This is a pre-publication draft from 29 July 2015 of: Ormond, M. (2016, forthcoming) ‘Knowledge transfer in the “medical tourism” industry: The role of transnational migrant patients and health workers’, in F. Thomas (ed.), Handbook on Migration and Health, Edward Elgar.
Knowledge transfer in the ‘medical tourism’ industry: The role of transnational migrant patients and health workers Meghann Ormond 1
Abstract Tapping into migrants’ diverse tacit healthcare knowledge can bring a range of stakeholders in countries of origin great insight, at both macro and micro levels, not only into how to improve on local healthcare delivery but also how to effectively respond to the needs and interests of ‘medical tourists’ and other types of travellers and migrants. This chapter reviews recent literature on migration and ‘medical tourism’ in order to look in greater detail at the role, first, of migrant patients and, second, of migrant health workers in the development of Global South destinations’ ‘medical tourism’ industries. It offers a series of lessons drawn from the many examples of migrant knowledge transfer and barriers presented. Keywords Knowledge transfer, diffusion of innovation, migration studies, healthcare, medical tourism Introduction ‘Medical tourism’ denotes purposeful short-term travel from one’s country of habitual residence to receive medical treatment paid for out-of-pocket in a country in which he/she does not habitually reside and within which he/she may not enjoy entitlements to healthcare beyond those availed to any other private consumer (Ormond 2014). Over the last 15 years, countries as diverse as India, Jamaica and the Philippines – keen to bank on rapidly increasing health and wellness consumption trends among the global middle classes – have been engaged in promoting ‘medical tourism’ and developing an industry around it in order to effectively attract healthcare consumers living outside of them. Proponents of ‘medical tourism’ have forcefully argued that potential benefits to lower- and middle-income destination countries include more foreign exchange earnings, diversified tourism offerings and a boost to the supply and quality of (private) medical care within these countries. In response, a growing number of stakeholders concentrated in Global South countries, like those mentioned above, has begun to develop their own ‘medical tourism’ plans and throw their hats into an already crowded, highly competitive global ‘medical tourism’ ring (Bookman and Bookman 2007; Connell 2011, 2013; see also Temenos and McCann 2013 on policy transfer). Over the years, these destination countries’ ‘medical tourism’ plans have also increasingly explicitly intersected with public and private sector policies and practices directed at attracting diverse forms of diasporic engagement and investment. Policy strategies abound at national, regional and local levels in migrants’ places of origin to build and intensify transnational identity and solidarity in order to increase diasporic contributions, investments and spending. In recent years, this has involved a shift from focusing mainly on remittances and the transfer of material resources to harnessing, transferring and sharing migrants’ acquired skills, knowledge and social capital back to their places of origin for the benefit of people living in them (e.g., return migration) (Faist 2008). This move towards developing both ‘bonding’ and ‘bridging’ social capital among diasporas reflects growing awareness of the range of power resources (e.g., economic, social, political, informational, moral and physical) that can be used to strategically embed places of origin in transnational networks that have the potential to avail them to new opportunity (Mitchell 1996; Opiniano and Castro 2006).
