with great cultural resources to rival any first-world nation in terms of technical expertise, despite their lower position in the global political economy. Therefore, developing nations are trying to “claim a stake in globalization” by exalting their modern culture, resources, and high quality services at the chagrin of the U.S. media, whose negative portrayals of cosmetic surgery tourism evokes a moralizing tale of personal failure as American
(generally, middle to lower class female) cosmetic surgery tourists leave “first-class medical care” for “gruesome outcomes” in the Global South (De Cassanova and Sutton
2013). Despite the ongoing inundation of “media myths” originating from both the
Global North and the Global South, the reality of the medical tourism industry is that: (1) legal redress is very difficult to obtain in the event of bad surgical outcomes; (2) physicians are reluctant to advise patients to travel abroad for elective procedures; (3) patient medical records are normally unavailable to medical staff abroad; (4) patients do not always follow medical advice abroad; (5) public (and some private) hospitals are generally ill-equipped to deal with aftercare once patients return home; and (6) medical tourism is not as risky as it is domestically purported to be, as health care providers, insurance companies, and other domestic health care stakeholders fear losing patients to overseas competitors (Holliday et al. 2014).
66 Theoretical Framework: Bourdieusian Organizational Analysis of Health Institutions
Bourdieusian Practice Theory
Practice theory is concerned with one’s practical relation to the world. In his attempt to bridge the social structuralist and cultural constructivist perspectives together into one theoretical paradigm (Dressler 2001), Pierre Bourdieu attempts to account for how social structures inhibit, “structure,” and situate individuals in the world and to each other. At the same time, Bourdieu also attempts to explain how individuals “construct” and proscribe cultural meaning onto the world (Bourdieu 1977, 1986, 1990, 2010;
Bourdieu and Wacquant 1992). As such, Bourdieu’s work can be classified as
“structuralist constructivism” or “constructivist structuralism” (Dressler 2001).
There are three relationally interdependent principles in Bourdieu’s practice theory: field, capital, and habitus. One of the most fundamental tenets of practice theory is the concept of field, which refers to the social space occupied and maneuvered by agents for the purpose of resource competition and exchange. In other words, a field is the context or arena in which any social action performed by an agent occurs. Interestingly, the boundaries of a field extend as far as relational differences appear to affect the positions of social agents without being confined to physical or spatial parameters. Therefore, it is possible for multiple fields to not only exist at once, but they may also interact simultaneously with or operate autonomously in relation to other fields. Fields can be as multifarious as the social arenas occupied and created by humans (Bourdieu 1977, 1990,
2010; Bourdieu and Wacquant 1992).
All fields possess their own type of valued capital. Like fields, there are
67 innumerable species of capital. The most commonly theorized forms of capital are: symbolic, social, cultural, and human capital. In short, symbolic capital refers to the honor, prestige, recognition, and status that one is afforded with its possession, while social capital signifies the value of the relationships established among one’s social network. Cultural capital can be understood as the value attributed to one’s actively and/or passively acquired or inherited skills, and how they are received culturally. There are generally three types of cultural capital: objectified (i.e. economic capital), embodied
(i.e. linguistic), and institutionalized (i.e. educational). Additionally, human capital refers to the social and cultural capital acquired that increases one’s economic capital (Bourdieu
1986). Capital could be used as “both as weapons and as stakes” for ascendency over others in the field (Emirbayer and Johnson 2008: 11). Ultimately, an agent’s accumulation of capital defines one’s social position among others, directly shaping one’s experiences of the world (Bourdieu 1977, 1986, 1990, 2010; Bourdieu and Wacquant
1992).
In essence, agents negotiate through fields according to one’s particular human, cultural, and social capital, as well as through one’s habitus. The habitus can be conceptualized as the embodiment of one’s subjectivity as it is influenced by conditions of particular classes of existence (Bourdieu 2010). As such, Bourdieu considers the agent’s negotiation through fields as practice. Additionally, doxa (or rules) are structurally inscribed within each field to govern and internally frame power relationships among agents. As both power and practice intersect within a given field, social agents are enabled to utilize individual agency, as shaped by one’s habitus (Bourdieu 1977,
1986, 1990, 2010; Bourdieu and Wacquant 1992).
68 The habitus acts as both the “opus operatum” (the result of practices) and the
“modus operandi” (the modes of practices), simultaneously (Bourdieu 1977: 36).
Moreover, the habitus is not only considered a product of an agent’s history, but it is also active in producing individual and collective practice, as the habitus is “a present past that tends to perpetuate itself into the future” (Bourdieu 1990: 54) The habitus of an agent is shaped in tandem by both one’s environment and society as one negotiates throughout the world. Therefore, the habitus, environment, and society are all considered to be
“structuring structures” that inform how agents navigate throughout all fields.
One’s habitus is highly liable to inform the actions, dispositions, thoughts, tastes, and perceptions that one has when exercising agency. Dispositions are instilled within agents by the (im)possibilities, freedoms, and opportunities inscribed within objective conditions, which ultimately give disproportionate weight to an agent’s early experiences.
As such, these characteristics of the habitus uniquely allow for production of both collective and individual practice, as no two individual agents’ experiences will be the same; however, convergent histories will influence groups of agents within fields.
Lastly, the habitus is also capable of protecting itself, to a certain degree, through homogamy within particular fields (Bourdieu 1977, 1986, 1990, 2010; Bourdieu and
Wacquant 1992).
Bourdieusian Organizational Analysis
Many anthropological studies grounded in practice theory tend to position humans as individual agents, as humans are frequently considered the primary unit of analysis of such studies (Bernard 2011). Within organizational anthropology, on the other hand, the unit of analysis generally shifts away from individual humans as agents to organizations
69 as agents (Baba 2012). This is particularly common in institutional and organizational studies employing organizational analysis, which foregrounds the concept of organizational field (Scott 1991) within (neo-)institutional theory. In general, neo- institutional theory asks the following question: how are social choices shaped, mediated. and channeled by the institutional environment (DiMaggio and Powell 1983, 1991;
Emirbayer and Johnson 2008)? In their search for answering this question, neo- institutional theorists have focused on research domains, such as institutional legitimacy, survival, efficiency, isomorphism and homogenization via legal regulations, cultural, cognitive, and behavioral processes, and the evolution of organizational dynamics, agency, and strategies to deal with environmental change (Wooten and Horton 2016).
Through analysis of these aforementioned research domains, the organizational field has been referred to previously as the institutional field (Meyer and Rowan 1977; DiMaggio and Powell 1983, 1991), institutional sphere (Fligstein 1990), societal sector (Scott and
Meyer 1992), and institutional environment (DiMaggio 1988; Orru, Biggart, and
Hamilton 1991; DiMaggio and Powell 1991) within organizational studies. As such, the notion of organizational field has evolved to focus on how institutions change over time alongside its dynamic institutional environment according to shared collective interests and objectives (Hoffman 1999, 2001), rather than focusing on the operationalization of the organizational field as a statically defined space, market, or technology (Wooten and
Horton 2016). While it is important to note that organizations are not concrete bounded- entities, particularly in light of modern technology, organizations not only foster and share internal dynamic sociocultural spaces, but they also engage in external sociocultural contexts and relationships with other organizations. In this sense, organizations are
70 “vessels” of culture that are simultaneously influenced by macro-sociocultural processes in which organizations are embedded (Gregory 1983; Schwartzman 1989; Fiske 1994;
Weick 2001). This is particularly the case for individuals who are involved in multiple organizations.
Typically, an organizational field encompasses all organizations involved in a particular role or activity, as multiple organizations tend to influence, either directly or indirectly, the structure and navigation of a single organization within a field. In other words, individual organizations do not exist in vacuums, isolated from other organizations, but are rather constantly interacting and negotiating with other organizational agents. Therefore, organizational fields are not necessarily bound by geography or goals, but by a common domain of shared rationality and meaning.
Organizational action is generally considered to be informed by institutional social facts that have been taken for granted in their passing down between organizational actors
(Nicolini and Monteiro 2017). In other words, organizations are ruled by “cultural- cognitive, normative, and regulative structures” (Scott 2008) that “structure” collective action (Warren 1967; Scott 1991; Wooten and Horton 2016). As such, the concept of organizational field has been reserved primarily for inter-organizational analyses as opposed to intra-organizational analyses (also considered an “Organization-as-Field” by some theorists; Wooten and Horton 2016; Nicolini and Monteiro 2017).
Unfortunately, the majority of organizational studies incorporating organizational analysis have mistakenly divorced the organizational field concept from both habitus and capital, usually unintentionally. Many studies have not recognized and associated the organizational field with Bourdieu’s original concept of field, thereby failing to link
71 individual action to macro-structural environmental contexts. Moreover, many studies conflate capital, an integral force to environmental change, to being purely economical and/or materialistic in nature, further ignoring other myriad intangible forms of capital, such as social capital, at play in Bourdieu’s practice theory (Emirbayer and Johnson
2008; Nicolini and Monteiro 2017).
Just as individual agents are capable of inculcating their own unique habitus,
Bourdieusian organizational analysis asserts that organizations also navigate throughout organizational fields via their own organizational habitus. Since individual agents bring their own habitus to an organization’s division of labor, it stands to reason that a unique organizational habitus becomes collectively “structured” from the different agential parts of its whole. Therefore, the organizational habitus shapes an organization’s future practice, strategy, and judgment as the organization navigates its way through organizational fields competing for capital among other agents (Emirbayer and Johnson
2008; Nicolini and Monteiro 2017).
Not all agents negotiating through an organizational field are organizations. On the contrary, some actors competing for capital among organizations may be individuals acting on behalf of themselves (i.e. autonomous agent), and not an affiliated institution
(Emirbayer and Johnson 2008; Nicolini and Monteiro 2017). Just as the organizational field should not be conflated with any particular industry, neither should an organizational field’s agents be assumed to be simply competitors, as various agents may partner with other agents for strategic alliance (Tsang 1999), or joint (Brannen and Salk
2000; Schuler 2001) or internal (Simon et al. 1999) ventures, all necessitating the accumulation and exchange of diverse forms of capital (Emirbayer and Johnson 2008).
72 Organizational fields have also been conceptualized as dynamic “spaces of strategic action” (Fligstein and McAdam 2012). Emirbayer and Johnson (2008) note that agents, either individual or organizational, tend toward one of two strategies in negotiating throughout organizational fields: (1) a conservation strategy, in which dominant agents attempt to safeguard and preserve their dominance and place within a given power- structured hierarchy; or (2) a subversion strategy, in which dominated agents attempt to transform field doxa in order to challenge and alter the current power hierarchy.
Organizational field agents differentiate themselves among each other via their habitus- informed “position-takings,” which may be materialized in the form of constructed goals and identities, products and services offered, competitive strategies formulated, and niche market targets, to name only a few. Of course, these strategies are implemented by both inter- and intra-organizational agents, as individual actors may push personal agendas and policy changes to drastically influence one’s relational power position in the organizational field among other agents. Also noteworthy is the fact that sociocultural spaces of class, gender, and race intersect, and may (dis)allow, catalyze, or protract transfigurations of intra- or inter-organizational field power dynamics from taking place
(Emirbayer and Johnson 2008).
At the Intersection: Organizational & Medical Anthropology
To date, there have only been a handful of medical anthropological studies that have focused primarily on medical or health-related organizations (either private or public) as units of analysis, with even fewer medical anthropological studies incorporating Bourdieusian organizational analysis. Ethnographic work focusing on the operational logistics of and communication within and between medical organizations
73 have uncovered numerous ramifications for both health care providers and patients
(Jordan and Caulkins 2012). Concentrating on the mundane aspects of large-scale, highly complex medical organizations has ethnographically illuminated many of these ramifications.
Probably the most elaborated ramification of studying mundane practices in medical organizations is the elucidation of the “invisible work” required to effectively and efficiently access medical information, or to simply maximize workflow. One example is Martin and Wall’s (2008) analysis of medical record management, and the
“invisible work” and practices required by nurses, physicians, and other clerical staff to maintain accurate and current accounts of patients’ medical case histories. Additionally, the work of Unruh and Pratt (2008) goes beyond analyzing the results of patient care (i.e. medication adherence, upholding clinical appointments, etc…) by describing the shortcomings of health care operations that inflict “invisible work” on patients. In their longitudinal study of breast cancer patients, Unruh and Pratt (2008) describe how patients’ lack of knowledge regarding their current state of health and organizational operations of their respective treatment facility ultimately drain organizational resources and highlight institutional inefficiencies. The most common inefficiencies are failure to provide seamless inter-institutional communication of patients’ cases, as well as the inability to help manage conflicting recommendations from healthcare providers on the patient’s behalf. In turn, all of these operational inefficiencies impose invisible, arduous work on patients in managing their respective self-care (Unruh and Pratt 2008).
In addition to focusing on “invisible work,” medical anthropologists performing organizational ethnography often discuss the “hidden values” of applying ethnography to
74 complex health organizations, most notably the U.S. Department of Veteran Affairs
(VA). For instance, Darrouzet and colleagues (2009) discuss the value of using
“participatory ethnography” for allowing organizational agents to understand their respective roles in relation to the roles of other agents working within the VA hospital system. In short, Darrouzet et al. (2009) affirm the value of enlisting organizational staff as “para-ethnographers” (Marcus 2006), in order to better articulate not only knowledge production within an organization, but also an organization’s highly complex social dynamics. Additionally, in their analysis of patient safety at the VA hospital, Goodman et al. (2005) document the approval process of a federal agency to incorporate the ethnographic method into its organizational auditing guidelines to better understand the social dynamics of its collaborating partnering institutions.
Lastly, medical anthropologists performing organizational ethnography have also highlighted the internal competing agendas of different stakeholder groups within medical organizations. Competing agendas often stem from the cross-cultural communicative differences that arise as a result (Sobo et al. 2008a, 2008b). Starting with the premise that medical organizations are “complex adaptive systems,” Sobo and Sadler
(2002), for example, highlight the need for health care organizations to improve internal accountability measures alongside implementing liaisons between employees and management to facilitate communicative differences.
75 Chapter 3: Methods
This study has three primary objectives: (1) to evaluate how a start-up medical tourism organization prepares for and shapes the prospective experiences of its future clients; (2) to understand how such an organization establishes strategic partnerships with agents from the health, tourism, and hospitality industries to construct a preferred network of service providers; and (3) to assess how such an organization’s interactions with and management of its chosen network of service providers influence the mobilization of a local unregulated industry. In order to address each of these objectives,
I employed a mixed-methods, cross-sectional ethnographic research design. Fieldwork was conducted throughout various hospitals, clinics, consultórios (doctors’ consultation offices), and hotels in Rio de Janeiro, Brazil over the course of twelve months in 2017 to
2018.
Data Sources
This dissertation examines the establishment of a medical tourism organization in a city undergoing rapid socio-economic, political, cultural, and structural change.
Moreover, this dissertation analyzes how this organization’s routine practice of two strategies of risk and partnership management shape its overall position-taking, ultimately compelling its competitive market advantage in a local burgeoning unregulated industry. As such, this private health organization, and therefore its stakeholders, has been purposively sampled as this research project’s primary unit of analysis (Bernard
2011). At the time of my fieldwork, this organization was composed of only six founding members, all Brazilian citizens. Two organizational members are female, while
76 four members are male. All founding members of the organization possess professional graduate degrees and highly specialized international training in their field. More specifically, three members hold a doctorate in medicine, two members possess a doctorate in law, and one member has a research doctorate in international finance. All members have lived outside of Brazil in foreign countries as part of their education and work experience, and are preceded with renowned reputations both within and outside of
Brazil. Every organizational member is a top-level executive in his or her respective work institution outside of the organization.
To understand how an organization routinely practiced risk and partnership management, and how these two strategies eventually sharpened the organization’s position-taking and compelled its competitive market advantage, this dissertation takes the “organizational meeting” as a primary data source. As an administrative, bureaucratic, supervisory, and collaborative tool and technique, meetings are key sites through which socio-cultural, political, and material realities are understood, delimited, positioned, negotiated, and transformed (Boded 1994; Jarzabkowski and Seidl 2008; Briody 2012;
Brown et al. 2017). As temporally prescribed, performative, and communicative events, meetings also serve as “the locus and embodiment of ideas of appropriate, transparent decision-making. […] While multiplicity (e.g. of people, perspectives, knowledge) is often their point of departure, singularity (e.g. in the form of objective agreement) is often their achieved outcome” (Brown et al. 2017: 11, 14). As such, meetings are authoritative venues that document an organization’s strategies of maneuvering and positioning throughout complex (and oftentimes competitive) socio-political fields.
Therefore, meetings not only reveal structural and operational problems encountered by
77 an organization, but also a history of an organization’s attempt to find resolutions to such problems. By focusing on meetings as a primary data source, researchers are able to gain a strong foothold on not only what are internal organizational processes and imaginations, but also on how such processes and imaginations become formalized and routinely practiced (Boded 1994; Jarzabkowski and Seidl 2008; Briody 2012; Brown et al. 2017).
Over the course of this research project, I observed a total of 85 meetings with organizational team members. Meetings were generally divided into three types: (1) intra- organizational brainstorming meetings; (2) site inspections of candidate service providers’ facilities; and (3) negotiation meetings with accepted or short-listed service providers. Meetings were always conducted in Portuguese. In the first two months, I attended sixteen brainstorming meetings. For the following 8 months, I attended 42 site inspections for 34 different service providers, as some providers required multiple site inspections either before or after negotiation meetings. Twenty-three site inspections were of private medical facilities, namely clinics, hospitals, and consultórios (doctors’ consultation offices), and the other 19 inspections were of hotels. Additionally, I attended
27 negotiation meetings for 15 different service providers (8 medical, and 7 hospitality and tourism). Since not all service providers were ultimately selected for negotiation meetings, there were fewer negotiation meetings than site inspections. All brainstorming, site inspections, and negotiation meetings were held in either upscale areas of the South or West Zones of Rio de Janeiro, or in prominent historical buildings in the Centro
(downtown area). In addition to observing meetings, I also conducted 36 semi-structured interviews with organizational team members and service providers either immediately
78 before or after meetings.
Data Collection
Three primary data collection methods were employed in this study to yield both observational and narrative data: (1) participant-observation; (2) continuous monitoring; and (3) semi-structured interviews. Each method has been shown to be highly effective in studying organizations (Boded 1994; Jarzabkowski and Seidl 2008; Briody 2012; Brown et al. 2017). All instruments were checked for face validity in the first month to ensure cultural applicability prior to conducting this research (Bernard 2011).
Participant-Observation
Participant-observation was conducted throughout the entirety of this study to document how a private health care organization’s team members manage risk and partnerships with other organizations, directly lending to the iterative development and refinement of not only the organization’s own internal position-taking, but also its preservation of its local competitive market advantage in an ungoverned industry. More specifically, participant-observation served to: (1) establish credibility and build rapport with organizational team members and their rotating list of preferred service providers;
(2) selectively focus on the activities that organizational team members prioritize when predicting consumer preferences and fostering strategic partnerships inside and outside of the “board room,” or, in this case, formal places of work, site-inspections, and networking events; (3) aid in describing the inter- and intra-organizational contexts in which executive decision-making and negotiation take place; (4) elucidate how organizational team members’ social interactions (and conflicts) with all service providers were influential to the concurrent iterative developments of strategic
79 partnerships, new industrial regulations and scope, and organizational position-takings; and (5) serve to triangulate interview responses with continuous monitoring (see below).
Ethnographic field notes and memos were recorded and transcribed on a daily basis.
Continuous Monitoring
As the mainstay of meeting analysis within organizational anthropology, continuous monitoring was employed throughout this study to gain direct observations of inter- and intra-organizational meetings. In short, continuous monitoring is a methodological technique that requires the researcher to “watch a person, or group of people, and record their behavior as faithfully as possible” (Bernard 2011: 413).
Generally, such recordings are spoken into tape recorders and transcribed at a later date to account for as many relevant focal observations as possible within a predetermined time interval. Since all of the meetings I observed were attended by top-level executives who were generally engaged in highly stressful, calculated, and tactful conversations, the expeditious and ultra-sensitive ambience of the meetings prohibited me from making disquieting voice recordings of my observations or from requesting that the meeting be recorded in its entirety. Instead, I recorded all of my direct observations with pen and paper using a shorthand system I created. In agreement with Briody (2012), I purposefully chose not to interact with other attendees during meetings whenever possible, mostly to construct highly detailed notes of the meetings, including noteworthy verbatim quotes of meeting attendees, and to ensure that the natural interactions being observed were not interrupted or influenced by my own actions as much as possible.
However, my silence at these meetings was not always realistic and practical, as organizational team members and service providers considered me as a type of “foreign
80 consultant,” and had expected me to contribute my specialized knowledge of the medical tourism industry to the conversation at hand. In trying not to disturb the natural flow of the meetings, I limited my active participation in meetings to answering direct questions about my role as a researcher or to medical tourism industry norms. Since it was impossible to record only verbatim quotes during all meetings, my meeting notes consisted of a mélange of direct quotes, and approximations and general descriptions of the meeting discussions observed. All meeting notes were subsequently transcribed and analyzed in an iterative manner. Whenever available, meeting documents, such as minutes, logs, agendas, presentations, brochures, and other supplementary literature materials (i.e. lists of services, bundles, amenities, and prices) provided by team members and/or service providers during meetings were electronically transcribed and analyzed alongside meeting notes generated from continuous monitoring (Bernard 2011).
All in all, continuous monitoring proved to be particularly useful and effective in:
(1) qualifying small-group verbal discussions among organizational team members and service providers under stressful circumstances; (2) capturing focal observations of bodily schema (non-verbal language) among executives within meetings; (3) providing a
“cultural record of the meetings and as a point of reference for follow-up discussions”
(Briody 2012: 240) with executives in semi-structured interviews (see below); and (4) cross-checking variance in standard meeting characteristics, such as location, duration, attendees present, seating arrangements, etc. (Primo 2009), with researcher cues, hunches, and conceptual inferences along with the “event narratives” (Lester 2007) elaborated on by executives in semi-structured interviews (see below).
81 Semi-Structured Interviews
Throughout the entirety of this research project, I conducted semi-structured interviews with organizational team members and their preferred service providers.
It was always my goal to ask a series of open-ended questions before and after every meeting with all attendees. However, given the limited time constraints of top-level executives, there were several instances when I could only interview attendees either before or after the meeting. The length of each interview varied according to not only the attendee’s time availability either before or after the meeting (particularly when compared to the actual duration of the meeting itself), but also the attendee’s willingness to expound upon a concept being explored or probed at any given moment. I quickly learned that the most productive strategy for successfully attaining both pre- and post- meeting interviews with top-level executives was to commute with them to and from meetings. Since the executive invariably would hire a driver to navigate him or her throughout the endless traffic in Rio de Janeiro, I was generally able to conduct longer, more relaxed semi-structured interviews during the commute to and from the meeting.
Generally, semi-structured interviews lasted anywhere between twenty minutes to two and a half hours. After six months of performing continuous monitoring and participant- observation, organizational team members would allow me to conduct post-meeting semi-structured interviews via phone, in the event that they could not meet me immediately following the meeting. Whenever feasible and permissible, interviews would be tape recorded, and then transcribed in an iterative manner.
In the first three months of fieldwork, my interview schedule centered on themes related to consumer preferences and foreign patient experiences, the primary topic of
82 brainstorming meetings. As the organization’s strategic plan began to mature after the first several months, interviews became grounded in themes centric to the purpose of the meeting at hand, such as (un)desired consumer services, tenets of good partnership,
(un)acceptable risks and liabilities, socio-economic and political upheaval, to name only a few. In general, pre-meeting interviews were meant to understand the rationale, strategy, communicative techniques, and intended goal(s) of the forthcoming meeting, and how the meeting’s intended successes or failures would affect the overall trajectory of the organization. In addition to the pre-meeting interviews, the overall purpose of the post-meeting interview was to gather thoughts and opinions surrounding the communicative events, or “event narratives” (Lester 2007), that took place during the meeting, including unexpected conflicts, welcomed accords, and (unanticipated) changes in perceived partnership capacity and/or services proffered to the development of a new local industry by providers.
Data Analysis
With a total of three data collection methods in this research project (participant- observation, continuous monitoring, and semi-structured interviews), a description of how data garnered from each collection method is warranted.
Field Notes and Memos
All handwritten field notes were either analytical or observational in nature.
Observational field notes were recorded based on participant-observation, while analytical memos were developed iteratively according to emergent themes and theories over the course of the research project. Both observational field notes and analytical
83 memos were all entered into Microsoft word, and subsequently into MAXQDA for thematic coding (Miles and Huberman 1994; Bernard 2011).
Meeting Analysis
As a form of content analysis, meeting analysis allows for themes and patterns to be detected among meeting participants’ statements and observed behaviors (Bernard
2011; Briody 2012). In addition to the actual content of the meeting, all of the following direct observations made from continuous monitoring were closely considered in identifying such meeting themes and patterns: (1) turn-taking structure (i.e. interruption, active listening); (2) attendee’s tone of voice, syntax, and diction; (3) argument structure; and (4) non-verbal body language or bodily schema. In performing a meeting analysis, one ultimately creates a composite structure of a typical meeting by focusing on analytical categories that point toward the defining characteristics of a common meeting
(Boden 1994; Drew and Heritage 1992; Wasson 2000; Briody 2012). Some of the analytical categories identified in the observed meetings of this research project are the following: meeting agenda items (i.e. problems to be solved, service offerings, and price negotiations); frequency of issues raised, decisions made, attendees present, and use of supplementary materials (i.e. documents, service and facility brochures, pricing sheets); enumerated goals of each meeting; and motivations for taking action.
Semi-Structured Interviews
A narrative analysis of interview data occurred iteratively throughout the course of this research. All interviews were first transcribed. Then, a series of observational techniques (i.e. word frequencies, indigenous categories, linguistic connectors, metaphors/analogies, and theory), and processing techniques (i.e. wordlists, metacoding,
84 and cutting and sorting) were used to identify micro and macro themes in the texts, respectively (Bernard 2011). Next, themes and narrative devices, were openly, axially, and selectively coded (Miles and Huberman 1994) in the original language that the data was retrieved (Portuguese). Nominal, ordinal, and interval value codes were assigned to non-overlapping segments of texts within MAXQDA. A native Brazilian Portuguese speaker crosschecked all translations of texts. A random selection of codes was also checked for intercoder reliability until a Kappa score of at least 0.8 was reached (Bernard
2011). Ultimately, narrative analysis was used to extrapolate key patterns to construct a meta-narrative of how the medical tourism start-up organization mobilized a local new industry by predicting what foreign patients’ experiential preferences would be, and by selecting, establishing, and managing its preferred network of service providers.
Triangulation of Data
In order to maximize this study’s validity and reliability, a triangulation of the observations made from participant-observation and continuous monitoring was conducted with participants’ interview responses and meeting documents, namely meeting minutes, logs, agendas, notes, presentations, brochures, and other supplementary literature materials provided by service providers and team members during meetings
(i.e. lists of prices and services offered), whenever available (Bernard 2011). It is possible, for instance, that some of my observations of particular events (i.e. the negotiation meeting) subjectively appeared contradictory to that of participants, as recorded by their interview responses, and vice versa. For example, I may have mistakenly ignored or misinterpreted an action as routine during a site inspection or negotiation meeting, which could later be elaborated on by a meeting attendee as
85 subjectively significant during his or her post-meeting interview. Therefore, it was imperative to crosscheck observational data with narrative data. I paid particular attention to domains of discrepant data, such as individual and organizational conflicts of interest and contingent incentives, motivators, and rewards that may have informed the intra- and inter-organizational processes of risk and partnership management. Close attention was given to these domains when analyzing qualitative data.
Ethics
Prior to fieldwork, this project was submitted to the Institutional Review Board at
Case Western Reserve University for approval to work with human subjects. Written consent was required from all participants, and was written and available in both English and Portuguese. Consent forms were read aloud to the participant in their preferred language prior to their inclusion into the study. The written consent forms, and the researcher’s oral description of the study, included the following: the purpose and objectives of the study; the time commitment required to participate in the study; the right to decline participation and/or withdraw from the study at any time; a list of interview topics that would be covered; permission for audio recording of the interviews; and all responses and information would remain confidential. Pseudonyms were used for all study participants. All data analysis and its subsequent findings focus on composite thematic experiences rather than on individual case histories.
86 Limitations
This study has a potential sampling bias, as the research design relies on purposive sampling techniques and recruiting strategies. However, given the nature of the research objectives, these non-probabilistic sampling techniques are the best way to gain access to such a hidden and hard-to-reach population: top-level elites, such as executives, specialists, and managers (Bernard 2011). Additionally, there may have been a potential attrition bias, as some service providers chose not to participate in the study. With the presence of an attrition bias, there may have been variance in the frequency I could shadow site inspections and sit in on negotiation meetings, yielding unequal observations of the management of the service provider network. Nonetheless, variables considered to affect attrition bias, such as willingness to disclose business operations, was adjusted for and later considered in the interpretation of data (Ahern and Le Brocque 2005). In the event that service providers dropped out of the study prior to negotiation meetings, new providers from the organizational team members’ list of candidate providers were enrolled.
In addition to an attrition bias, this research project may also have a reactivity bias. A reactivity bias occurs when participants modify their “normal behavior or performance” when they are aware that they are being observed (Miles and Huberman
1994; Bernard 2011). An organizational team member and myself always explained my role as a researcher to service providers prior to site inspections and negotiation meetings. As a result, some service providers may have changed their communicative style and organizational agenda to accommodate or impress me: the “foreign consultant” and “medical tourism expert,” as introduced by organizational team members. Since all
87 service providers were considered elites in their respective organization, and that most of the meetings concerned sensitive subject matter (i.e. strategy talk, negotiations of deal terms), some providers may have felt particularly wary of my presence as a continuous note taker and “perceived expert.” Even though I was never denied access to a meeting, I could sense a reactivity bias whenever I would see meeting attendees glancing at my note taking.
Lastly, while I was invited and present for every formal meeting, there were invariably other methods of electronic communication (i.e. emails, voice / text messages, and phone calls) between organizational team members and (potential) service providers in which I was not involved and where some negotiations may have played out. Since many negotiations among elites take place “outside of the boardroom” (Hoon 2007), there may have also been a slight observational bias. However, the context and content behind any private communication exchange was generally uncovered and elaborated on during semi-structured interviews with both organizational team members and service providers either before or after formal in-person meetings for which I was invited and present.
88 Chapter 4: Managing Risk With Prospective Problem-solving
All start-up organizations are confronted with numerous opportunities to fail. To succeed, organizations must engage in strategic risk management to secure their competitive market advantage. I argue that team members of a start-up medical tourism organization routinely practiced a key strategy at brainstorming meetings to secure its competitive market advantage, while simultaneously refining its position-taking: managing risk via prospective problem-solving. In the context of this dissertation, prospective problem-solving refers to predicting what could possibly go wrong in the future, and then inductively developing and implementing solutions in the present to curtail such wrongdoings from occurring at a later date.
By repeatedly practicing this key strategy unknowingly in brainstorming meetings since the organization’s early establishment, team members efficiently deciphered the factors they considered essential to the ideal medical travel experience for foreign patients in Rio de Janeiro (objective 1). For example, organizational team members determined that a primary requisite of a positive medical tourism experience in Rio de
Janeiro would be the use of American or other internationally accredited medical facilities. Team members inductively determined this requisite by first identifying the risk that prospective patients may not trust the organization’s overall competence to select a clean medical facility that possessed up-to-date technology. To proactively mitigate this risk, team members proposed the solution of only partnering with facilities that already had or could likely receive an American accreditation upon application. The determination of perceived consumer preferences provided a guideline for which to find,
89 vet, and select (or reject) candidate service providers (objective 2), ultimately kick- starting the delineation of the organization’s position-taking.
In this chapter, I describe my entry into the field, and provide a contextual overview of the rapid socio-economic, political, and structural changes that occurred in
Rio de Janeiro leading up to and following the city’s hosting of two global events back- to-back: the 2014 FIFA World Cup and the 2016 Summer Olympics. Next, I give an ethnographic description of the start-up medical tourism organization and its stakeholders, the primary unit of analysis in this dissertation. Finally, I present narrative and observational data gathered from participant-observation, continuous monitoring, and semi-structured interviews from brainstorming meetings with organizational team members. To trace the intra-organizational practice of prospective problem-solving, I divide the perceived requisites of an ideal medical travel experience, as well as the prospective risks and proposed solutions to mitigate such risks, into three non-mutually exclusive categories: organizational competence, personal safety, and patient comfort. I conclude this chapter with a model of the process of prospective problem-solving, and an explanation of how the routine practice of this key strategy by team members helped to refine the organization’s overall position-taking.
Entering the Field: A City in Transition
In 2013-2014, the city of Rio de Janeiro prepared to welcome over one million international guests from 202 countries for the 2014 FIFA World Cup, and another million guests for the 2016 Summer Olympics two years later (Alves dos Santos Junior and Novaes 2015; Zirin 2016). During this time, I was invited to follow and interview a cadre of surgeons and dentists who were actively forming a professional network of
90 health care providers for the purpose of attracting and accepting foreign patients, mainly from the U.S., Canada, and Europe. During this time, I participated in biweekly meetings with them, toured their facilities, and was welcomed as a type of “foreign consultant.”
As the World Cup neared, this network of physicians was increasingly motivated to formalize a medical tourism health care provider network. This was, in part, to opportunistically attract prospective medical tourists traveling to see the month long soccer games. In the context of this dissertation, “to formalize a medical tourism health care provider network,” means to legally establish an organization or business that directly connects foreign patients to a tightly moderated group of local health care providers. In other words, a legal entity that organizes health care for foreign patients locally and directly, without the need of a foreign medical tourism facilitator company.
Therefore, the founders of this network of health care providers were taking advantage of the fact that the World Cup, combined with the imminent Summer Olympics, was about to position the city of Rio de Janeiro on the global center stage as a modern premier tourist destination.
I observed a serious discrepancy between what physicians thought would be foreign patients’ motivations and consumer preferences in comparison to patients’ experiences as reported in the global health and anthropological literature on medical tourism. For instance, many of the Brazilian physicians I interviewed in 2014 expected that foreign patients would: (1) not utilize medical tourism facilitators; (2) travel with caregiver companions who also desire medical procedures; and (3) splurge on high-end services. A quote from an interview with a prominent oral and maxillofacial surgeon in
91 Rio de Janeiro illustrates all three of these expectations:
“I think everyone that comes to Rio is going to be surprised with what we can offer. Not only is our medicine very good, but we have so many beautiful places to go. Like fancy restaurants, shopping, and really nice tourism activities, like boat rides and helicopter tours. I have a friend who is a plastic surgeon, and he says whenever he has a patient come from the exterior of Brazil, they always come with another person to take care of them after surgery. He normally gives that person a free consultation if they want it. He says that the companion is always interested in doing something, like Botox at least, while they are here taking care of them. That’s why I think we could sell things to the companions too, and they have the downtime waiting on their companion to have something done. So why wouldn’t they? You know, after they find out how much cheaper it is here, and they see how clean our facilities are. […] I have several people in Miami that say they can bring me people, but they want a commission for it. I don’t see why we need them if we can do everything they do, especially if we give the patient more discounts if they schedule with us directly.”
This quote illustrates that many physicians in this group believed that caregiver companions are a potentially untapped market in the medical tourism industry, and that they could upsell services to them easily while they are in Brazil. Also, this quote shows that doctors believed that they could persuade foreign patients to not use a facilitator company by giving greater procedural discounts directly to the patient. Enticing foreign patients with cheaper services would ultimately allow patients to enjoy luxury services, like “fancy” tourism excursions, and shopping for luxury goods.
Medical tourism research rarely addresses tourists-turned-foreign patients after they arrive at their destination for global events, presumably because of the difficulty in locating this hidden population. There is research that demonstrates that foreign patients tend to travel internationally with the intention of receiving medical care. These foreign patients tend to exhibit the following behaviors: (1) outsource facilitator companies; (2) bring caregiver companions for the sole purpose of providing social support and decision- based guidance; and (3) have very limited financial resources to spend on luxury goods
92 and services outside of procedural costs (Bookman and Bookman 2007; Connell 2011).
As such, I expected that the majority of foreign patients traveling to Rio de Janeiro for health care, and not solely for the World Cup, would not combine their medical travel experience with exclusive touristic activities (Bell et al. 2011), despite Rio de Janeiro’s highly publicized tourism offerings and “salubrious climate” (Kangas 2010) repeatedly posted on medical tourism consumer websites and web fora, a central informational conduit for prospective cosmetic surgery and dental tourists (Connell 2011; Ackerman
2010; McDonald 2011). Instead, it was expected that patients would apply more money in securing and grouping multiple procedures (Mazzaschi 2011), further requiring the need to expand a local health care provider network to accommodate such high demand for medicine, and not tourism per say.
It has long been established that Brazil is a very “body conscious” society, as exemplified by its world-renowned aesthetic medicine (Edmonds 2007, 2010).
Commencing at the end of its dictatorship in 1985, Brazil’s extremely successful nation- making modernization project, like those of Costa Rica (Ackerman 2010) and Argentina
(McDonald 2011), elevated the country’s international status to a premier destination for cosmetic surgery tourism (Edmonds 2011). Brazil’s steady rise in globally competitive cosmetic surgery tourism is due not only to its reputation for high medical quality and bedside manner, but also that Brazilian surgeons have tested and perfected novel procedures that leave “almost invisible scars” on its patients (Edmonds 2011). As a result, this expertise in cosmetic surgery has attracted patients from all over the world after having been enticed by internationally propagated, mobilized, and marketed
Brazilian racialized “beauty myths,” a trope for national identity (Edmonds 2007, 2010).
93 Doubling in size since 2006, in year 2014, it was estimated that more than 60,000 foreign patients traveled to Brazil annually for health care (Brasil 2011). This figure is only expected to increase by 35 percent over the next five years (Abratus 2015). The
Brazilian Ministry of Tourism attributes this exponential growth to Brazil’s (1) provision of elective procedures at an average of 40 percent the cost of care received in the United
States, and (2) significant medical expertise in plastic surgery (Brasil 2010b). Following the U.S., Brazil has the second highest number of practicing cosmetic surgeons (4,000) per capita in the world (Brasil 2010a). Interestingly, more plastic surgeries are conducted in Rio de Janeiro than in any other city in Brazil (Edmonds 2010, 2011). As such, Rio de
Janeiro is commonly considered Brazil’s top medical tourism destination for plastic surgery, and even cosmetic dentistry (Bookman and Bookman 2007).
Currently, Brazil ranks fourth in the world for having the greatest number of Joint
Commission International (JCI) accredited institutions, the world’s chief international health care accrediting body that assesses both quality of care and patient safety standards. As such, Brazil has the largest number of JCI accredited hospitals and medical institutions than any other country in the Western Hemisphere. In fact, Brazil still has over 50% more JCI accreditations than Argentina, Barbados, Bahamas, Bermuda,
Cayman Islands, Chile, Colombia, Costa Rica, Ecuador, Mexico, Nicaragua, Panama, and
Peru, combined. Given its enormous resources, Brazil is actively targeting foreign patients from North America and Europe, as foreign patients from the Global North are thought to spend twice as much as the conventional tourist (Brasil 2010b, 2011; Sarruf
2007).
Given Brazil’s international reputation for being “the empire of the scalpel” and
94 the “plastic surgery champion and capital of the world” (Edmonds 2010, 2011), it is no surprise that cosmetic surgery tourism is the predominant draw for foreign patients.
Brazil’s government is actively trying to successfully attract foreign patients over global competitors in the cosmetic surgery market. Other countries with strong cosmetic surgery tourism markets include Thailand, India, Korea, Argentina, Colombia, and Costa Rica
(Bookman and Bookman 2007). One method in which Brazil’s government is attractively attracting medical tourists is by streamlining the visa application process for traveling to Brazil for medical treatment. Instead of having to go through an arduous, time consuming, and expensive application process for receiving a consular medical visa, citizens of the U.S., Australia, Canada, and Japan can now apply online for a much cheaper electronic visa (e-visa) that arrives in less than five days (VFS Global 2018).
Brazil has a free universal public health care system called Sistema Único de
Saude (SUS), which serves about three quarters of the population. However, twenty-five percent of the Brazilian population chooses to receive health care from the private sector, as many public hospitals have long wait times and are underfunded by the State. Private health care services tend to be very expensive for Brazilian nationals. Like the U.S., some Brazilian employers offer private health insurance services and benefits that allow their employees to only receive health care in the private sector. Many of the private sector hospitals and clinics are found in urban areas, making it particularly difficult to seek private health care in rural parts of the country (Edmonds 2007, 2010, 2011). With the announcement of the 2014 World Cup and the 2016 Summer Olympics, the city of
Rio de Janeiro received increased funding from the private sector to construct private hospitals and clinics (Zirin 2016).