1
Cultural Geography, Wageningen University, The Netherlands. E-mail:
[email protected]
1
In spite of the significance of these shifts, Williams (2007a, 2007b) argues that insufficient scholarly attention has been given to the role of international migrants with different socio-economic and politico-legal statuses in knowledge transfer. When attention is given to migrants’ role in knowledge transfer and diffusion of innovation, it predominantly frames highly skilled migrants (e.g., those involved in information technology (IT), medicine, etc.) as the knowledgeable agents (see, e.g., Wang 2014). This racialised and gendered focus, however, overlooks the contributions of migrants engaged in unskilled, informal and heavily feminised care/emotional work – people who instead are often framed not as agents but rather as ‘knowledge dupes’ (Williams 2007b, p. 37). In response, Williams (2007a, p. 362) advances a more holistic approach to valorising human capital, ‘whereby all international migrants are understood to be potential knowledge carriers or knowledgeable workers’, regardless of their educational qualifications, income or occupation. In this chapter, I build on earlier work on the nexus of migration and tourism (Williams and Hall 2000) – and more specifically migration and ‘medical tourism’ (Ormond 2012, 2013) – in order to explore the role of knowledge transfer by both migrant health workers and patients in these countries’ developing ‘medical tourism’ industries. This focus allows me to take Williams’ (2007a, 2007b) critical approach a step further by recognising migrants not only as knowledgeable (skilled or unskilled) workers but also as knowledgeable transnational citizens, family members and healthcare consumers. In the next sections, I review a wealth of recent literature in order to look in greater detail at the role of both migrant patients and migrant health workers in tacit knowledge transfer relative to the development of Global South destinations’ ‘medical tourism’ industries. I then conclude the chapter by summarising and drawing lessons from the many examples of migrant knowledge transfer and barriers to it presented below. Migrants’ roles in health-related tacit knowledge transfer In order to examine how knowledgeable migrant patients and health workers are engaged in the ‘medical tourism’ industry, let me first clarify what types of knowledge are held at a premium and what is being transferred. A distinction can be made between explicit knowledge, which is codified in documents and databases and is easily identified, stored and retrieved, and tacit knowledge, which encompasses intuitive understanding developed through experience and practice that ‘cannot, or cannot easily, be expressed in explicit forms’ (Williams 2007a, p. 30). In his work on the distinctive contribution that migrants can make in knowledge transfer and exchange, Williams (2007a, 2007b) predominantly draws on Blackler’s (2002) four categories of tacit knowledge: embrained, embodied, encultured and embedded. Embrained knowledge involves mental models, conceptual skill and cognitive ability. Embodied knowledge comes from practical ‘learning by doing’ in specific contexts, which builds on physical presence and sensory information. Encultured knowledge involves shared understandings and values derived from socialisation and acculturation. Finally, embedded knowledge is not pre-given but rather emerges contextually through shared (organisational) rules and processes. While these categories are transferable through international travel and migration, in practice they are not equally so. Embrained and embodied knowledge are more straightforwardly transferrable, with limited barriers to their implementation elsewhere (e.g., diagnostic and surgical procedures). Encultured and embedded knowledge (which do not merely serve as facilitators for the former two), however, derive from socially-situated, localised experience. As a result, they are more difficult to enact outside of their generative contexts, leading to their partial transferability to other places and groups where shared meaning may be lacking or limited. Yet, their partial transferability can still be implemented productively. For example, migrants’ translation of their experience – as patients and/or medical professionals – of how Country A’s health system operates may be highly sought after for comparison and emulation by those both using and working in the health system of Country B, even if most of those in Country B are not familiar with Country A. Williams and Baláž (2008, p. 1925) found Blackler’s typology particularly useful for examining skilled health worker (SHW) knowledge transfer because it acknowledges the range of knowledge necessary to the profession: academic knowledge (embrained), technical skill (embodied), cultural 2
knowledge (encultured) and management skills (embedded). Yet, as noted earlier, in their physical boundary-spanning, migrants are ‘distinctive knowledge bearers’ (Williams 2007b, p. 366) with the potential to access, interpret and refine information gleaned from reflection on the intersections of their own unique range of transnational experiences, relationships, networks and resources that may be of use to other social actors. Blackler’s typology, therefore, can also serve as a useful heuristic to reflect on the range of knowledge necessary for patients and their companions to pursue and receive medical care abroad. Scholars and practitioners alike have noted how both patients and their companions are increasingly savvy healthcare consumers. This is well-illustrated by Casey et al.’s (2013) study of how family and friends accompanying Canadian ‘medical tourists’ may assume different roles throughout their medical journeys: knowledge