95 The network of physicians I followed in 2014 had assumed that foreign patients would only be interested in aesthetic medical procedures, that is plastic surgery and cosmetic dentistry. The physicians I followed presumed that patients would prefer aesthetic medical procedures divided into four empirical categories: (1) augmentation versus reduction (i.e. breast and buttocks); (2) cosmetic versus reconstructive (i.e. blepharoplasty and rhinoplasty); (3) invasive versus minimally or noninvasive (i.e. surgical and topical laser procedures); and (4) long recovery time versus minimal downtime (i.e. tummy tuck and All-on-Four dental implants). In prioritizing aesthetic medicine, network physicians did not seek out other specialists common in medical tourism, such as fertility and reproduction, oncology, cardiology, and orthopedics.
By the end of my research period in 2014, a tenuous network of providers was formed prior to the World Cup, but it had quickly disintegrated prior to accepting foreign patients. The disintegration of this provider network was primarily attributed to the frequent public instability and protests surrounding the exorbitant amount of government spending required to host two mega-events, particularly during the worst economic, budgetary, and political crisis of the century. During 2014 to 2016, Brazil had experienced the worst recession on record, as restrictions on credit and rising interest rates resulted in surging inflation and high unemployment. Compounded by the economic crisis was increased public discontent regarding a political crisis that ensued, in which
President Dilma Rousseff was impeached for breaking budgetary laws and her incredibly unpopular Vice President Michel Temer assumed office. Moreover, due to the two-year economic recession weakening tax reserves alongside rising government expenditures,
Brazil was also facing an extraordinary budgetary crisis (Zirin 2016).
96 Mounting civil dissatisfaction due to socio-economic and political change was compounded by the government not having leftover public funding to invest into the local health care, education, and transportation systems after spending billions of dollars on the infrastructure deemed necessary by FIFA and the International Olympic
Committee (Zirin 2016). As the most expensive tournament to date, the 2014 FIFA
World Cup alone cost over $11 billion, while the 2016 Summer Olympics cost an additional $4.6 billion (Flyvbjerg et al. 2016; Zirin 2016). It is estimated that an additional $1.5 billion dollars were invested in the tourism industry alone in Rio de
Janeiro to prepare for and accommodate international tourists traveling for the 2016
Summer Olympics. This investment included the construction of over 70 new hotels and residences in Rio de Janeiro, creating an estimated 16,000 jobs for staffing alone
(Flyvbjerg et al. 2016; Zirin 2016). To make way for such massive infrastructural development, tens of thousands of the city’s poorest citizens residing on real estate deemed valuable “for public use” were evicted and displaced for new private construction ahead of the World Cup and Olympic games (Zirin 2016).
When I returned to Rio de Janeiro in 2017-2018, the World Cup and the 2016
Summer Olympics had already come and gone. However, the billions of dollars of infrastructure that these global events brought with them, sat empty, or at best, grossly under-utilized. Upon arrival, I immediately reached out to the physicians who attempted to build the first formal network of medical tourism health care providers in Rio de
Janeiro, in hopes that they were successful in their previously failed pursuits. In the end, they were not. After interviewing all of the primary members of the dissociated network, and the dozens of other physicians that were referred to me as potential candidates (for a
97 total of 42 interviews), I began to understand the herculean feat in organizing such a network.
After reaching thematic saturation in these interviews (Bernard 2011), I was able to assess the commonly reported variables as to why this network never materialized from the period following the World Cup up until the end of the Summer Olympics.
First, there was a general internal disagreement on network partnership, management, remuneration, and investment (re)structuring. An excerpt from a roundtable meeting with several surgeons describes this dissension on who to allow into the network, and problems with unfair compensation:
“I just don’t agree that we should include him [a potential plastic surgeon] in the project. Yes, he is famous and one of the best in his field. But you know, his prices are really high. And on top of that, he is not willing to give us our fee from his procedures. He wants to charge those insane prices plus our fee to the client. It’s just way too high! Especially when you factor in the hospital fees.”
This quote depicts why physicians frequently disagreed on whom to allow into the network or not: exorbitant costs to patients. The network’s primary concerns centered on deciding how to choose the best physicians in Rio de Janeiro, while simultaneously managing how the group was going to be compensated despite the exorbitant prices for charged by the provider and the operative and recuperative facilities.
Second, many physicians listed that they had underdeveloped marketing techniques for targeting foreign patients outside or inside of Brazil. For example, many physicians could not figure out ways to find potential clients without the use of a facilitator company. Moreover, physicians were challenged on how to attract tourists already present for the World Cup into their private clinics for elective procedures. The physicians I interviewed often cited that they did not have an organized plan to
98 methodically convert tourists into voluntary patients, if tourists were not already seeking help for medical emergencies. Dovetailing the lack of marketing techniques was a lack of communicative and administrative support in managing current foreign patients. This variable was reported the most for the project’s failure. An excerpt from an interview with a dentist summarizes this problem:
“Even if we could manage to convince a tourist to get something done, like in my case a simple teeth cleaning, we had nobody capable of answering all of the problems the patient needed once they left our consultório (consultation office). For example, I had one patient come in wanting new porcelain veneers, but he never came back after the initial consultation. The lab created the veneers, but he disappeared. He never got them, because we didn’t know where he went afterwards. I’m sure we could not have even done any follow-up care to see if they took well if he did get them. We had no one keeping in touch with his whereabouts. There was no accountability for the patient. It was just too much we had not considered.”
As indicated here, physicians noted that they possessed insufficient connections and partnerships to other industries vitally ancillary to medical tourism, namely the hospitality, tourism, and transportation industries. For this reason, this network of physicians did not have non-health care related partnerships to help manage the overall tourism logistics of medical travel.
Lastly, many physicians had diminished confidence in accepting new referrals from outside of their established professional networks in Brazil and/or medical specialty.
An excerpt from an interview with a plastic surgeon explains why he did not welcome referrals outside of his close professional network:
“I get a lot of doctors that recommend me for correcting bad surgeries. While I generally accept referrals for Brazilian patients, when it comes to foreign patients I was not clear of the liability of correcting something that was done outside of Brazil. I was too cautious to accept the bad work of doctors I do not know.”
The quote reveals that many doctors expressed concern about continuing or correcting the
99 medical treatment plans initiated by doctors they were not familiar with because of potential liability risks. Additionally, doctors reported that many partnering medical facilities were currently undergoing complete intra-organizational, conceptual, and/or geographic restructuring of their individual consultórios (doctor’s offices), clinics, or hospitals. Doctors felt hesitant about accepting new patients during such drastic transitional phases of their medical practice. All of the aforementioned variables are clear demonstrations of the barriers to formalizing a medical tourism health care provider network.
Data gathered from semi-structured interviews with plastic surgeons, dermatologists, cardiologists, and dentists demonstrated that the current state of the medical tourism industry in Rio de Janeiro was haphazard and problematic. Even though the government claims that there are tens of thousands of foreign patients that come to
Brazil annually for the intention of receiving medical procedures (Brasil 2010a, 2011;
Abratus 2015), the prominent doctors I interviewed all firmly asserted that the current medical tourism industry in Rio de Janeiro was “tenuous,” “very disorganized,” and all
“too informal.” More specifically, this referral network of physicians, all of whom irregularly treat foreign patients in their offices, asserted that there are no dominant facilitator companies, either in or outside of Brazil, that directly refer foreign patients to them. Instead, foreign patients currently enter into direct contact with the physician’s office manager, secretary, or receptionist at his or her consultório (consultation office).
The office manager, secretary, and/or receptionist are then generally relegated, by default, the responsibility of planning and organizing the medical travel itineraries on the foreign patient’s behalf. One internationally renowned orthodontic surgeon I interviewed
100 describes the unfortunate reality of having to rely on his own staff to act as travel agents for prospective foreign patients:
“You can imagine the problems this gives my office. My secretary does not speak anything but Portuguese. When a foreign patient calls, I have to stop what I’m doing and try to sort these problems out myself. She’s not a travel expert. I don’t think she has ever left the state of Rio de Janeiro. It’s not her job to help patients apply for their visa, find an apartment or book a hotel. I don’t have time to organize all of the things foreigners need to come to my office, and my staff are not trained do it. Sometimes I just have to say no to foreigners coming because I don’t have anyone that can take care of everything that they [foreign patients] need to get here. It is so much work!”
As seen from this quote, physicians expressed distress and concern that not only have they not adequately equipped or trained their staff to handle the tourism and hospitality aspects of medical travel, but that they also should not even have to do so.
Many physicians referred to their own international training and education when asked how foreign patients find Brazilian doctors. Additionally, physicians repeatedly mentioned that they typically receive referrals from other colleague physicians with whom they studied outside of Brazil. For example, one very prominent plastic surgeon who completed years of his medical training in Europe describes how his patients usually learn of his health services:
“About ninety percent of my foreign patients, like twenty more or less, come from the area where I did my residency training after medical school. Some of them know me from living in that area for years before I came back to Brazil, but others are new patients. They [new patients] are referred to me by other colleagues that are still there. Once they [foreign patients] come here the first time, they always come back for touch-ups and check-ups. Sometimes they [recurring foreign patients] bring new clients with them. It’s always easy to treat returning patients because they don’t need anything spectacular- they already know how to navigate the city, and my team does not have to manage their travel details, which frees up so much more of my time to serve more patients that live here in Rio.”
This quote depicts the general ways in which foreign patients learn of doctors’ medical
101 services in Rio de Janeiro: from physicians’ own international reputations, and direct referrals from their own international medical professional network. Additionally, this statement alludes to why physicians maintain great interest in participating in medical tourism, provided that they can outsource a third party to take care of the non-medical details: very loyal, repeat clients who generate effortless referrals on the doctor’s behalf.
I performed semi-structured interviews with physicians, surgeons, and dentists from this referral network by way of purposive sampling for the first couple of months after my arrival in Rio de Janeiro. From these interviews, I was eventually referred to a prominent, extremely well respected physician in Rio de Janeiro who was seeking to organize a formal medical tourism network of her own. This network would be a comprehensive medical tourism network, unlike the aforementioned health care provider network that failed to materialize. This new network would include both health care and tourism and hospitality service providers, and would be designed to fulfill all of the demands of local physicians and foreign patients to be successful on-the-ground. After chatting with Alexandra for seven hours over cafezinhos (espressos) inside one of
Brazil’s most renowned hospitals, overlooking the city skyline of an exclusive neighborhood in Rio de Janeiro, I quickly realized that Alexandra possessed all of the tenacity, and social and material resources to successfully mobilize a medical tourism industry in Rio de Janeiro.
Meeting the Team
One week following my interview with Alexandra, I was cordially invited by
Alexandra’s secretary to meet her team in a law office in downtown Rio de Janeiro.
102 In English, Alexandra introduced me individually to all of her team members: Tomas, a powerful attorney in Rio that was gracious to allow us to use his law office for the meeting; Maria, Tomas’ law partner; Antonio, a financial planner that lived in London for over a decade with expertise in foreign exchange rates and international banking;
Lucas, a medical director of a top hospital in Rio de Janeiro with “unparalleled connections” according to Alexandra; and Rafael, a renowned plastic surgeon with his own private clinic in Leblon (arguably the most exclusive neighborhood in Rio’s South
Zone). As for Alexandra, she is a managing physician and medical director of another large hospital chain, who I quickly learned is also in charge of all international patients
(and their foreign health insurance negotiations) in the event they are rushed to the hospital for emergency care during their business trip or vacation.
I quickly realized that there was already a power structure at play within this team, and that Alexandra had the final say-so, no matter what. I was impressed not only with the assertive and direct style and diction she chose to implement in speaking with her team members and myself, but also with the inflections and cadence in her voice that provoked individuals to “rise to the occasion” or to be quickly left behind. By strategically switching between Portuguese and English, I began to notice that Alexandra was tactfully exerting power through displays of competence and worldliness. From my past experiences with highly ambitious business professionals, they all enacted similar tones to assert power and dominance, as well as to challenge someone’s bluff, a refined skill of which I would soon understand the value in establishing quality partnerships.
After telling everyone about myself in Portuguese, I was briefed on the current and past developments of their fledgling organization. Alexandra explained that she and
103 Lucas first heard of medical tourism at an international conference for hospital directors four years ago in Europe, and that they became “totally enthralled with the idea of caring for foreign patients and hosting them in our marvelous city.” Lucas, who I was told unanimously by the group, is a visionary that wanted to organize only the “best of the best” for their future clients in order to provide an “ultimate experience” that would show the world what Brazil can really offer: “world-class health care at competitive prices.”
Alexandra and Lucas have been trying to find strategic partners for the past two years to help realize their dream of bringing foreign patients to Rio. Team members’ search for strategic partners brought them outside of Brazil to international conferences on medical tourism, in hopes of working with foreign medical tourism facilitator companies. Alexandra and Lucas both explained that they did not “trust” or “have good a impression” from the dozens of foreign facilitator companies present at these international networking events, and became quickly discouraged from outsourcing foreign partners after receiving requests for illegal medical procedures. Soon after their return to Brazil, Alexandra described that Raphael, her longtime close friend and colleague, had expressed genuine interest in the project to her privately, and had connections to the best legal minds one could find, a plus when Brazil is just as, if not more so, litigious and bureaucratic than the United States. After six months, Maria and
Tomas were almost finished filing the legal paperwork for starting a for-profit business organization in Brazil, so everyone could quickly start investing in marketing strategies, website development, and terms and conditions of service contracts with future patients, local health care providers, and hotels. Recommended by Tomas, Antonio was responsible for organizing, accepting, distributing, and making financial payments for
104 future services rendered. Alexandra and Raphael recently began brainstorming their top candidates of plastic surgeons to invite into the network, and how they were going to hold interviews and inspections of provider facilities.
All team members noted that their primary motivation in starting this organization was to weather the current economic crisis in Rio de Janeiro. The economic crisis in Rio de Janeiro was compounded by the city’s recent back-to-back hosting of the World Cup and Summer Olympics. The longstanding economic crisis plaguing Brazil had only been exacerbated by the billions of dollars the government had spent on trying to build the
“necessary” infrastructure ordered by FIFA and the International Olympics Committee.
All team members viewed the medical tourism industry as a way to salvage personal, community, and national losses not only from the economic crisis, but also as a personal insurance to safeguard them from further politico-economic detriment that may transpire in the near future. Lucas describes how the current political and socio-economic changes in Rio de Janeiro personally led him to invest in co-founding this medical tourism start- up organization for his future:
“Its like this, you see, opportunities are extremely limited right now because of the crisis. It’s getting more and more expensive to live in the city, and its really hard for everyone right now. When I heard of medical tourism, I immediately started to see an opportunity, which is not normal nowadays. At the medical tourism congress I went to last year, there were many people talking about the tourism part of health tourism. I started to think of all of the new hotels and developments that were just built for the Olympics, and thought, ‘my city has all of this right now. Why not start?’ Because opportunities are not common right now, when one comes along, you must grab it, you know? And who knows what will happen to Brazil in the future, with the new upcoming president, and our economy, the way it is and has been in the past few years. I think you have to always invest in yourself in Brazil, because nothing else is guaranteed. Brazil is not for beginners.”
This quote describes how team members considered medical tourism to be a positive opportunity for gaining solid footing amidst the numerous furrows of the economic crisis.
105 More specifically, team members viewed the establishment of a local medical tourism industry as a means to repurpose the massive tourism infrastructure that had already been developed from recent global events.
Many team members also detailed that medical tourism was a logical career move for them, given their previous experience working abroad or with international clients or patients in Rio de Janeiro. Others claimed medical tourism was the opportunity “worth making a career change for,” since they expect to be the first in the business locally, if not nationally, to formalize medical tourism in Rio de Janeiro. All team members claimed they had a personal financial interest in undertaking the project, and that their “sweat equity would pay off in the near future.” When probing further into why they believe
Brazil is a better option for medical tourism over other countries, namely Costa Rica and
Mexico (their self-reported competitors), I received two additional motivations for starting this organization: (1) to provide community support through local job creation, language training for new and existing employees, and expansion of professional services for contracted providers; and (2) to help position Brazil on the global map as the leader in hospitality and health care not only in the Global South, but in the Western Hemisphere, following the U.S.
In the end, this introductory meeting lasted a little over two hours, which in retrospect was extraordinary, as all of these team members were incredibly busy executives in their “other corporate lives.” Before I had the opportunity to ask if I could participate and observe any of the future meetings, I found myself already scheduled for the next three brainstorming sessions the following week. Additionally, Raphael had already passed me a folder with a list of potential plastic, orthopedic, and cardiac
106 surgeons that he wanted to me review, in case I had already interviewed any of them in the recent past. Also in the folder was a preliminary list of hotels and private dental and dermatological clinics the team was considering for partnerships, all circled on a photocopied map of Rio’s South and West zones. Alexandra smiled at me as I took the folder in my hands before I had the chance to respond to Raphael, and said in Portuguese,
“We are excited to have you with us. See you next week.”
Forecasting the Market
Over the next month and a half, I met with all of the team members multiple times for numerous brainstorming meetings averaging about forty-five minutes to one hour each. All brainstorming meetings were conducted entirely in Portuguese. These meetings were generally scheduled during team members’ lunch breaks at their respective offices or places of work, or during the last hour of their scheduled work day. All in all, I was present for sixteen brainstorming meetings with whoever was available on any given day.
While the average brainstorming session included two team members and myself, there was never a brainstorming meeting with more than three team members present. Even though it proved especially difficult to gather everyone at the same place and time following our initial introductory meeting, considering everyone’s incredibly busy and chaotic work schedules, there were surprisingly never any communicative issues across meetings and between team members. This was likely due to the efficient structure of the meetings.
The typical brainstorming meeting was divided into three primary agenda items.
The objective of the first ten minutes of every brainstorming meeting was to strictly recap
107 the content of the previous meeting, which generally focused on describing the most favored and disliked ideas, propositions, and decisions made in the last meeting. No time was allotted for pleasantries, gossiping, or non-business conjecture. Next, the objective of the following ten to fifteen minutes of the meeting was to cross-check the completion statuses of time sensitive items on to-do lists generated from the previous meeting.
Lastly, the objective of the remaining twenty minutes or so of the brainstorming session was to discuss what team members believed their future clients would expect out of the organization in the near and distant future. As the conversation persisted, team members would devise a list of time sensitive items to do by the next brainstorming meeting.
Towards the end of the meeting, team members would delegate items to be accomplished according to one factor alone: the team member who possessed the respective background or third-party contact that could quickly eliminate the task at hand.
Table 2 outlines an extensive enumeration of ideas and propositions generated by organizational team members during 16 brainstorming sessions. More specifically, Table
2 itemizes probable risks and potential actionable solutions to curb such risks as proposed by team members. Additionally, Table 2 lists the perceived requisites of a positive medical tourism experience as determined by organizational team members, and therefore addresses objective one of this dissertation. Moreover, Table 2 divides these perceived requisites into three empirical categories that are not mutually exclusive. These three empirical categories were developed after coding and sorting direct observations from brainstorming meetings and interview response narratives.
During interviews, all team members detailed that the majority of their proposed ideas during brainstorming meetings were influenced by the following: (1) the dialogue at
108 hand; (2) continuous contemplation of the previous meetings’ content; and (3) years of personal experience doing business in Brazil. Team members frequently attributed their years of experience of successfully navigating through complex Brazilian bureaucracy on and off the job for their quick creative synthesis to intricate problems. Furthermore, all team members cited that their daily reading and analysis of medical tourism market research influenced their brainstorming ideas and propositions. Also, team members generally described their market research on medical tourism as case studies within interviews. Case study research was largely focused on two nations, Costa Rica and
Mexico, as team members frequently referred to these two countries as their primary competition “within our hemisphere.”
109 Table 2: Perceived Medical Tourism Risks, Solutions, and Requisites, as Determined by Organizational Team Members in Brainstorming Meetings
Empirical Mitigated Perceived Predicted Solution Presumed Foreign Category* Risk Patient Requisite 1) Accept pre-payment of services on behalf of contracted 1) One lump-sum 1) Non-payment of providers payment for high services after delivery 2) Select doctors with quality, low cost 2) Dependence on primary medical services Organizational health care translation training completed in 2) American trained Competence services the U.S. doctors 3) Perception of sub- 3) Select American 3) American standard quality of accredited facilities accreditations for care only, or facilities facilities willing to acquire an accreditation 1) Hire a personal 1) Late appointment driver 1) Private on-the- arrivals from random 2) Hire security guards ground acts of city violence at all facilities transportation Personal Safety 2) Perception of high 3) Contract Brazilians 2) Insulation from crime and danger that have lived in city violence 3) Cross-cultural English speaking 3) Personal assistant disorientation countries 1) Select foreign 1) Perception of sub- owned hotels with 1) Internationally standard quality of international brand branded hotels Patient Comfort accommodations recognition 2) Personal care and 2) Perception of after- 2) Select nurses to attention care neglect visit patients in hotels daily during recovery * Empirical categories are not mutually exclusive.
Organizational Competence
The first empirical category of organizationally valued risks, solutions, and requisites of a positive medical tourism experience is organizational competence. In the first brainstorming meeting, it was unanimously decided that, in order to design a “world- class medical tourism experience in Rio de Janeiro,” the organization would have to
110 focus on the consumer preferences of only one demographic: Americans. The following excerpt from the first brainstorming meeting explains the organizational rationale for designing future medical travel experiences befit specifically for Americans.
Frank: “Who is your target market?” Alexandra: “Look, we’ve all spent a lot of time in the U.S., and Americans tend to be the most carente (needy), no offense. So I think if we can make them happy, we can make anyone happy with our services.” Tomas: “I completely agree. I think we need to focus only on what Americans want and need because of their current health care situation. It’s just so expensive there. I have several family members in Miami who are really afraid of getting sick, and they pay a ton for insurance! It would be cheaper for them to fly back to Brazil whenever they are [sick]. Plus, the dollar is really strong right now too. They [Americans] will get more here for less [money], so we can enter with our choice of everything.” Alexandra: “Yes! If they spend less [dollars] here in Brazil, because our real (Brazil’s currency) is really bad right now, they would get a better experience overall, and go back and tell everyone they know how great it was.” Antonio: “Right. If they spend less money, everyone will want to come because it is so cheap right now for them because of the crisis. With a better exchange rate, we can give them a luxury experience for cheap, because we can get better options, and guarantee them [providers] more business. So they [providers] will want to stay with us in the future.” Frank: “How will the providers be paid?” Antonio: “People here only want to be paid in local currency before they perform their services. They don’t trust any other method, mainly because they don’t have any experience bringing in foreign money into Brazil. That’s where I think we should come in.” Alexandra: “So we should pay the providers, and not the client? Let me see. If the client pays us everything before they leave the U.S., then we pre- pay the providers here. Ok- so that way the client doesn’t have to worry about that either, and the provider will always need us and keep us informed before they do any additional work [procedures]. Great. Decided.”
The above brainstorming dialogue demonstrates that team members upheld Americans as the “gold standard” in deciding what all foreign patients would deem as an extraordinary medical travel experience in Rio de Janeiro. Team members collectively perceived
Americans as the pickiest consumers, and therefore the most difficult to appease among
111 any nationality. As such, team members decided to model all of their future organizational service offerings based on what would make Americans extremely satisfied, since, under this assumption, foreign patients of any nationality would be extremely pleased with their medical travel experience as long as it satisfactory by
American standards.
Additionally, the above excerpt reveals how team members improvisationally solved the impending problem of receiving money from future clients and paying health care providers. In short, team members first identified a likely risk or concern they believed would be raised by service providers in the near future, that is providers would require payment in full before services are to be rendered to foreign patients. Next, team members then generated a solution to a hypothetical problem in real time: have the client pre-pay the organization before leaving their respective country, so the organization could pay service providers in advance, strengthening the patient’s and the provider’s ties and dependencies to the organization. The logic or reasoning behind such a proposed solution was that both parties could avoid engaging in cross-border currency transactions themselves. Therefore, one can see that team members identified a perceived value of a good medical travel experience, in this case pre-payment of services, by justifying to other team members what the actionable solution to the hypothetical problem should be.
Lastly, this conversation reveals how team members presumed that Americans would take advantage of a great currency exchange rate between the dollar and the Brazilian real, ultimately recasting the economic crisis from current hindrance to future incentive.
General consensus determined that the design of the organization’s “world-class medical travel experience” was to be based on the perceived values that would make
112 Americans content. Brainstorming sessions narrowed further into what Americans would want specifically during their stay in Rio de Janeiro. One requisite value of a positive medical tourism experience repeatedly identified in subsequent brainstorming meetings was doctors who were trained in the United States. The following excerpt from the fourth brainstorming session explains team members’ reasoning for having only U.S. trained physicians.
Lucas: “I’m afraid Americans will not trust our medical expertise. Americans are accustomed to their own doctors. I think we should only start looking for, at least in the beginning, doctors who were trained in the United States. That way we can prove that our doctors are just as good as theirs, only much cheaper.” Alexandra: “That would totally make our selection easier.” Lucas: “Yeah, but what should that be? I know a lot [of doctors] who did their medical school training here in Brazil, but they went there [the U.S.] for post-doctoral training. Didn’t you do that Alexandra? [Alexandra nods yes]. Should we include them, or only those that did their primary medical education in the U.S.?” Alexandra: “Hmm. Let’s see. We should definitely short-list the ones who did their primary medical education there. That way we know their English is better, because Americans will not want a translator. They [Americans] are so branded, you know. I think they will only want their own brands. They will recognize the schools and hospitals our doctors went to, and we won’t have to sell them on the quality of our doctors, if we do that. We can always put the other ones on another list to contact later, if we can’t find any good doctors that did their primary training there [in the U.S.].”
This brainstorming passage highlights how team members arrived at yet another perceived value of an ideal medical travel experience in Rio de Janeiro: American trained physicians. First, team members conveyed a particularly troubling risk early on, that is the fear of rejection of medical expertise. Next, team members proposed a solution on the spot to mitigate a risk before it was able to manifest problems in the future. In this case, team members decided to select only American trained physicians to treat their foreign patients. Finally, in justifying the organizational rationale for proposing such a
113 an actionable solution to a problem that has yet to occur, team members arrived at an additional requisite of an exceptional medical travel experience: fluent English speaking doctors who do not require translation services. In order to eliminate the need for translation services, and consequentially a higher cost markup, both in terms of time and money, the organization avoided a great hurdle in competing in the global medical tourism marketplace: not having to “prove” that their doctors are the best in Brazil, as
Americans were thought to define such a measure.
Another requisite value of a positive medical tourism experience considered equally important to provider education was the facility itself. The following excerpt from the ninth brainstorming meeting highlights that the group would target only accredited medical facilities.
Raphael: “Congratulations on the new [American] accreditation! That’s fantastic.” Lucas: “Thanks! Yeah, I am so glad that’s over. It took us months to get it, you know. I had to make sure everything at the hospital was absolutely perfect before their [evaluation committee] arrival.” Raphael: “Well, now we have our first hospital then.” Lucas: “Actually, now that we have it, I think we should only use accredited places, or at least only facilities that can get one [an accreditation]. I’m afraid people won’t believe our cleanliness and technology in our facilities if they do not have an accreditation to show that they have been evaluated by a third-party from the U.S. That way everyone knows our places are clean and up to American standards. We can definitely sell that.” Raphael: “I think you’re right. We should only be focusing on American accreditations then. Makes sense.”
The above brainstorming selection demonstrates how another perceived value of an ideal medical tourism experience was determined. Here, an organizational team member expressed a doubtful concern that Americans would not trust the organization’s overall competence to select a clean medical facility that possessed up-to-date technology. After
114 identifying the probable risk that could hinder the basic underlying tenets of the relationship forged between the organization and the foreign patient, that is not having full client trust in the organization’s competence to select medical facilities, team members quickly proposed the best actionable solution to curtail said risk in a decidedly proactive and swift manner. The proposed solution to this identified potential risk was to only accept facilities that already had or could likely receive an American accreditation upon application. In justifying the logic of proposing such a risk and its solution, team members were able to identify another valued factor of a positive medical travel experience: American accredited facilities. In the process of determining such a positive experiential value during the meeting, team members simultaneously evaded yet another barrier to global market entry: establishing trust with foreign patients early on by proving that chosen facilities are just as good as American hospitals and clinics, if not better, because of their American accreditation.
Personal Safety
The second empirical category of valued risks, solutions, and requisites of the medical tourism experience as determined by organizational team members is personal safety. Team members of the newly established organization repeatedly expressed great concern for the safety of foreign patients throughout numerous brainstorming meetings.
Interestingly, there was very little discussion during brainstorming meetings about medical safety during patients’ stays within hospitals or clinics. When asked why focus was given to personal safety, and not medical safety, in a post-meeting interview with
Alexandra, she responded:
115 “That will come later. It’s way easier to control variables within our own facilities, and then creating protocols [for medical safety] in the clinics we decide to contract after doing inspections. Besides, the accreditations will take care of that. We are more concerned about thinking about the factors out of our control, so we can control them somehow.”
Allusions to personal safety were always foregrounded in discussions of city violence. Team members expressed great anxiety over foreign patients being safe while in Rio de Janeiro. Many were deeply concerned about the “overly hysterical” media coverage of civil unrest and protests preceding preparations for the World Cup and the
Summer Olympics. For example, months leading up to the World Cup, the city of Rio de
Janeiro was trying to “clean up of the streets” from drug traffickers, prostitutes, and gangs by spending considerable public resources on pacifying and upending favelas
(urban squatter settlements) established on highly coveted real estate in glitzy neighborhoods of the city’s South and West zones for private development (Zirin 2016).
Team members were greatly fearful of whether the explosive media coverage of the government attempting to “sanitize” the city in response to hosting two mega-events back-to-back for the first time would disincentivize potential clients from choosing Rio de Janeiro as their medical travel destination on account of the media exposing “the dark and dirty” of the city. Maria expressed her fears and doubts of general patient safety in one brainstorming meeting with Lucas.
Lucas: “So Alexandra and I decided in the last meeting that all medical facilities and hotels have to have security. They all need cameras and guards in case someone from the street tries to get in. I mean, most places we would consider would already have that in anyway. But, you know, that’s our basic requirement above anything else in what we need [from providers].” Maria: “My main worry is that something will happen to someone, and it will be completely out of our control. It keeps me up at night. People are crazy and desperate right now during the crisis and political situation, you know. You never know what somebody may do. I’m afraid
116 something terrible is going to happen to someone. If it does, then our project is done. All the work we are doing right now will be for nothing. If just one person goes back home and leaves us a bad review, it will be over before it even started. No one will ever want to come to the City of God for health care when they would be better off going somewhere else that’s safe.” Lucas: “I know. That worries me too. I read an article in Globo (the name of a popular Brazilian newspaper) yesterday about some kids from Rocinha (the largest favela in Rio’s South Zone) stopping cars in the streets out of protest.” Maria: “Oh my God. I just decided I’m going to find a private car service for us then. They will do whatever we say, and take only the safest roads to and from the hotels to their [potential clients’] appointments. We can control what they [hired private drivers] do.” Lucas: “I think we should hire local experts that will be with patients the entire time they are in Brazil, so they can calm them [foreign patients] down and explain any problem [to clients] that comes up, you know in case they are confused or find themselves in any weird situation. They will also tell them where to go and not go.” Maria: “I really like that. We can train both the drivers and the assistants how to handle all of the bad situations in case something happens. The assistants need the best English out of everyone, though. We should only get people who have lived abroad for a long time. Ok, now I feel a lot better about this.”
The above excerpt from a brainstorming meeting on general patient safety reveals the identification of three valued requisites of a positive medical tourism experience by way of first isolating future risks, and then by generating solutions to prevent such wrongdoings from manifesting: private on-the-ground transportation, insulation from city violence, and a personal assistant. First, the fear of random city violence conflated from the aftermath of civil unrest and protests of hosting both global events sparked the identification of the following potential risks: foreign patients arriving to medical appointments late, and thereby offsetting the subsequent medical protocol of the client, likely starting a backlog of itinerary problems for other clients as well; patient disorientation and confusion from being in a new culture and urban geography; and pervasive perception of high crime and danger from random acts of
117 city violence. After articulating such risks that could negatively impact the best possible medical travel experience for foreign patients in Rio de Janeiro, team members constructed practical solutions to diminish such risks from occurring. The solutions fashioned by team members during the meeting were making sure all facilities, both medical and touristic, had top-of-the-line security in place, and that clients were chauffeured by private drivers and a local city expert with excellent
English. Only in justifying their solutions for resolving expressed fears did team members artlessly identify what they believe should be a requisite of an ideal medical tourism experience in Rio de Janeiro.
Patient Comfort
The third empirical category of valued risks, solutions, and requisites of the medical tourism experience as brainstormed by team members is patient comfort. During the final brainstorming meetings, perceived consumer preferences shifted toward patient comfort. If patients were to have a medical tourism experience worth telling their friends and family back home about, and therefore a healthy effortless referral system, team members would have to ensure that patients were comfortable at all times, both inside and outside of the medical facility. The following brainstorming conversation underscores the perceived organizational need for patient comfort to have a positive medical travel experience in Rio de Janeiro.
Raphael: “Alexandra and I already have a list of hotels to inspect. I would say that about ninety percent of them are international. The other ten [percent] are small and Brazilian. Do you think we should consider the Brazilian ones?” Tomas: “Let’s focus on the American hotels first. Then the international hotels. And then we go to the Brazilian hotels. Clients will feel better about a name they recognize. Plus, the international hotels have training
118 standards. I’m afraid to use the Brazilian hotels because they are not as organized. Yes, they [Brazilian hotels] may be cheaper, but that could cost us money in the future- not to mention stomach pain if we have to refund them [clients] in case they do not like it.” Raphael: “You know, I talked to a hotel manager [at an international hotel], and she said that she was familiar with this type of market- medical tourism, you know. She said they had people doing that when she was managing a hotel in Colombia. She mentioned that they always gave special privileges to those clients because they stay for a long time. They also registered nurses at reception, since they would have to come and change bandages and check on them [foreign patients] daily. That way the nurses would not have to go to reception every time they came in.” Tomas: “Did you already tell Alexandra or Lucas that? They both need to interview their best nurses, so they [nurses] can go to their hotel room every day to check on them. Some [clients] may not want that, but we need to require it. Most [clients] will be super-carente (really needy), and they will feel better with a nurse there everyday.” Raphael: “If we do that, we will need the personal assistants to check on patients every day too. All of the hotels will need to be very open to that.”
The above dialogue reveals, once again, how organizational team members identified requisites of an exceptional medical tourism experience by first identifying a potential risk, and then quelling such risk with an applied solution, extemporaneously. Here, team members expressed a concern about whether hotels would be competent enough to train their employees to provide a level of comfort that Americans are accustomed. Building on the notion that Americans are overly brand conscious and loyal, as established in early brainstorming meetings, team members proposed the following sensible solution: choose internationally branded hotels that not only immediately signify quality and comfort to the patient, but that also reassure the patients, the organization, and partnering health care providers of the hotel brand’s international standard of staff training. In justifying the reasoning behind pursuing such a solution to a conceivable problem, team members further refined another requisite for a positive medical travel experience: internationally branded hotels.
119 One can see that team members identified an additional experiential requisite in this same brainstorming blurb by following the same process. Team members worried about the risk of patients being too needy while recovering from medical procedures in their hotel room, so team members iteratively proposed the solution of hiring private nurses.
In so doing, team members were able to pinpoint that a future requisite of an exceptional medical tourism experience in Rio de Janeiro is personal care and attention.
The little information known about Americans who travel abroad for health care did not fully inform team members’ brainstorming sessions of determining the ideal medical travel experience in Rio de Janeiro. In 2015, the U.S. International Trade Commission estimated that 150,000 to 300,000 Americans traveled abroad for health care, amounting to ten percent of all foreign patients worldwide that participated in medical tourism.
However, the exact size of the global market of medical tourism is unknown, since medical travel data vary by the agenda of the institution, as well their location in either a sending or receiving country. In general, American foreign patients typically cite lower cost as the primary reason to travel abroad for health care (Chambers 2015).
Team members recognized that Americans would be highly motivated to travel to
Brazil because of significant savings on out-of-pocket spending for elective or non- elective medical services. However, team members did not account for the fact that additional luxury services, such as private transportation and five star hotel accommodations, as determined in brainstorming sessions, may disincentivize Americans from traveling to Rio de Janeiro in the long run. By augmenting medical travel experiences with non-medical services, team members failed to consider whether the presumed requisites of a positive medical tourism experience in Rio de Janeiro would
120 out-price the cost savings of Americans coming to Brazil for affordable health care.
Routine Practice of a Key Strategy: Prospective Problem-Solving
As depicted in all of the above excerpts from brainstorming meeting transcripts, team members underwent a patterned process of inductively formulating perceived value requisites of what makes a good medical travel experience in Rio de Janeiro. Figure 1 outlines this patterned process, and is described at length below. Here, I refer to this process as prospective problem-solving. In the context of this dissertation, prospective problem-solving is defined as predicting what could possibly go wrong in the future, and then crafting and implementing solutions in the present to curtail such wrongdoings from negatively impacting subsequent client experiences.
Figure 1: The Process of Prospective Problem-Solving, as Routinely Practiced by Organizational Team Members during Brainstorming Meetings
Determine Find Infer Probable Actionable Client Risk Solution Requisite
During pre- and post-brainstorming meeting interviews, all team members considered it highly productive to openly express to their fellow organizational
121 stakeholders their fears, anxieties, doubts, and overall concerns about establishing an organization that soon will mobilize a local unregulated medical tourism industry in a city undergoing drastic changes. Team members would frequently refer to the final segment of the brainstorming meeting agenda when citing encouragement to express doubtful concerns and freely associated ideas, no matter how insignificant, for addressing problems raised. By purposefully allocating time for attendees to discuss what compulsory client services the organization would have to arrange, team members became quickly accustomed to actively listening to their fellow teammates and to creatively managing foreseeable risks. As such, the brainstorming meeting served as an inviting space to iteratively express uncertainty about the organization’s future capacity to accommodate its future clients. In so doing, team members considered this routine practice of discussing risk as not only intentional and strategic, but also incredibly valuable for identifying goals and delegating actionable tasks.
As seen in Figure 1, organizational team members would first identify a probable risk that could negatively affect a future client’s medical travel experience. After explaining one’s reasoning why such a problem could in fact be risky, organizational team members would brainstorm solutions on how to preclude impending problems from arising, thereby mitigating risks early on. Interestingly, team members only proposed solutions that were realistic, and capable of being implemented immediately by at least one team member. Typically, brainstormed solutions would dictate the time sensitive items on to-do lists that were then delegated to team members best-positioned to accomplish tasks the most efficiently and effectively as possible. After formulating practical solutions to mitigating probable risks, team members would arrive at their
122 perceived requisite of what makes a good client experience. Team members would always crosscheck the organization’s presumed requisites during the recap portion of the subsequent brainstorming meeting. If a team member proved to already implement the solution by the next meeting, the organization would move to the next risk to be managed. If the tried solution had proven to be difficult or impossible to be implemented, team members would brainstorm and schedule the testing of new solutions before postulating new risks to be managed.
Every iteration of strategically practicing the process of prospective problem- solving, as explained above, honed the organization’s current position-taking. In this dissertation, the term position-taking refers to the distinguishing features that make an organization truly exceptional in terms of its unique perceived benefits, such as its product and service offerings, constructed goals and identities, or target market and niche specialization. As the organization brainstormed what could potentially go wrong, it was forced to examine the risks it was willing to accept or deny. For every decision to accept or deny a proposed risk, the organization came closer and closer to understanding not only its future roles and responsibilities, but also its imagined target market and desired niche specialization. Additionally, by implementing solutions to foreseeable problems, the organization was able to zoom in on what client services would be possible or impossible in the mercurial landscape of Rio de Janeiro post-global events. Once organizational team members began demarcating the purview of what they believed clients would desire in an extraordinary medical travel experience, which they accomplished via prospective problem-solving, so too did the organization begin to construct goals and identities, propelling its position-taking to come into clearer view.
123 Since the predictive categories of risks, solutions, and requisites discussed in this chapter eventually guide the selection criteria used by team members to vet service providers and their respective facilities, which I discuss in Chapter 5, the organization’s position-taking continues to be fine-tuned during the negotiation process with candidate providers regarding service offerings.
124 Chapter 5: Managing Partnerships by Affirming Amenability
Service delivery organizations may choose to outsource providers to successfully render high quality services to clients. In determining which service providers to outsource, organizations must carefully establish selection criteria for which to choose candidate providers. Organizational selection criteria serve to measure whether a candidate provider is capable of delivering services to the quality commensurate to the value sold to clients. After finding candidate providers that meet organizational selection criteria, organizations must then vet candidates with whom to contract and partner.
Contracting multiple service providers requires effective and strategic organizational partnership management.
In this chapter, I show how team members of a medical tourism start-up organization developed and managed a network of candidate service providers. First, team members verified that each candidate had met basic organizational selection criteria, as determined from prospective problem-solving exercises in brainstorming meetings depicted in Chapter 4. Next, over a series of site inspection and negotiation meetings, team members informally tested candidate providers’ capacities for long-term partnership. To test a candidate for long-term partnership capacity, team members would repeatedly and knowingly assess whether candidate partners were amenable to negotiation or not. Team members perceived candidate partners’ timely response to constructive organizational feedback, generally by implementing changes to operational protocols to reflect the ideal protocol of the organization, as a sign of a provider’s
125 amenability to negotiate or not. Team members interpreted a provider’s greater propensity for amenability to negotiate with a greater capacity to be a high quality long- term partner in the future. Once candidate providers proved they were amenable to negotiate, they would be on-boarded and contracted to fulfill services. Conversely, in the event that candidate providers demonstrated that they were not amenable to negotiation, they would be dismissed as candidate service providers. In the context of this dissertation, I call this organizational process of determining whether a service provider would be a high quality long-term partner as “affirming amenability.”
I argue that team members repeatedly and purposefully practiced the key strategy of affirming amenability with every candidate provider to refine the organization’s overall position-taking to secure its competitive advantage in the marketplace. In this dissertation, the term position-taking refers to the distinguishing features that make an organization truly exceptional in terms of its unique perceived benefits, such as its product and service offerings, constructed goals and identities, or target market and niche specialization. Team members efficiently deciphered the factors they considered essential to fostering meaningful, long-term, mutually beneficial partnerships by onboarding service providers that already demonstrated their willingness to negotiate (objective 2).
Team members then gauged perceived partnership characteristics as a guideline or baseline from which to further select and manage their ongoing network of service providers (objective 3). Over time, as the network of highly qualified service providers grew, the organization’s position-taking became greatly enhanced and more refined, as anticipated and unanticipated available services were made known through agreed upon contractual negotiation terms. I further argue that while this strategy could be
126 generalized to other industry defining start-up organizations, this organization was able to successfully practice this strategy because of one opportunistic advantage: the pooling of candidate providers who were negatively impacted by the aftermath of the FIFA World
Cup and the Rio Summer Olympics.
The strategy of affirming amenability was performed in many ways. For example, organizational team members determined that a primary requisite of a long-term partnership was selecting service providers that did not outsource their own services.
Team members consistently cross-checked this requisite by monitoring the actions of candidate providers. One action that was perceived by team members as being amenable to negotiate was the provider consistently lowering the pricing of their services to be rendered to the organization. In observing providers’ intentional lowering of prices, team members inferred that providers possessed three highly valued characteristics of a long- term partner: flexibility, enthusiasm, and receptiveness to innovation. These characteristics were subsequently used to monitor whether the service provider would ever be subject to network dismissal in the future.
For every provider added to or removed from the provider network, the organization’s position-taking was further refined according to the availability and quality of lower cost services sold to clients. Therefore, team members perceived a greater insulation from future competition once they amassed more quality partnerships.
Armed with long-term partnerships with the best local providers at considerably low costs, team members considered their product of available services to be superior to what could be offered by any new local competitor in the future.
127 In this chapter, I give an ethnographic description of the standard protocol of site inspection and negotiation meetings. I present narrative and observational data gathered from participant-observation, continuous monitoring, and semi-structured interviews from numerous site inspection and negotiation meetings with organizational team members and candidate and partnering service providers. To trace the intra- organizational practice of affirming amenability, I divide the service provider selection process into three non-mutually exclusive categories: fixed preparedness, high supply and low demand, and insourcing of services. These three categories subsume team members’ perceived fundamental requisites of a quality partnership, the observable actions taken by service providers to prove dedication to the organization, and the characteristics of a valued partnership inferred from such actions. I conclude this chapter with a model of the process of affirming amenability, and an explanation of how the routine practice of this key strategy by team members helped to refine the organization’s current and future position-taking and competitive market advantage.
Standard Protocol for Selecting, Onboarding, and Dismissing Providers
After two months of brainstorming meetings, team members felt adequately prepared to start the lengthy process of recruiting health care providers, medical facilities, and hotels to join their preferred network of medical tourism service providers. In an interview with Alexandra immediately before the first site inspection meeting, she explains the overall purpose of the site inspections:
“It’s not enough to partner with vendors over the phone. In Brazil, business partnerships take a very long time to establish. There will be multiple meetings, definitely, if we decide to go forward. Both sides must spend a lot of time getting to know each other to build reciprocal trust. We [organizational team members] have to do site inspections to obviously see if we can use them or not, like if their
128 facility is old or modern, test the English of the staff, walk around the location, see what they have to offer, and if we need to make a lot of changes or not. Things like that. But the real reason we do site inspections is to see if they are good people or not to invest in, and entrust our clients’ welfare when we are not present.”
This quote suggests that site inspections are pivotal in laying the preliminary groundwork for establishing a long-term partnership with a service provider. While the site inspection functions as a formal organizational procedure for evaluating what the candidate provider can offer the organization or not, the site inspection serves a more tacit purpose: to discern whether the candidate warrants all of the considerable time and effort required to nurture a long-term partnership or not. In other words, the goal of the site inspection was not only to see the facility “as is” and assess its “barebones,” but to also gauge upper management’s initial capacity for long-term partnership.
For eight months, I accompanied team members on 42 different site inspections
(23 medical facilities and 19 hotels). As a general rule, all team members were responsible for researching potential facilities one to two weeks prior to scheduling a site inspection. Team members would always start with referrals from their immediate professional network. Since site inspections required considerable time off work to conduct, team members had to prepare a convincing rationale, normally in terms of a cost-benefit analysis, to justify why the candidate was “worthy” of such a time-costly site inspection.
Once all team members agreed to move forward with a site inspection, Lucas was always in charge of making first contact with the potential partner. During the “cold call” to the new candidate, Lucas would invariably have to describe the concept of medical tourism at length, and the premise of the organization at least three times before the
129 candidate provider could understand the organization’s business venture. The first description was typically to administrative personnel, the second to a director of sales or operations, and the third was to the owner of the facility, unless of course a team member already knew or had a direct connection to the facility owner, in which case Lucas would go directly to the owner. Even in the event that Lucas could make direct contact with the owner upon first attempt, he still found himself having to explain everything again to the facility’s director of operations or sales.
Lucas was inadvertently charged with having to “prove” or “persuade” the potential candidate of the organization’s expertise and authority to successfully organize a comprehensive medical tourism network before the candidate would propose a meeting.
Lucas describes how he would have to “sell” the concept of medical tourism and his organization to the facility’s upper management to secure a site inspection meeting, and why he thought this was necessary every time:
“Nine out of ten times, nobody knows what medical tourism is. I have to explain it to everyone. It normally takes me three or four times for someone to understand it. I have to frame my description in a way for the owner, director, or secretary to arrive at the conclusion of what this opportunity can do for their business- expand their clientele, guarantee monthly income, and improve their reputation, etc… Because we all know they need it. It takes a while. I would say that twenty-five percent never make that connection, so they are not interested. They always say no because they do not truly understand its [medical tourism’s] potential. All they see are liabilities and hard work. To try to convince them otherwise, I talk about statistics in the industry from other countries, like how many people [foreign patients] do this per year. I also explain who is involved in our organization- throw around names, so they can see who they are really dealing with- that our project is not basic. It’s very legitimate. Then I can tell they are interested, and I know I got them. They always ask when they can schedule to meet with us.”
This interview excerpt highlights team members’ first barrier to market entry: having to explain a novel industrial concept to already prestigious, and presumably cognizant, professionals in either the medical or hospitality and tourism sectors. As seen here, Lucas
130 relied on two strategies to gain initial access, in the form of a site inspection, to prominent, yet circumspect, service providers: (1) reporting of industry facts and statistics to substantiate a lucrative business opportunity; and (2) describing the overall qualifications of his fellow organizational team members to corroborate a high probability of success. While both strategies were generally required to successfully get candidate providers to understand the basic premise of the organization, only candidate providers making the connection that the medical tourism industry could only improve, not hinder, their current business growth were interested in proposing a site inspection meeting.
All site inspections followed the same basic format. On average, a site inspection would typically last three hours. Even though the tour of the provider’s facility would last only half an hour, it was obligatory for team members to sit down with the facility’s owner, manager, or director of sales (DOS) or operations (or at times all three), either for lunch, dinner, or a lanche (snack), and the always compulsory cafezinho (espresso).
During this time, candidate providers would highly encourage team members to recount industry statistics and facts regarding medical tourism, and the organization’s plan to design a medical travel experience specifically for Americans.
Candidate providers would persuade organizational representatives why they should choose their facility over other candidates. Generally, owners and managers would invariably begin with what their respective facility had to offer the organization, typically focusing on its privileged location, imported technology, reputation and branding, and/or its history of serving Americans. The following quote from an interview with Antonio after a site inspection summarizes how team members typically
131 felt once candidate providers finally expressed interest in partnering with the organization:
“Once the owner understands the potential of what we are trying to do- you know, create an industry in Rio- and starts to piece together how accepting foreign patients may improve his business, that’s when we know we do not have to sell anymore. Instead, that’s when you have to be quiet. Candidates get really excited about the future, and want you to start verbally promising them opportunities to work with us.”
This quote illustrates that once candidate service providers express overt interest in the organization’s project, team members felt as though they had regained clout and leverage over the candidate provider. A feeling of vindication was ignited by no longer having to sell the idea of a novel, potentially lucrative industry to prominent providers. Instead, team members internalized their successful attempts to convert cautious providers into excited potential partners that outwardly expressed: (1) interest in a foreign new enterprise; and (2) confidence in the organization’s competency and capacity to successfully organize a formal industry in Rio de Janeiro.
Candidate providers pressured team members into making verbal commitments to work together as colleagues, as a sort of trial partner, once the provider realized the many ways in which medical tourism could enhance their overall business. In the end, team members would never succumb to the pressure applied by candidate providers, and therefore would never agree to anything at the first site inspection. Nor would a team member ever make suggestions or recommendations on how to improve the facility’s condition or operations to enhance the organization’s design of the ideal medical travel experience, as described in chapter 4. Instead, Alexandra had instructed all team members to gauge the owner’s “maximum,” the point at which the organization could benchmark the most leverage of power over a facility to acquire the maximum number of
132 concessions possible in future negotiations. To find this maximum, team members would aggressively inquire into the facility’s current state of profitability to see what the facility
“truly” had to offer the organization, as well as to instill doubt in the facility’s exaggerative claims of having high client demand despite the current economic crisis.
After performing the initial site inspection, team members determined if the provider warranted a subsequent site inspection and/or a negotiation meeting, signifying that the service provider was a potentially good candidate for partnership. Team members would normally make this decision within an hour of leaving the site inspection. Normally, the team member would determine the quality of a candidacy facility based on a complex calculus of the following factors (in no particular order): (1) the overall security and safety in and around the facility; (2) the perceived and communicated willingness of the owner or director to make bespoke accommodations on behalf of the organization to enhance future clients’ medical travel experiences; (3) the available capacity, space, and number of employees to accommodate future clients (for medical facilities only, the type and number of procedures that could take place within the facility at a given time were also considered); (4) facility cleanliness and modern decor; (5) walking distance to nearby services (i.e. restaurants, banks, grocery stores, shopping, etc.); (6) basic and luxury amenities available to clients; (7) new and outdated technology within the facility; and (8) the amount of “promised” services that were really outsourced by others (medical facilities only). The above calculus served as an initial selection criteria for candidate providers.
Team members were responsible for passing or failing candidate providers after the first site inspection. If a candidate successfully passed the first site inspection, the team
133 member who performed the inspection would recommend the facility to other organizational team members. Then, a different team member would schedule and perform a subsequent inspection of the facility. Once two team members recommended a candidate facility for incorporation into the service provider network, the iterative process of negotiations would commence. In the event that the facility failed its first or second site inspection, the team member denying its recommendation for partnership would explain to the facility’s owner or director that they would inform them of their plans to move forward in the upcoming months. As such, team members never outright externally rejected potential facilities after failed site inspections. Instead, failed site inspections only demoted candidate facilities to a lower priority status, allowing the organization to stockpile a list of second or third tier candidates for potential future use, in the event that a first tiered candidate was ever removed from the network.
Upon approval from two or more team members, Alexandra would notify the candidate provider that the organization would move forward with the negotiation process. All in all, I was present for 27 negotiation meetings split across 15 candidate facilities. Two organizational team members were present for every negotiation meeting: one of the former site inspectors, and Alexandra. Generally, negotiation meetings would consist of Alexandra, another team member who previously performed an initial site inspection, the owner of the facility, and maybe one or two project managers assigned by the owner or upper management to handle organizational business.
All negotiation meetings followed a similar format. On average, the first negotiation meeting would last anywhere from three to four hours in length. At this time, the candidate provider would provide an ideal “taste of” or “glimpse into” the quality of
134 services that could be offered to the organization’s potential foreign patients. For hotels, this generally included elaborate gourmet meals and beverages at on-site dining halls overlooking the beach, mountains, and city skyline. Meetings would generally start here, and continue into a private office following dessert and coffee for more one-on-one conversations concerning pricing. All hotel facilities offered team members complimentary services to “test for themselves” the great experience the hotel can offer its guests. For medical facilities, negotiation meetings would generally take place in private offices on-site, while the owner and his or her respective project managers would sit opposite from team members behind desks. Medical facilities would also offer team members free gifts in the form of elective medical or dental procedures. Team members were extremely hesitant of accepting such complimentary services at this stage, particularly prior to finalizing partnership negotiation terms. When asked why team members refused gifts prior to negotiations, Raphael responded:
“I do not want to give the impression that we are here to cheat anyone. I am very interested in knowing the quality of what each one [provider] can provide our future clients. We have (his emphasis) to know this before we bring anyone here. At this point in time, though, we don’t need to know how superior the services are in comparison to other providers. The more [services] we try out, the less power we have in negotiating good rates in the future, because they could say, ‘we gave you so much for free. Now it is your turn to help us.’”
This quotes illustrates that while the quality of services was extremely important to ascertain before negotiating partnership terms, team members did not want to give up any leverage in future negotiations by accepting complementary, gratuitous gifts.
The first negotiation meeting was always intense. Alexandra would begin the meeting with the positive reasons why the organization had chosen the candidate facility for potential partnership. Next, candidate providers were strategically asked a series of
135 questions designed to make the provider uncomfortable and to challenge the budding trust being established between the two parties. For example, Alexandra would inquire further into the facility’s next two or three-year business plan. Were there any forthcoming facility renovations, or changes to branding in the near future? Was the facility going to transfer ownership anytime soon? What were the sales projections in the next couple of years? After receiving satisfactory answers to her questions, if at all,
Alexandra would then request a current pricing list of all available services that were offered at the facility. The owner and project manager(s) would invariably deny such an early request, that is until team members would declare that the provider “was not serious about their proposal,” and would threaten to leave and remove them from the service provider network.
In fear of immediate, pre-mature dismissal, candidate providers would then request a makeshift price sheet (generally with exorbitantly high prices) from his or her project manager(s) for team member perusal. At this time, organizational team members would generally schedule another negotiation meeting for the following week, firmly requesting an amended price list prepared specifically for the organization. Alexandra explains why she feels that she must be extremely forthright and straight-edged with providers at negotiation meetings:
“In Brazil, people tell you want they think you want to hear. They will never give you their best offer in the beginning. We could spend weeks and weeks going through meetings of false promises and deals to be made (her added emphasis), and no talk of terms. If I ask questions that they are not prepared to answer, because they think I will skirt around the issue for weeks before asking, there is a greater probability of getting honest answers [from them]. Every time I have another meeting with someone, they [providers] have time to prepare what they think I want to hear, so they can avoid any issues we think are important. I need to know if they can offer what we need right now, and if they will be flexible in getting those things to me immediately. Above all, if they can not fulfill my
136 request right now, how will they be able to reach our clients’ needs on demand, especially when they change in the future?”
This quote explains the most frequently reported problem that organizational team members faced during negotiation meetings: provider procrastination to solidify partnership terms. Team members considered forthright answers to difficult and “socially impolite” questions to be a sign of knowledgeable experience, and flexibility to adapt to clients’ ever-changing needs in the future, both desired characteristics of a long-term partnership.
After proving to team members that candidates were in fact open to negotiation, team members would on-board providers as part of their service provider network. On average, providers required three meetings to agree on preliminary negotiation terms.
Even if team members were not completely satisfied with the preliminary negotiation terms outlined during these meetings, team members would temporarily on-board providers once they portrayed their ability to meet three fundamental organizational requisites of an excellent partnership: (1) demonstration of “good faith” to accommodate the exceptional arrangements deemed valuable to future clients (i.e. the requisites of a good medical travel experience formulated during brainstorming meetings from prospective problem-solving exercises, as seen in Chapter 4); (2) overt enthusiasm and gratitude for the opportunity to be at the forefront of a “promising industry”; and (3) trust in the organization’s expertise and authority to successfully organize and capitalize on future global market gains.
In the event that facilities never produced (or never even merely attempted to produce) any changes to their pricing by the second negotiation meeting, team members would immediately halt communication with the provider, informally dismiss them from
137 the network, and would then re-direct their attention towards new candidates. When asked why team members would discontinue negotiations after the second meeting if the provider made little to no effort in changing their pricing, Antonio responded:
“We don’t have time to waste. We have already been informing other providers of our plans to accept clients in the next few months. If these owners can’t lower their already ridiculously high prices, then they won’t be flexible to make other arrangements for us in the future. Sometimes here in Rio, people just tell you what you want to hear with no intention of following through once you walk away, probably because they don’t want to offend you, and they don’t believe in what you can do to begin with, you know.”
The above quote illustrates that team members internalized a provider’s refusal to negotiate competitive rates early on as: (1) a failure to adapt to unforeseen changes in the future; (2) a tendency to engage in “false promises”; and (3) a resistant display of skepticism and distrust in the organization’s capacity to assemble a lucrative medical tourism industry in Rio de Janeiro. As such, team members extrapolated the actions of candidate service providers as future predictions of partnership norms.
Once a provider moved from candidate to on-boarded status, team members would intermittently perform informal random site inspections by showing up unannounced to see the natural flow and operations of things. In the event a random site inspection would trigger a reason for another negotiation meeting, namely observing a break in negotiation terms with the provider’s current clients (i.e. maltreatment of clients by staff members, absent security guards), team members would enumerate the problems they had witnessed to the provider (generally the project manager), and request that the provider make timely changes to resolve the noted issues. Once the candidate service provider had successfully negotiated partnership terms with the organization and was officially on- boarded as a partnering service provider, team members would then “test out” and
138 “experiment” the complimentary services offered by providers during the first negotiation meeting. Team members would, once again, bring to the project managers’ attention any issues with the complimentary services, firmly requesting their resolution by the next meeting.
In the event that feedback was not “welcomed” by the provider, or that the provider refused to make any of the suggested organizational changes, team members would dismiss the provider from the network accordingly. In addition to ignoring team members’ constructive feedback, on-boarded providers faced network dismissal if they did not update team members on the following: (1) drastic intra-organizational changes and structural readjustments (i.e. the hiring, firing, or retirement of project managers or upper management staff); (2) revision to price lists and services offered; or (3) inter- organizational communication and/or development of side partnerships among other known partnering service providers. Therefore, team members routinely assessed on- boarded network providers for partnership potential, and would dismiss those who failed to demonstrate ongoing compliance to organizational requirements.
Organizational Review of Service Providers’ Partnership
Team members regularly conducted an organizational review of candidate providers during site inspection and negotiation meetings. The overall purpose of the review was to informally test whether candidate provider would be an excellent long- term partner to the organization. To test a candidate for being an excellent long-term partner, team members would assess whether the provider was amenable to negotiation or not. Team members interpreted a provider’s greater propensity for amenability to
139 negotiate with a greater capacity to be a high quality, long-term partner in the future.
Once candidate providers proved they were amenable to negotiate, they would be on- boarded and contracted to fulfill services. Conversely, in the event that candidate providers demonstrated that they were not amenable to negotiation, they would be dismissed as candidate service providers.
Table 3 outlines organizational team members’ extensive enumeration of perceived measures of partnership, as observed and reported from participant-observation and continuous monitoring of 42 site inspections and 27 negotiation meetings, as well as semi-structured interviews conducted before or after meetings. More specifically, Table 3 itemizes three empirical categories of fundamental requirements that team members valued when considering candidate service providers as potential partners. Additionally,
Table 3 lists the actions taken by service providers that signaled to team members the candidates’ continued commitment to partner with the organization, as well as the characteristics of an ideal business partner that were inferred by such actions. All of these perceived measures of partnership were developed after coding and sorting direct observations from site inspection and negotiation meetings, as well as from interview response narratives that occurred either before or after meetings.
140 Table 3: Perceived Measures of Partnership Selection, Allegiance, and Quality, as Determined by Organizational Team Members in Site Inspection and Negotiation Meetings
Empirical Category of Observed Actions Quality Partnership Fundamental Requisite Inferring Characteristics for Partnership* Partnership Allegiance Demonstrated
Assigning Competent Accountable Fixed Preparedness Employees as Project Risk Averse Managers Proactive
Disclosing Business Communicative High Supply, Low Demand Performativity and Transparent
Productivity Early On Credible
Discounting Prices
Adjusting Micro- Receptive to Innovation Insourcing Services Managerial Protocols Flexible Enthusiastic
Offering Unsolicited Amenities
*Empirical categories are not mutually exclusive.
Fixed Preparedness
The first fundamental requisite of a partnering service provider is fixed preparedness. Here, “fixed preparedness” signifies all of the immutable material and non- material resources in a candidate partner’s current possession that enables the timely delivery of high quality services to foreign patients. Starting with the requisites of a good medical travel experience generated from prospective problem-solving exercises during brainstorming meetings, as articulated in Chapter 4, team members created a list of minimal requirements for both hotel and heath care providers that would signal one’s
141 fixed preparedness to begin accepting foreign patients. All potential candidate service providers were required to meet both of the following basic provisos: (1) an exclusive geographic location (select neighborhoods in Rio’s South Zone and Barra de Tijuca in the
West Zone); and (2) a stellar reputation, as measured by branding, education, training, and English language proficiency. Team members refused to consider any health care provider that did not meet both of the aforementioned requirements in order to mitigate their risk of project failure in the future.
Team members only considered service providers located in Rio de Janeiro’s most exclusive neighborhoods in the South and West Zones, as these neighborhoods were perceived to be “highly touristy,” and therefore safe. An interview quote from Antonio explains why these neighborhoods were selected for their safety:
“Rio de Janeiro, like every big city in the world, has a problem with crime and violence. Since all of the wealthy neighborhoods are near the beach or the lake, for the most part, there is more infrastructure there for tourists, like hotels, restaurants, shopping, and the like. There’s more for them [tourists] to do. With more infrastructure and money, the area tends to be safer because the residents there pay for greater policing. So it’s safer when we have clients here walking around. We don’t have to worry too much about violent crimes, just maybe petty theft. We are trying to insulate them [future clients] as much as possible from problems, big or small. Also, if we only choose facilities close by, it will be cheaper and faster for them to get around, and if something happens, it will take less time to get them to another one of our facilities.”
As seen in this quote, team members were mitigating the potential risk of having to place clients in presumably unsafe, violent circumstances by strategically confining their search for partnering providers to areas of the city deemed safe because of established infrastructure and stricter policing. By confining their search for service providers to exclusive neighborhoods in Rio de Janeiro that are adjacent to one another, team members maximized their clients’ best interest in the following ways: (1) minimized the
142 financial costs of hiring a private transportation company; (2) minimized the amount of time spent being transported from one area of the city to another for appointments and accommodation; and (3) in the event of a personal or medical emergency, health care providers would be in close proximity to other partnering medical facilities and hotels.
Therefore, geographic neighborhood was considered mutually beneficial for the organization, its service providers, and future foreign patients.
Organizational team members considered exclusive neighborhoods resource rich in addition to be being safe and touristy. When asked why all of the service providers were to be concentrated in neighborhoods in the South and West Zones, Tomas explained:
“Well, everything is concentrated near the beach. Because mountains divide the city, many of the poorer areas are further from the beach. The majority of the best clinics, hospitals, and hotels are all near the beach or the lake. That’s where all of the money is. And since we, the city, is so divided by the mountains, real estate is pretty limited. That’s why so much of the new development has expanded beyond the South Zone and into the West Zone, you know. They have been developing Barra de Tijuca for a while now as a residential alternative to the South Zone, and the Olympics really took advantage of that area of Rio, like with the new Olympic Park built out there. So many hotels were built up out there, and even hospitals and consultórios (consultation offices). And many shopping malls. It looks like an American suburb almost doesn’t it? It’s definitely safer to be in the West Zone than in the Centro (downtown) or the North Zone.”
Here, Tomas explains that Rio de Janeiro is drastically divided physically by natural geography, which has contributed to the high concentration of quality medical, tourism, and hospitality resources to be isolated in privileged neighborhoods near the beach. This quote also explains why the organization has widened its selection of service providers beyond the ritzy, glamorous neighborhoods of the South Zone and into the West Zone: many new hotel and medical facilities were developed to accommodate the 2016 Summer
Olympics games. Furthermore, organizational team members were adamant that all clients would require nice views while recovering for days or weeks from their health
143 procedures in Rio de Janeiro, and so therefore would only consider beachfront hotels.
All service providers were also expected to have an extremely high proficiency level in English. For potential health care providers, organizational team members considered having studied or completing medical education and training in the U.S. to have satisfied this requirement for health care providers. In an interview before a site inspection with a candidate health care provider, Maria explains, reflexively, why team members require such high English proficiency from their doctors, and why she values doctors who studied in the U.S. above other candidates that studied in Brazil:
“If I go to another country for a medical procedure, I would need to speak in my own language. It would make me feel more in control of my own body and health. If I didn’t understand what the doctor was saying to me, I would not go forward with my surgery or whatever. I need to know exactly what is going on at all times, and I feel like my doctor would understand me better if he spoke the same language and lived where I’m from, you know. Like you, Frank, you understand us [organizational team members and candidate providers] so much better because you’ve lived here for a long time, and vice versa.”
Interestingly, this quote explains that in order to closely bridge linguistic and cultural barriers expected between foreign patients and health care providers, team members believe that partnering service providers should not only speak the same language as patients, but also relate to them on a culturally experiential plane. As such, a candidate health care provider would maximize his or her odds for organizational partnership candidacy by proving his or her medical, linguistic, and cultural competency simply by showing completion of his or her training in the U.S.
Organizational team members valued American or internationally recognizable brands above Brazilian reputations, as team members considered foreign hotel brands to have proven measures of comfort, security, and specialized training to accommodate
American clients. It is important to note, once again, that all of these aforementioned
144 measures were determined iteratively from routine practice of prospective problem- solving during brainstorming meetings, as detailed in Chapter 4. However, in interviews occurring before or after site inspection or negotiation meetings, team members were more reflexive about what American clients would desire from providers by imagining what they, Brazilians, would want from a provider after paying for services they were sold. Periods of reflexivity in interview responses served to ground team members in the impending reality of having to care for foreign patients in the very near future.
Consequently, team members felt motivated to pressure candidate service providers about accommodating their rigid demands for high quality service delivery.
Organizational team members scheduled site inspections to observe a candidate’s potential partnership capacity. In the eyes of team members, simply meeting the fundamental requisite of fixed preparedness did not warrant the opportunity of long-term partnership alone. As described in the first section of this chapter, successful site inspection meetings would necessitate that candidate providers and team members hold several negotiation meetings to decide if providers should be on-boarded as organizational partners or not.
During the interim between site inspections and the scheduled negotiation meetings, the owner of the candidate facility would frequently assign one or two of his or her employees, typically the director of sales or operations, as a project manager to oversee the facility’s ongoing relationship with the organization. In an interview following an initial negotiation meeting, Alexandra describes the value of assigning project managers to the organization:
145 “I’m always very happy when I see providers take initiative and make changes before we even start our negotiation meetings. That tells me they [candidate providers] are serious about our project, and that they truly believe in it and want to work with us. When the owner brought in Katia [an assigned project manager], I was immediately pleased with him [the owner] after she started talking. She [Katia] is going to be excellent in case our clients have any issues when we are not there. I have a really good feeling about her, and now I feel better about this guy [the owner]. I was concerned about his English and if he was going to present problems for us in the future, but now that we have Katia, I know that they could handle the amount of people we are going to send in his direction. I can’t believe she works there to be honest! Her English was near perfect, and she spent over ten years living and working in Toronto and New York. Unbelievable! She’s perfect. We need to know that they can handle all of our clients’ problems, and make their own solutions to ones [problems] we don’t even know we will have. It makes a huge difference, I think, to have an internal person handle everything we need there. To have one extremely competent contact person there is definitely encouraging.”
This quote describes the tremendous value ascribed by team members in having internal contact representatives within candidate partners’ organizations. As seen above, team members interpreted the action of assigning a project manager, or internal contact representative, as a positive sign of a successful long-term partnership. More specifically, this quote highlights that team members frequently considered such an unsolicited action as a sign of the provider’s proactive work style. By assigning one or two project managers already based inside of the candidate’s facility to handle all future business transactions, quality control, and implementation of adjusted changes, team members perceived this action as solidly aligning with the organizational core values of risk aversion and accountability.
Team members’ confidence in the candidate’s competency increased, even after initial reservations, upon learning the project manager’s highly desired credentials. As such, project managers’ excellent credentials only catalyzed the prospect of entering into a long-term partnership with candidate providers. As a result, team members were able to
146 trust the candidate’s judgment in selecting only highly qualified personnel to accommodate the organization’s future clients.
High Supply, Low Demand
The second fundamental requisite of a partnering service provider is having a high supply and a low demand. Here, having a high supply and low demand means possessing a surplus of resources, such as time, personnel, and space, to deliver services to an already markedly low number of existing customers, thereby positioning providers to readily accept new clientele for business sustenance and growth. Given the overwhelming effects of the current economic crisis in Rio de Janeiro, compounded by having just had hosted two global events back-to-back, this requisite was not hard to fulfill for the majority of businesses in the city. In an interview before two site inspections, one of a hotel and the other of a small nearby plastic surgery clinic, Raphael explains why he believes the hospitality and medical industries have taken such a hard economic hit due to the current national crisis:
“Most of the doctors we are trying to secure right now perform elective procedures. All of these procedures are paid out-of-pocket. When you’re rich, you’re rich. The money you have to spend on unnecessary things is not affected all too much. Maybe slightly. But when you are middle class, you no longer have as much disposable income to throw around on luxuries like porcelain veneers, face-lifts, and Botox. Same with vacations. Since this economic crisis is affecting everyone in Brazil, many of these hotels are empty because many Brazilians cannot afford to travel to Rio right now. There are just too many hotels now in Rio because they were built for the games with the hope of more tourists coming. Now they [hotels] just sit there empty because Brazilians are not even traveling to Rio. All of this is even worse when you add in such high inflation. The cost to operate these hotels and clinics are getting extraordinary. I don’t know how many of them are still in business- they are completely empty.”
The above quote illustrates the current typical hardships experienced by the majority of hotels and medical facilities that were considered for partnership. In short, team
147 members considered the confluence of the political, economic, and financial crises in Rio de Janeiro, exacerbated only by the government’s recent unwise spending of billions of dollars on hosting the World Cup and Summer Olympics, to blame for facilities having a low demand for non-essential services, such as holiday hotel stays and aesthetic medical procedures.
Organizational team members purposefully targeted service providers who were negatively impacted by the aftermath of hosting global events back-to-back. When asked why the organization strategically pursued candidate providers facing an economic downturn, Alexandra responded:
“Well, from a business side it makes sense, right? They need business, and we found a way to potentially offer them a steady intake of clients without them having to find them. This alone gives power to negotiate. I think that once we finally get out of this economic crisis, and we [the economy] get better, we [the organization] will already have a strong partnership with the provider. They will continue to honor our agreements even when business is good for them, because we helped keep them in business, you know.”
This quote from a post-negotiation meeting interview highlights why the organization focused on service providers struggling to increase the demand of their services: to maintain the upper-hand in future negotiations, as well as to preserve the organization’s
“carrying capacity” in the future once the economy recovers and the providers do not depend on the steady influx of clients that the organization plans to bring. Team members assumed that candidate providers were not in an economically advantageous position to turn away potential business proposals, and therefore would make concessions in exchange for securing a steady stream of new clientele. Additionally, team members were averting their risk of potential failure once the economy recovers when the provider no longer becomes dependent on the organization’s direct line of referrals. At the same
148 time, however, team members believed that helping partnering providers survive the current economic crisis would only strengthen their long-term partnership, and encourage providers to honor the organization’s negotiation terms well into the future.
Team members would often probe the candidate provider for details regarding the current economic condition of their business. While these questions were meant to provoke honest answers from the owner to test their flexibility and transparency with organizational team members, these questions were also meant to further gauge the provider’s maximum ceiling of negotiation. An example excerpt from a site inspection of a hotel illustrates this tactic:
Alexandra: “This is truly a beautiful hotel. Everything looks so new and up-to-date. When was it built?” DOS: “It was built to accommodate the Olympics. We are super close to Olympic Park.” Alexandra: “What are your current occupancy rates, now that the Olympics are over?” DOS: “Well, we are very fortunate right now, unlike other hotels in Rio. It is a high rate. A steady high rate, even though it changes according to the season.” Alexandra: “Like what? What is the average percentage?” DOS: “It’s a high one. You know the other hotels are having difficulty right now.” Alexandra: “Yes, I know. We have already toured a dozen others. Many are your competitors. What is the average rate of occupancy?” DOS: “Which hotels?” Alexandra: “Many near you, but more are in a better location. What is your average rate?” DOS: “Well, I would say we average about forty percent occupancy at any given time- seventy in the high season.” Alexandra: “Ok. So you would have plenty of rooms for our clients then. Great.”
This dialogue exchange from a site inspection reveals how candidate providers were generally unwilling to discuss details highlighting their current state of high supply and low demand. Team members, however, tactfully pressured candidate providers to supply
149 such information to understand how much pressure could be applied to candidates in upcoming negotiation meetings regarding pricing. Furthermore, as an ancillary strategy to extracting information from candidate providers regarding their current rates of supply and demand, team members would never provide information about already on-boarded partners prior to negotiation meetings.
Team members would always refuse to divulge information about their previously on-boarded partners at site inspections if probed by candidates. However, team members greatly valued full disclosure, both solicited and unsolicited, of candidates’ business performativity and productivity, particularly in the midst of the current economic crisis.
Team members always expected candidate service providers to readily disclose information regarding their current business performativity and productivity, particularly their low demand for services. The following statement from Tomas explains why organizational team members refused to provide information about their current partners to potential candidates, and the exception to the rule:
“We purposefully try not to tell the potential vendors who we have already partnered with because we do not want them to communicate with each other until after negotiation terms are settled. It would not be in our best interest for some providers to speak with others because different providers have different thresholds for negotiating better prices and deals. […] The only time we tell them who we partner with is if their partnership depends on the quality reputation of another partnership.”
This quote indicates that team members strategically refused to name on-boarded partners with potential candidates out of fear of losing leverage at subsequent negotiation meetings. More specifically, team members were particularly concerned that candidate providers with a higher negotiation ceiling would settle on the higher prices negotiated with on-boarded providers with circumstantially lower threshold ceilings. Since no
150 service provider possessed the exact same immaterial and material resources to offer the organization (read: fixed preparedness), then it would be disadvantageous for the organization if all service providers negotiated the same terms for every partnership, as some services varied in mere quality. For example, team members did not want a four star hotel to demand the same pricing terms negotiated with a five star hotel located in the same neighborhood. For this reason, team members mitigated this risk entirely by purposefully waiting until after on-boarding a candidate provider before enumerating other partners in the service provider network.
The only exception to this rule, as indicated in the aforementioned quote, was in trying to appeal to a prestigious service provider to participate in the network. For highly reputable and sought after service providers, normally health care providers with a very niche medical specialization, team members would strategically “name drop” some partners to prove the legitimacy, seriousness, and exclusivity of the provider network.
However, these prestigious service providers could be classified as outliers when compared to the typical candidate provider, as these individuals always possessed a high supply and a high demand given their unique expertise and high costs.
Failure to divulge business information was viewed by team members as a sign that candidate providers would engage in “false promises” with no intention of honoring negotiated terms in the future, the antithesis of a preferred long-term partner. Moreover, candidates’ hesitance or outright refusal to answer economic and financial questions regarding their business operations signaled to team members that potential providers could not be trusted, the cornerstone of a quality partnership in the eyes of team members. Conversely, organizational team members viewed full disclosure of the current
151 state of business operations as a token of valuing transparency and communication. In being pressured to truthfully describe the livelihood of one’s business operations, candidate providers proved their overall credibility to organizational team members, only compelling the development of a long-term partnership.
Insourcing Services
The third fundamental requisite of a partnering service provider is insourcing services. Here, insourcing services refers to offering and delivering all provider services in-house, and not relying on the outsourcing of additional sub-contractors to fulfill the services negotiated with the organization. During site inspection and negotiation meetings, team members routinely asked candidate providers they owned and operated all of the resources required to render services directly to future clients. Generally, these resources referred to expensive new technologies necessary to carry out in-office medical and dental procedures. For hotels, these resources included equipment and employees required to run spas, restaurants, and beachside and transfer services. When I questioned
Alexandra after a negotiation meeting why candidates were required to demonstrate direct ownership of resources, she replied:
“Here in Brazil, many people say they have immediate access to anything and everything you are looking for. They just want your business. They always say, ‘yes we have that,’ when in they don’t, especially during the crisis. What happens is they find other people who have what you need, contract that person, and then charge a finder’s fee for doing nothing. We are the broker. We do not want any other middle-men. The more people we contract, the more we must manage. If we contract someone for a service, and they can not provide it immediately when we require it, it only wastes time while the patient is here for a short period of time, and then we lose credibility with the client, especially if the client pre-pays us and we can not deliver a service we already charged for because of another person we do not know. Also, we will get cheaper prices if we talk to the owner of what we need. It cuts out headaches and another person to negotiate with. Negotiations in Brazil take a long time.”
152 This statement describes the common practice of outsourcing providers for services in
Rio de Janeiro, and the problems that ensue from doing so. As seen above, service providers frequently make innumerable claims, assurances, and promises that they can render all of the services needed by the organization. Only upon requesting to view the materials required to perform contracted tasks (i.e. laser machines for minimally invasive or non-invasive cosmetic procedures, laboratory and diagnostic equipment for routine pre-surgical evaluations) would team members realize that providers might only be offering indirect access to services via outsourcing. In other words, some service providers might not own the materials outright, and therefore not have direct access to the necessary equipment or support whenever they need it.
It was not uncommon for health care provider candidates to report leasing, borrowing, or cost-sharing any or all expensive imported technologies with other physicians. For team members, contracting service providers who also outsource materials adversely exposes the organization to the following risks: (1) loss of quality control of outsourced services; (2) loss of credibility among clients if outsourced services are not rendered as sold; and (3) loss of financial control if outsourced services surpass agreed upon rates outlined in negotiation meetings with on-boarded partners. Therefore, team members perceived a candidate’s direct ownership of materials and technologies as a positive sign of being a risk adverse partner. For team members, partnering with providers with direct access to services guaranteed the organization confidence in promising desired services to future clients in a timely manner.
As seen earlier in this chapter, team members would begin to discuss pricing at the first negotiation meeting. Typically, service providers would price their services at
153 exorbitant prices. Alexandra explains why candidate providers would start their negotiation with such high pricing:
“Many of these owners hear ‘medicine’ and ‘tourism’ and think they will make a lot of money. But when we say we are focusing on Americans, and they know the Americans have a strong dollar right now, they raise their prices so much because they think they [Americans] will pay it. It is absolutely ridiculous. We have to remind them [providers] that their facility is completely empty [her emphasis], and has been like that for over a year. It is really simple. I do not understand why they will not make any [of the] changes we ask for. But, you know, to think they can make that [her emphasis] amount of money is crazy, especially without us! No one would pay that. They do not understand that they [clients] must also pay for the trip to Brazil, and that the reason they come here in the first place is because it is cheaper! It is so frustrating. We do not want to partner with anybody who does not understand basic economics.”
This quote illustrates that service providers rarely considered the total cost of patients’ medical travel as part of determining pricing for their services. Instead, providers would price their services according to what they thought Americans were capable of paying. In choosing to provide revised pricing lists at the second negotiation meeting, providers signaled to team members that they were flexible in their negotiation terms, another benchmark of good partnership. Additionally, the act of lowering prices revealed to team members that candidate providers were being overtly enthusiastic about being at the forefront of a promising new industry, and receptive to fostering innovative ideas.
Team members perceived candidates’ direct ownership of materials as great flexibility in not only just pricing services, but also in making (un)anticipated changes to standard protocols in which services were typically delivered. For example, team members were frequently observed providing ideas of how to streamline the administration of many cosmetic medical and dental procedures in-office to make clients more comfortable. Since service providers were not required to follow the rules, regulations, or policies of another contractor who owned the medical device for
154 performing any given procedure, doctors were able to re-evaluate and refine their service delivery protocol according to the desired preferences of the organization. By accommodating and revising proposed organizational changes to the provider’s micro- managerial protocol of service delivery, service providers signaled to team members their inclination toward innovation, and their eagerness to make flexible concessions for the sake of bettering the foreign patient medical travel experience in Rio de Janeiro.
Lastly, team members were consistently impressed with service providers who proposed to offer future clients with complementary amenities. Amenities ranged from bundled medical services to room upgrades and welcome packages. Service providers only proposed amenities that could be delivered in-house, precisely to limit providers’ dependence on outsourced materials. For team members, the act of making the client’s experience extra-special at no cost signaled that providers were truly invested in the long- term success of formalizing a local medical tourism industry, and the overall position- taking of the organization. By default, team members considered providers highly receptive to innovation, enthusiastic about entering into a mutually beneficial partnership, as well as extraordinarily flexible to provide free services. Team members consistently noted these perceived valued characteristics of a quality partner during interviews.
Routine Practice of a Key Strategy: Affirming Amenability
As depicted in all of the above direct observations and excerpts from site inspection and negotiation meeting transcripts, team members underwent a patterned process of recruiting, selecting, and managing service provider partnerships in Rio de Janeiro.
Figure 2 outlines this patterned process, and is described at length below. Here, I refer to this process as affirming amenability. In the context of this dissertation, affirming
155 amenability is defined as regular organizational review of candidate service providers’ and on-boarded partners’ dedication to successfully support a novel local industrial enterprise, as measured by continuous demonstrations of willingness to negotiate and foster long-term partnerships.
Figure 2: The Process of Affirming Amenability of Service Providers, as Routinely Practiced by Organizational Team Members during Site Inspection and Negotiation Meetings
Observe Assess Deduce Minimum Demonstrated Partnership Requirements Dedication Capacity
As seen in Figure 2, organizational team members would first identify a list of fundamental requisites, an overall baseline, for choosing candidate service providers to deliver services that, when taken together, would make up the ideal medical travel experience, as designed and discussed in Chapter 4. This list of minimal selection criteria requirements, also referred to as fixed preparedness, to join the organizational partnership network included an exclusive geographic location confined to specific neighborhoods in the South and West Zones of Rio de Janeiro, and a stellar reputation, as measured by branding, education, training, and English language proficiency. A candidate’s fixed preparedness requirements were all generated from multiple brainstorming sessions by
156 routinely practicing a key strategy of prospective problem-solving, as articulated in
Chapter 4.
Organizational team members would perform site inspection and negotiation meetings on location at providers’ facilities after selecting candidate providers from the basic criteria above. During both meetings, team members would adjudicate whether candidate providers satisfied two additional fundamental requisites for long-term partnership: (1) being negatively impacted by the economic crisis in the form of having a high supply and low demand for one’s services; and (2) insourcing all services. Since site inspection and negotiation meetings were always physically conducted at providers’ facilities, team members considered it compulsory to visually observe that all fundamental requisites had been satisfied first and foremost.
Next, team members would measure a candidate service provider’s allegiance to the organization by witnessing if the provider purposefully engaged in numerous actions, either solicited or not by the organization. In performing such acts, service providers demonstrated their capacity to negotiate and foster long-term partnerships with team members at multiple site inspections and negotiation meetings. The five actions performed by candidate service providers that were inferred by team members to demonstrate dedication to the organization were: (1) assigning highly qualified employees to serve as project managers for organizational business; (2) disclosing business performativity and productivity reports early on in the recruitment process; (3) lowering prices for services rendered; (4) making greater adjustments to micro- managerial protocols; and (5) offering complementary amenities to prospective clients.
By performing the aforementioned actions, service providers signaled to team members
157 that they possessed the highly valued perceived characteristics of a long-term partner.
Uncovered during pre- and post-meeting interviews, these characteristics were enumerated by team members as being: accountable; risk averse; proactive; communicative; transparent; credible; receptive to innovation; flexible; and enthusiastic.
Every iteration of strategically practicing the process of affirming amenability, as explained above, honed the organization’s current position-taking. In this dissertation, the term position-taking refers to the distinguishing features that make an organization truly exceptional in terms of its unique perceived benefits, such as its product and service offerings, constructed goals and identities, or target market and niche specialization. As the organization continued to recruit, vet, on-board, and dismiss candidate and partnering service providers, it was forced to determine which risks and services it was willing to accept or deny. For every decision to accept or deny a proposed risk and service from a prospective or current provider, the organization refined its list of service offerings, and its overall process of constructing the ideal medical travel experience for foreign patients in Rio de Janeiro. In respect to medical tourism, the organization’s overall product is only as good as the providers delivering its services. By continuously practicing the strategy of affirming amenability, which inherently cross-checks the ongoing validity and reliability of its prospective and current partners, organizational team members not only fine-tuned its position-taking in the present, but it also projected the refinement of its position-taking well into the future. In safeguarding the continuity of its position-taking, the organization enhanced the source of its true innovation and competitive market advantage: long-term partnership. As will be described in Chapter 6, the continuous development of the organization’s position-taking, through risk and partnership
158 management as seen in the past two chapters, propels and secures its competitive advantage into the future. The organization always attempts to secure its competitive advantage in the future, as it desperately tries to gain footing and traction in an economic, social, and political environment wrought by rapid tenuous changes.
159 Chapter 6: Practice in Action: Demarcating the Organizational Field
Inherent in every good ethnography employing Bourdieusian organizational analysis is a selective description of not only the organizational field in question, but also an attempt to understand its boundaries. One would be remiss in thinking that an organizational field’s boundaries can be merely operationally defined. Any field’s boundaries are relationally determined to the extent in which power relations occur within the field itself. To ignore the power relations that operate within a field, and the overarching structures that shape such power interactions, would border on nominalism instead of interactionism, the opposite goal of Bourdieusian organizational analysis.
Many neo-institutional ethnographies have been criticized for being overly nominalistic and less interactionist in their analyses. The tendency to be overly nominalistic likely stems from having divorced Bourdieu’s fundamental tenets of habitus and capital from one’s conceptualization of field (Emirbayer and Johnson 2008). After all, according to
Bourdieu, one should take a dialectical approach of looking at how structures and social actor interactions mutually presuppose each other through the conduits of capital exchange and habitus (re)filtering (Bourdieu 1977, 1986, 1990, 2010).
Taking an interactionist approach, then, suggests that an organizational field’s boundaries are not congruent with the boundaries of a particular industry. Instead, an organizational field’s boundaries may bleed and extend further into other industries
(Emirbayer and Johnson 2008). For example, in this dissertation, the organizational field broadens beyond the medical tourism industry per say, as the success of the industry
160 depends on agents from multiple industries, namely from the health care, tourism, hospitality, and transportation industries. I believe this is the primary reason why the network of doctors I interviewed in 2014 were unsuccessful in creating such a strong network of medical tourism providers. The doctors’ concentration of agent selection was strictly confined to the medical sector, and not other tourism sectors. As such, one must empirically, and therefore repeatedly, inquire into the ever-changing temperospatial exchange of power relations among interactive agents to fully understand the mutable boundaries of a field. Also, one must understand the intentions behind why agents strategically add or remove other agents to the organizational field. To do this, it is imperative to account for not only the current social actors that operate within a field, but also the historical agents that have been forcibly dismissed or voluntarily removed from the field (Emirbayer and Johnson 2008).
The ethnographic vignettes documenting the developmental process of a nascent organizational field in chapters 4 and 5 illustrate a selective interactionist description of the organizational field. Documenting the developmental process of a nascent organizational field is rarely available to the ethnographic researcher because of access to high-level executives. Therefore, these vignettes provide significant theoretical and corporate implications for newly minted organizations requiring industry collaboration.
Here, I describe how the iterative process of formulating a formal network of medical tourism service providers, controlled tightly by a fledgling non-state civil society health organization, maps the development of an organizational field.
To incorporate a true Bourdieusian organizational analytical framework into one’s ethnographic description and analysis, researchers are required to map out continuous
161 changes to the organizational field, replete with portrayals of meaningful events (either quotidian or intermittent, major or minor), and the structures that confine and enable them to thrive or strive (Emirbayer and Johnson 2008). A field is only as relevant as the agents that participate within it. Therefore, ethnographic descriptions using Bourdieusian organizational analysis must also convey how power configurations mutually inform and affect how agents’ develop their habitus (both individual and organizational), and employ key strategies (agency) to design and manipulate field doxa to accumulate capital
(Emirbayer and Johnson 2008).
As such, this description focuses on the configuration of power relations, and the structures that both restrict and enable such interactions from occurring. Figure 3:
Theoretical Model From Bourdieusian Organizational Analysis delineates the theoretical model of how this organization routinely created, challenged, and altered the boundaries of the organizational field. Informed by a Bourdieusian organizational analytical perspective, this model explains how power was configured, enacted, exchanged, and transferred via habitus (re)construction, doxa acceptance or rejection, and agent (re/de)selection.
162
Figure 3: Theoretical Model From Bourdieusian Organizational Analysis
Organization Legend
(1) Organization Forms Habitus (1) (2) Habitus Establishes Doxa (3) Doxa Pre-Selects Agent (4) Agent Protects Habitus
Habitus (5) Habitus Confirms Agent
(6) Agent Accepts or Denies Doxa (4) (2) (7) Doxa Refines Habitus (8) (7) (10) (8) Habitus Approves or Dismisses Agent (9) Agent Modifies Field Boundary (5) (6) (10) Field Boundary Re-Structures Agent Doxa Organization
(3) Exchange of Capital
(9)
Field Boundary
163 The ethnographic description presented above outlines three phases of constructing a network of medical tourism service providers: (1) market forecasting; (2) recruiting candidate providers; and (3) negotiating with and managing the expanding network of service providers. Respectively, these three phases could broadly be interpreted in
Bourdieusian terms as organizational habitus construction, agent selection, and doxa compliance. In applied corporate terms, the process of building a provider network could be seen as establishing: (1) a reputable brand identity and authority; (2) quality partnerships that insulate, protect, substantiate, and enhance the organizational brand; and
(3) negotiating terms and policies that regulate ongoing partnerships.
An initial understanding of how field boundaries are demarcated by way of the habitus, agent, and doxa would be incomplete without the notion of capital. In
Bourdieusian organizational analysis, one conceptualizes capital not only in terms of financial currency, but also in social relations. Therefore, capital exchanges may involve economic trade of material resources, such as financial goods and services, but they always include the leveraging of immaterial resources of socially and culturally prescribed value (Bourdeiu 1977, 1986, 1990, 2010). In describing the flow of Figure 3,
I present numerous forms of intangible capital at play in this organizational field, both intra- and inter-organizationally. Outlined in ten steps, I delineate a snapshot of how the organizational field’s boundaries are modified by capital exchange, habitus, and field doxa and agents.
Step 1 of the theoretical model refers to the initial establishment of the organization and the construction of an organizational habitus. I would argue that the organization informally started when two team members, Alexandra and Lucas, first came together
164 with the goal of finding strategic partners two years ago. Although, one could argue four years ago when they both agreed on working towards the same goal of mobilizing a medical tourism industry in Rio de Janeiro. As the organization grew to six members over the past three years, one could see a natural hierarchy forming based on two characteristics: seniority (the order in which team members joined the organization), and the cultural and social capital they brought with them to the organization (that is, the unique value they brought with them to the team). As such, all team members entered the organization with their own individual habitus, already refined by their own educational, linguistic, human, and economic capital that had uniquely oriented each team member to different life experiences, which would ultimately come to shape the overall habitus of the organization.
Step 2 of the theoretical model refers to organizational team members experiencing greater agency in designing their own field doxa. In addition to political and economic structures, agents’ habitus are generally restricted by legal, administrative, and bureaucratic structures, among others. The establishment of the organization as a legal entity demands that the organization be held liable to existing Brazilian and international medico-legal and bureaucratic structures. Bourdieu would call these controlling structures of what agents can or cannot do “a space of possibles and impossibles” (Bourdieu 1996:
236; Stringfellow and Maclean 2014). However, the medical tourism industry is still highly unregulated, both nationally and internationally, unlike other organizational fields that transect already established (hybridized) industries (Cortez 2012). Therefore, team members were allowed greater flexibility in designing field doxa precisely because they had limited accountability to non-existent state-regulatory structures governing the
165 medical tourism industry.
Some neo-institutional theorists have argued that true innovation comes from solving problems within strict structural control (Emirbayer and Johnson 2008). While true for many established industries, organizational team members were able to devise innovative solutions inductively through prospective problem-solving. Prospective problem-solving was strategically enacted by team members to help navigate them through a novel space devoid of overly litigious legal, bureaucratic, and administrative structures in the medical tourism industry. As such, team members’ repeatedly revealed an enormous propensity to proactively create novel solutions to minimize future risk despite a dearth of overwhelming restrictive state-regulatory structures. The propensity to predict and then prevent risk came directly from team members’ past experiences of working in industries, namely, medicine, law, and finance, with well-documented overarching restrictive structures. As such, team members were informed by their individual habitus to navigate throughout an unregulated space. One could deduce, then, that team members’ individual habitus constructively oriented them to engage in the key strategy of prospective problem-solving to protect the collective habitus in the future, that is the organizational habitus.
During numerous brainstorming meetings, team members iteratively developed the preliminary doxa of the organizational field via intra-organizational task formation and delegation. Team members also developed preliminary doxa to mitigate future risks in the form of “predicted solutions,” as outlined in Table 2. These predictive solutions enabled team members to construct an initial set of selection criteria that would later guide provider (read: agent) selection.
166 Brainstorming meetings allowed not only the construction of preliminary field doxa, but also, subsequently, the organization’s emerging “position-taking” (Emirbayer and Johnson 2008), as structured by the slowly maturing organizational habitus. In applied corporate terms, a Bourdieusian description of an organizational position-taking could be translated into the mission, core values, vision, and/or products or services of an organization. Based on numerous hours of participant-observation and continuous monitoring, as well as interviews and selected transcripts from brainstorming meetings, organizational team members engaged in a key strategy of prospective problem-solving to fashion a unique position-taking in the medical tourism market. The position-taking crafted by team members was a comprehensive, affordable, and luxury package of services for foreign patients that was, above all, incredibly safe, and culturally and medically proximate to the consumer. To accomplish this position-taking, team members utilized their cultural and social capital to first find, vet, and select potential providers according to previously formulated intra-organizational doxa. The process of finding, vetting, and selecting potential providers is Step 3 of the theoretical model in Figure 3.
As team members began to engage in social relations with other organizations in pursuit of creating long-lasting, mutually beneficial partnerships, an ethnographic shift occurred. The development of an intra-organizational field (a longitudinal ethnographic approach) shifts to the initial construction of an inter-organizational field (horizontal ethnographic approach). Even though the ethnographic focus shifts from one field to the other, this does not suggest that the intra-organizational field ceased to function. Instead, both fields operated concurrently, if not semi-autonomously.
Step 4 of this theoretical model refers to the process of candidate providers
167 conveying their value to the organization’s provider network. One should not ignore the fact that a highly developed, autonomous intra-organizational field had already long been established in providers’ organization(s) well before the initial site inspection.
Throughout the course of the initial site inspection, candidate providers consistently oriented themselves to perceive and thoroughly understand the position-taking of the organization. Candidate providers attempted to understand the organization’s position- taking to convey their dedication to bolster, if not dramatically improve upon, the position-taking outlined by the site inspector. Candidate providers were able to infer what they believed the organization’s position-taking to be because of their own respective organizational habitus in tandem with the human and cultural capital they accumulated in their individual past.
Some candidate providers were more successful than others in perceiving the organization’s position-taking. Candidate providers’ understanding of the organizational position-taking was dependent on two factors. The first factor was the capacity of the organizational team member to successfully articulate, communicate, and demonstrate the organization’s overall position-taking to the candidate. The second factor was the candidate provider’s own (limited) enactment of human and cultural capital as dictated by their individual and organizational habitus. For example, some candidate providers were perceived by team members to lack the fundamental cultural capital to adequately answer questions about their current state of profitability. Failure to answer such intrusive questions about internal business operations was viewed by team members as a subversion to the organization’s leverage of power over the candidate provider.
168 Step 5 of the theoretical model refers to the process of modifying the organizational habitus. Upon the completion of the initial site inspection, team members utilized a complex calculus to determine if they wanted to move forward in on-boarding a candidate provider or not. Through a Bourdieusian organizational analytical lens, team members were “filtering” the pros and cons of on-boarding providers by way of their organizational habitus. Filtering candidate providers based on organizational selection criteria forced team members to consistently reflect and re-constitute their organizational habitus experientially in order to map the organization’s immediate and future trajectory in the market place. Therefore, the refining of the organizational habitus in this way compelled their competitive market advantage.
During the initial negotiation meeting, Alexandra and one of the site inspectors, would continue their intrusive questions about the fiscal well-being of the provider’s organization. In so doing, team members were powerfully claiming negotiation capital, while testing out their more refined form of symbolic capital: trust in organizational competency. To team members, the most valuable reward was trust in their social and cultural capital to successfully construct a formal medical tourism industry locally. Since team members were in the “start-up” phase of the organization, they could not provide actual, only anecdotal, evidence to potential partners that they would be successful in carrying out their position-taking. For team members, the ultimate sign of quality partnership was witnessing providers’ willful and enthusiastic acknowledgement and acceptance of team members’ symbolic capital.
Trust in organizational competency extended to future clients as well. Considered the greatest privilege to team members, a foreign patient’s trust in their capacity to
169 arrange “the best Brazil has to offer” in terms of comprehensive medical travel packages was key. Having an imagined client trust would signify not only to the organization and their network providers, but to all of the effortless future referrals generated from patients’ positive experiences, that team members were truly competent in the medical tourism industry they helped mobilize. Team members, then, ultimately perceived client trust to be another form of symbolic capital that would signify their capacity to fiercely compete in the global medical tourism market.
Step 6 of the theoretical model refers to the process of testing whether candidate providers would be amenable to the organization’s established doxa, that is its negotiation terms. Team members asserted power over candidate providers in the first negotiation meeting by threatening network dismissal. Network dismissal was considered if the provider did not accept the doxa of conceding to the organization’s symbolic capital. As outlined in Table 2, team members required an observed demonstrable effort from candidate providers that proved that candidates accepted the organization’s symbolic capital or not. These “observed actions” were internalized by organizational team members as qualities of a “good partner” and of long-term
“partnership allegiance.”
Step 7 and 8 of the theoretical model point toward the process of modifying the organizational habitus after candidate providers prove their partnership capacity or not.
Team members would observe the (in)actions of the candidate providers to infer and gauge their long-term partnership capacity (symbolic capital) during negotiation meetings. After negotiation meetings, team members would discuss the interplay of the meetings, re-strategize, and at times, provide candidates with additional opportunities to
170 further prove their partnership capacity. Team members would decide whether to give candidates additional opportunities to prove their partnership capacity according to the amount of selection criteria the candidate possessed. Further opportunities for negotiation meetings always coincided with candidate’s ticking off a greater number of organizational selection criteria than the provider’s competition. Every negotiation meeting necessitated a team reflection on whether a partner could compel, hinder, or halt the organization’s trajectory, competitive market advantage, and position-taking. Post- meeting interviews also served as a designated time for team members to individually reflect on whether a candidate provider could positively or negatively impact the organization if they decided to engage in a long-term partnership deal.
Step 9 of the theoretical model refers to the process of on-boarding or dismissing candidate providers once they had adequately shown their acceptance or declination of the organization’s symbolic capital. For on-boarded providers, organizational team members left very little room for providers to inculcate subversion strategies to gain power within the inter-organizational field. This was likely due to the fact that a subversion strategy would require providers to assume control of the team members’ symbolic capital, a feat that would prove to be extraordinary. To acquire the symbolic capital from organizational team members would require a mastery of the informational capital of medical tourism, as well as the possession of the social and cultural capital to form one’s own network of service providers across industries. Since providers were recruited from multiple industries, many providers lacked the necessary social and cultural capital to perform such a task.
However, the lack of informational, social, and cultural capital did not prevent
171 some on-boarded providers from trying after learning the logic of the field. One subversion strategy that providers unsuccessfully attempted to implement was forming side partnerships with other known providers in the network, thereby subverting the power held by organizational team members. This was considerably more frequent among health care providers than hotels. Any subversion strategy implemented by on- boarded providers was immediate grounds for network dismissal, as this went against established doxa. Team members would also execute conservation strategies, such as the
“testing of complimentary services,” to re-direct provider attention from engaging in and formulating subversion strategies toward improving the quality of their own services for organizational gain.
Finally, step 10 of the theoretical model refers to the process of updating the provider network, thereby altering the boundaries of the field. A re-consolidation of the service provider network, and therefore ongoing updates to the network management system, was required whether a provider was on-boarded or dismissed. Since the boundary of the organizational field extends insofar as the configuration of power relations inside of the field, for every on-boarded or dismissed provider (either intra- or inter-organizationally), the boundaries of the field would change in order to conform to its participating agents. Since the organization never formally outright removed providers entirely, only merely stockpiled them in lower “reserve” tiers after halting further communication with dismissed providers, one would have to revisit “historical” agents if they ever rejoined the field, either by force or invitation.
In taking a Bourdieusian organizational analytical perspective, this ethnographic snapshot of how an organization constructed a medical tourism service provider network
172 has generated two theoretical results unlikely to be “uncovered” otherwise. First, start-up organizations can revolutionize new industries by not only determining what the symbolic capital can be in an organizational field, but also by developing strategies of choosing agents and doxa that preserve the organization’s hoarding of such symbolic capital in the future. The two strategies engaged by organizational team members were prospective problem-solving and affirming amenability. Perhaps, the frontrunners of organizational fields become “venerable establishments” (i.e. big brands; Emirbayer and
Johnson 2008) by way of engaging in conservation strategies that first prevent invited field agents from formulating subversion strategies for the purpose of seizing symbolic capital. In so doing, the organization positions itself as gatekeeper of symbolic capital, thereby perpetually altering the trajectory and configuration of power for newcomer agents to a subordinate position.
Second, this ethnographic depiction reveals how start-up organizations are able to directly control and design not only intra-organizational position-takings, but also the
“space of position-takings” (Emirbayer and Johnson 2008). By controlling the “space of position-takings,” a start-up organization compels its own trajectory in the inter- organizational field it helps to establish. As a result of governing the initial “space of position-takings,” start-up organizations delimit the position-taking of its future competitors by limiting competitive market advantage opportunities. This allows start-up organizations to further insulate themselves from the position-takings of their future competitors.
173 Chapter 7: Conclusion
Summary of Main Findings
This dissertation employed a mixed-methods approach in understanding how a newly established private civil society health organization constructed a network of medical tourism service providers in Rio de Janeiro, Brazil. The results of this dissertation are grounded in organizational team members’ practical experiences of: (1) predicting future requisites of positive medical tourism experiences for foreign patients;
(2) finding, vetting, and selecting service providers capable of fulfilling such requisites; and (3) negotiating with and managing their ongoing network of service providers based on organizational team members’ perceived measurements of dedication, accountability, transparency, and feasibility. Team members’ experiences of undertaking such tasks were documented using both longitudinal and horizontal organizational ethnographic techniques (Emirbayer and Johnson 2008).
The theoretical framework employed in this dissertation was a Bourdieusian organizational analysis. A Bourdieusian organizational analysis was used to explain the complex configuration and exchange of power relations between organizational team members and its network of service providers. By taking a Bourdieusian organizational analytical perspective, this dissertation provided an in-depth look into how a private health organization iteratively created, tightly monitored and controlled, and sharply refined the space in which informal and formal partnerships were made and unmade.
Furthermore, this dissertation foregrounded the local contextual backdrop that enabled this network to be successfully formulated in the face of rapid politico-economic and
174 socio-cultural change: the political, economic, and budgetary crises dovetailing the aftermath of the 2014 FIFA World Cup and the 2016 Summer Olympics.
Hosting global events typically result in tremendous economic and political upheaval, including significant urban restructuring (Zirin 2016). Rio de Janeiro is the only city to have accommodated two global events back-to-back, both amid serious national political, economic, and budgetary crises. From 2014 to 2016, Brazil faced a national economic crisis as restrictions on credit and rising interest rates led to the worst recession on record, resulting in surging inflation and high unemployment. Compounded by the economic crisis was increased public discontent regarding a political crisis that ensued. In short, President Dilma Rousseff was impeached for breaking budgetary laws, and her incredibly unpopular Vice President, Michel Temer, assumed office. Moreover,
Brazil was also facing an extraordinary budgetary crisis due to the two-year economic recession weakening tax reserves alongside rising government expenditures. All of these crises have been exacerbated by the billions of dollars that were invested into the city’s infrastructure to accommodate the massive influx of tourism for global events. At the time of my research, there was palpable dissatisfaction on the ground with the state of
Brazil’s current domestic and global politico-economic standing (Zirin 2016).
The aftermath of these global events and national crises had resulted in significant under-utilization of “leftover” private investment facilities, such as hospitals and hotels.
Owners of these private facilities were positioned to seek out new opportunities and sources of revenue for economic stability. With Brazil’s recent departure from arguably one of the greatest recessions of the century in mid-2017, coupled with the impending presidential elections of 2018, many participants I interviewed reported a “new hope” for
175 the future of their nation. Such optimism was one of the primary motivations why both organizational team members and their partnering service providers were so dedicated to mobilizing a formal medical tourism industry in Rio de Janeiro at this point in time. For participants in this study, proactively investing in and establishing a formal medical tourism network provided them with the perceived safeguard or insurance policy against further politico-economic and socio-cultural upheaval. According to organizational team members, the timing was perfect for on-boarding “struggling” providers given the precarious politico-economic state of the nation. In starting a medical tourism service provider network post-global events, team members were opportunistically positioning themselves to: (1) choose the best service providers at lower negotiated costs, given providers’ declining number of active clientele; (2) offer cheap medical travel packages to foreign patients, considering lower exchange rates; (3) capitalize on the recent global media coverage of Rio de Janeiro as an up-and-coming trendy tourist destination; and (4) take advantage of the newly invested tourism infrastructure and “deep-cleaning” that the city of Rio de Janeiro had recently accomplished.
One research objective of this dissertation was to evaluate how organizational team members prepared to accept foreign patients coming to Brazil for health care. During numerous brainstorming meetings, organizational team members iteratively determined what they thought future foreign patients would expect from a positive medical travel experience by first engaging a key strategy called prospective problem-solving. In short, team members would ruminate about the exhaustive problems or conflicts that could possibly arise after welcoming foreign patients to Rio de Janeiro for health care. Then, team members would devise and implement strategies to prevent such transgressions
176 from occurring. Potential problems were not limited to the health care setting or facility alone. Instead, team members holistically considered every aspect of patients’ medical travel in Rio de Janeiro, from tourism, transportation, and accommodations to financial considerations. Team members formulated practical, cost-effective, and actionable solutions to potential problems to mitigate their own risk by solving problems that could possibly happen in the future. Also, prospective problem-solving enabled team members to simultaneously identified the core values of what they considered a positive medical tourism experience to be in an improvisational manner.
The top three reported core values of a positive medical travel experience were organizational competence, personal safety, and patient comfort. Team members were ultimately able to develop and refine their organizational “position-taking” by forecasting their potential market’s preferences through prospective problem-solving. A position- taking is a Bourdieusian moniker that could be interpreted as the organization’s overall mission, strategic vision, and/or product or services offered (Emirbayer and Johnson
2008). During sixteen brainstorming sessions, organizational team members contrived their position-taking as offering an “American standard,” comprehensive, affordable, and high quality package of medical tourism services deemed safe, and culturally and medically proximate to the foreign patient. After articulating their position-taking, team members narrowed their potential candidates of service providers by placing in priority the providers that could match the maximum number of service delivery specifications outlined during predictive problem-solving exercises. Therefore, the organization’s position-taking informed the preliminary selection criteria used to select, vet, and recruit service providers and their respective facilities.
177 Another research objective of this dissertation was to understand how organizational team members found, selected, and recruited candidate providers to be added to the organization’s preferred network of medical tourism service providers.
Starting with the pre-selection criteria generated from brainstorming sessions, team members generated a list of potential providers that met the most criteria first. The pre- selection criteria for service providers were as follows: (1) geographically located in an exclusive (and therefore safe) neighborhood within Rio’s South and West Zones; (2) in- house possession of the most advanced technology available on the market (and therefore not outsourced by the service provider); and (3) health care providers who completed their medical school training in the United States with current or demonstrated willingness to procure American accreditations, or in the case of hotels, affiliation with internationally recognizable brands. Team members first sought service providers directly in which team members had a formal connection. After exhausting their collective personal network connections, team members sought out referrals from colleague physicians for health care providers, and would “cold call” hotels that they considered the most culturally proximate for American standards of comfort and safety.
Upon selecting candidate providers, a site inspection would be performed by two team members to assess the overall resources available for the organization’s potential clients. After performing an initial site inspection of the candidate provider’s facility, team members would expand their selection criteria to include the following factors: (1) overall security and safety in and around the facility; (2) perceived and communicated willingness of the owner or director to make future tailored accommodations on behalf of the organization; (3) available capacity, space, and staff to accommodate clients (for
178 medical facilities only, the type and number of procedures that could take place within the facility at any given time); (4) facility cleanliness and modern decor; (5) walking distance to nearby services (i.e. restaurants, banks, grocery stores, shopping, etc.); (6) basic and luxury amenities available to clients; (7) new and outdated technology within the facility; and (8) the amount of “promised” services that were really contracted by others (medical facilities only). All of the above factors were considered to hold equal weight, and were judged in relation to one another.
After two organizational team members performed different site inspections of the same facility, the two site inspectors would decide if the candidate provider warranted a subsequent negotiation meeting or not. Team members would internalize unanimous consensus as a shared affirmation that all organizational team members truly understood and adopted the organizational position-taking, as it was clearly delineated at that present moment in time. In the event that two team members had differing opinions about whether to use a service provider or not, site inspectors would “plead their case” to other team members by rationalizing why the organization should continue forward with on- boarding or dismissing the respective candidate. In this instance, team members would first reflect on the current organizational position-taking, and decide whether a candidate provider would ultimately improve or hinder it. Interestingly, when team members disagreed on on-boarding or dismissing candidate service providers, the organization was restrictively forced to innovatively emend its position-taking, and therefore its projected strategies, trajectory, selection criteria, services offered, and planned operational logistics. The internal organizational process of reaching consensus or resolving dissension attests to the iterative construction of an organization’s position-taking and
179 habitus. It does this by further clarifying and honing the organization’s overall purpose, mission, and goals, while simultaneously strengthening intra- and inter-organizational
(and therefore inter-personal) social dynamics and relationships.
The last research objective of this dissertation was to determine how organizational team members negotiated with and managed their ever-changing network of medical tourism service providers. Provided that organizational team members internally approved the candidate provider, a negotiation meeting among two team members, the facility’s owner (service provider), and one or two of the provider’s assigned project managers (generally the candidate institution’s Director of Sales or Operations) would take place. During the negotiation meeting, team members would inquire into the projected profitability, trajectory, and structural changes of the candidate facility in order to prefigure whether the potential partnership would be incongruent to or supportive of the organization’s position-taking. Team members would on-board providers based on whether the provider: (1) demonstrated continued receptiveness and enthusiasm to not only support, but also enhance, the organization’s position-taking; and (2) not engage in subversion strategies to assume power over the organization. Team members would assess service providers’ dedication to the organization’s position-taking based on providers’ actions, and not on verbal promises or deals made during negotiation meetings.
Team members interpreted several actions from candidate providers as indicative of being a long-term high quality partner. One action considered highly valuable was providing drastic pricing discounts for services to be rendered in exchange for bringing a steady clientele. Another valued action was heeding to and implementing any
180 amendments to facility operations that team members considered more conducive for future foreign patients. In the event that providers would employ subversion strategies, which were most commonly seen as either crafting side deals with other known partners in the network or withholding information commensurate to internal structural readjustments, providers were immediately dismissed from the preferred network of providers.
Research Implications
Anthropology of Health Organizations
This dissertation has numerous implications for the field of organizational anthropology. More specifically, this research contributes to our understanding of the anthropology of health organizations by applying the theoretical framework of
Bourdieusian organizational analysis to health organizations. I view the anthropology of health organizations as a bridge uniting organizational anthropology to medical anthropology, and, as I describe later, to the anthropology of global health diplomacy and governance. As such, this project demonstrates the theoretical power of employing
Bourdieusian organizational analysis to ethnographies on health institutions. In short,
Bourdieusian organizational analysis propels analysis beyond administrative bureaucracy to explanatory models of intra- and inter-organizational dynamics, and the socio-cultural and politico-economic contexts in which organizations operate.
This dissertation has attempted to provide ethnographic descriptions by way of employing a Bourdieusian organizational analysis. In so doing, this dissertation proposes a theoretical model of how a newly formed health organization entered into, framed, and constructed a locally untapped market by ingeniously drawing on under-utilized
181 resources from local service providers across the health care, tourism, and hospitality industries. The limited number of ethnographies that have already adopted a
Bourdieusian organizational analytical perspective has focused on complex organizations that already strategize and operate within established markets and industries.
Only in using a Bourdieusian organizational analytical framework did this dissertation “unearth” two additional theoretical implications that may shed light on our understanding of how newly established civil organizations can gain competitive market advantage in the mobilization of new industries. The first theoretical implication from the explanatory model presented in this dissertation is that new organizations have the power to determine what symbolic capital should be within a developing organizational field.
New organizations are also charged with determining which agents and doxa should be present in the organizational field. As such, new organizations possess a lot of strategic leverage to prevent other agents from possessing the organization’s symbolic capital. In other words, start-up organizations are uniquely positioned to control not only their own trajectory (in so far as strategic agency is permitted within the fluctuating confines of external structures), but also the trajectory of the agents they (dis)allow into the field.
Perhaps, this is a possible reason why start-up agencies or organizations are successful in monopolizing new industries, given their initial power to select partners capable of elevating, detracting, or competing against the organization’s future bearing on the market.
The second theoretical implication of this dissertation is that in having carte blanche to pre-select the field’s agents and doxa means that newly established organizations are also uniquely oriented to iteratively control not only their own position-
182 taking, but the space of position-takings in which field agents must subscribe. This does not mean that new organizations control the structures of the space of position-takings.
On the contrary, new organizations may prove to be highly influential in controlling what their selected field agents stand for, and consequentially what they are permitted to offer the market, through mandates (doxa) outlined in negotiation terms. Coupled with the mission of hoarding symbolic capital, new organizations are then sanctioned with a “field advantage” of preserving their power and authority (conservation strategy) in the organizational field by restricting their partners and competitors from engaging in subversion strategies of their own.
Anthropology and Global Health of Medical Tourism
Within anthropology and global health, many studies on medical tourism have taken an experience-near approach from the perspective of foreign patients.
Supplementary to such analyses are themes extending from the roles of caregiver companions and medical tourism facilitators to problems encountered before and after receiving treatment abroad, including state barriers to care and cross-cultural communication with foreign health care providers, to name only a few. Fewer studies, however, on medical tourism in anthropology and global health have concentrated on how comprehensive networks of service providers have been selected, arranged, and moderated on behalf of foreign patients, thereby shifting ethnographic attention away from patient-as-savvy-consumer to organization-as-savvy-seller.
This dissertation contributes to our understanding of the medical tourism industry by extending our knowledge past the patient’s experiential process of medical tourism to the organizational processes intrinsic to industry development on-the-ground. In
183 providing an ethnographic description of the organizational processes inherent in establishing a medical tourism industry in a location undergoing drastic socio-cultural and politico-economic change, this dissertation proves valuable in understanding how
“facilitator” services are refined iteratively and structurally, and how health care and hospitality providers and facilities are vetted, selected, and managed for patient safety and comfort. As such, it is vitally important to “study up” (Nader 2002) in medical tourism organizations, if only to understand the motivations, strategies, and operational protocols of organizations serving as direct arbiters of foreign patient experiences and provider compliance.
Anthropology of Global Health Diplomacy and Governance
This dissertation has attempted to provide a meaningful ethnographic depiction of how a private civil society health organization helped mobilize a local medical tourism industry in the face of rapid socio-cultural and politico-economic change. In so doing, this dissertation falls under the burgeoning field of the anthropology of global health diplomacy and governance. As stated in Chapter 2, one of the most pressing needs in the anthropology of global health diplomacy and governance is ethnographies that contribute to the teasing out of open-source anarchy (which has also been referred to as an “unruly mélange” in anthropology; Adams et al. 2008, Pfeiffer 2003), for the purpose of guiding diplomacy and governance towards a more structured pluralism (Fidler 2007). This effort requires thick descriptions of public and private stakeholders’ roles in improving the coordination, coherence, and effectiveness of governance and diplomacy for global health. In response to this need, this dissertation has focused on a major new type of non- state actor that is quickly gaining traction and presence within the “unstructured
184 pluralism” of global health: global health entrepreneurs (Fidler 2007). As less formal diplomatic representatives of for-profit organizations engaging in trans-border health negotiations, global health entrepreneurs are quickly gaining independent governance power as their resources continue to skyrocket, irrespective of state funding, particularly in the face of outdated or non-existent health policies (Fidler 2007; Kickbusch and
Rosskam 2013).
This dissertation has also endeavored to demonstrate the applicative value of incorporating a new analytical framework to understanding topics rooted in global health diplomacy and governance: Bourdieusian organizational analysis. Since it is highly compulsory for anthropologists working in this domain to include analyses of how governance organizations and actors shape, operate in, and affect local and global political-economic contexts, Bourdieusian organizational analysis provides the theoretical tenets necessary to elucidate such inter- and intra-organizational interactions in the contexts of changing environments. For example, the notion of organizational field may be particularly useful in describing global health governance issues, as governance is characterized as the political space in which collective problem-solving on health issues, rules, and regulations (read: doxa) by governmental, intergovernmental, and non- governmental actors (read: agents) takes place. Additionally, notions of habitus-informed
“position-takings” may help articulate how state and non-state stakeholders engage in negotiations, decision-making, and the restructuring of new-old partnerships (read: exchanges of capital), the premise of global health diplomacy (Fidler 2010).
While many diplomacy and governance topics can be macroscopically analyzed from a political-economic perspective or from the social determinants of health model, as
185 is quite common within anthropology and global health, a deeper understanding of how structures influence the internal micro-social phenomena within and between governance actors is required. Since ethnographies of diplomacy and governance should explore and interrogate known and unknown power relations, as well as the effects of diplomatic negotiations and decisions made between state and civil society stakeholders, it stands to reason that the anthropology of global health diplomacy and governance would be primed to incorporate a Bourdieusian organizational analysis into their methodology. While the medical tourism industry currently operates under far fewer state sanctioned structures than other industries in global health, this dissertation has nevertheless attempted to explain the configuration of power relations within and between civil society health organizations.
Future Research
The results of this dissertation present a number of theoretical and topical questions that warrant future research. Since organizational fields are dynamically unstable throughout time and space, this research would greatly benefit from a longitudinal follow-up study in which changes to the organizational field are observed, accounted for, and analyzed. For instance, during my fieldwork, the state and local government had not yet established special laws or policy regarding medical tourism. In the event that health law and policy are written to impose direct legal, bureaucratic, and administrative structures on the medical tourism industry in the future, how will these structures affect organizational position-takings, the space of position-takings, as well as strategies of action for organizations? Will such newly imposed state-sanctioned
186 structures, possibly in the form of bilateral or multilateral agreements with other sending countries, restrict or enable the provision of medical tourism services to foreign patients?
Will there be intra- and/or inter-organizational resistance or acceptance to such structural changes and (im)possibilities, and how will this affect the trajectory of the organizational field and its agents?
After generating a steady influx of foreign patients traveling to Rio de Janeiro for health care, will the organizational field expand to other areas in Brazil, and if so, how will this industry expansion position the organizational field relative to transnational fields replete with already established competitors (i.e. Costa Rica, Mexico, Thailand, and India)? How will foreign patients respond to the services that the organization has prearranged on their behalf? How will foreign patients’ responses directly and indirectly alter the configuration of the field’s boundaries, doxa, agents, organizational habitus, and the strategies and species of capital exchange? All of these questions point toward the exciting opportunities that Bourdieusian organizational analysis bestows to the ethnographic process: the ability to track, unravel, and ground the dynamism of intra- and inter-organizational relationships to rapidly developing industries undergoing constant structural changes, be it governmentally, ecologically, politico-economically, and/or socio-culturally.
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