broker, where information is transferred between patients and doctors; navigator, where information is gathered and care coordinated; and companion, where emotional and physical support are provided. The four types of tacit knowledge can be discerned in these roles: embrained (e.g., gathering, reflecting on and organising different medical perspectives on a medical concern or treatment), embodied (e.g., tailoring physical and emotional care to patients’ specific constellations of ailments), encultured (e.g., sensitivity to and cross-cultural translation of cultural views and values related to illness and impairment and their treatment) and embedded (e.g., understanding and advocating for patients’ rights, negotiating patient/doctor relations, etc.). Patients In delimiting ‘medical tourism’ as the purposeful short-term travel by people from their country of habitual residence for medical treatment in a country in which they do not habitually reside and within which they may not enjoy formal healthcare entitlements, we can distinguish ‘medical tourists’ from travellers whose temporary medical pursuits abroad are subsidised or reimbursed by the governments or insurers in their country of habitual residence usually as a result of bi- or multilateral agreements (e.g., the European Union’s 2011 Patients’ Rights in Cross-Border Health Care Directive). The definition also differentiates ‘medical tourists’ from those engaging in not only short-term but also longer stays or settling permanently in receiving countries for reasons not primarily linked to medical treatment and who may or may not enjoy formal healthcare entitlements in the receiving country as a result of their political-legal status (e.g., economic migrants, students, return migrants, refugees and retirement migrants). Such discernment enables recognition of the great diversity of socio-economic, political and legal statuses of people pursuing and receiving medical treatment abroad (Ormond 2014). Undermining attempts at introducing greater conceptual nuance, however, current recording practices in many countries promoted as ‘medical tourism’ destinations often do not effectively differentiate between these different statuses. Instead, published ‘medical tourism’ figures frequently lump all recipients of medical treatment with foreign passports together as ‘medical tourists’, effectively overestimating the volume of ‘medical tourists’ and paying limited regard to the diverse range of health issues and the urgency of care needs in the various places to which not only ‘medical tourists’ but also other (medical) travellers and migrants may be rooted. The de facto diversity of statuses and origins of people receiving care abroad have been still further eclipsed by a widely pervasive imaginary of ‘average medical tourists’ as predominantly middle-class whites of non-migrant origin who, unhappy with medical care in their home countries in the Global North, combine short-term travel to world-class hospitals with leisure consumption (e.g., luxury hotel and resort stays, safari and city tours, etc.) in the Global South for treatment or care inaccessible to them back home. While some of those pursuing medical care abroad may in fact possess such origins and status, they are thought to be a minority. Recent work has shown that much ‘medical tourism’ – the purposeful short-term travel by people from their country of habitual residence for medical treatment in a country in which they do not habitually reside and within which they may not enjoy formal healthcare entitlements – is instead largely undertaken in the form of intra-regional and cross-border travel between lower- and middle-income countries within the Global South (Ormond and Sulianti 2014; Crush and Chikanda 2015). Yet the pervasive imaginary of 3
‘average medical tourists’ as middle-class whites from the Global North has profoundly shaped how policy-makers, industry actors, journalists and everyday people have come to understand and legitimise the growing ‘medical tourism’ industry, including its key actors, its benefits and disadvantages, and how such transnational mobility links up healthcare issues and responsibilities at ‘home’ with those ‘abroad’. This chapter contributes to work that seeks to complicate the predominant ‘average medical tourist’ imaginary by paying attention to actually-existing ‘medical tourists’, medical travellers and migrants, how they pursue and receive medical care, and their neither necessarily linear nor binary relationships to ‘home’ and ‘abroad’ (de Freitas 2005). Migrants of all types and their offspring are returning for longer or shorter periods to their places of origin or receiving care in countries with important diasporic centres that are meaningful to them. Short-term visitors are travelling with growing frequency from neighbouring countries with comparatively poorer healthcare offerings. Elite ‘expat’ executives and retirees are seeking out the best treatment options within the regions in the Global South in which they have settled. Such pursuits reveal a broader, richer transnational configuration of peoples and places around medical care – one that is far more socio-economically polarised and ethnically, geographically and politico-legally diverse than the predominant ‘medical tourist’ imaginary. In their study of UK residents’ pursuit of treatment outside the UK and the EU, Hanefeld et al. (2015) looked not only at ‘medical tourists’ of British origin but also those of non-European migrant origin settled in the UK. In contrast with ‘medical tourists’ of British origin, respondents of Somali and Indian origin were found to be more familiar with both the UK’s public and private health services and those in their countries of origin and third countries in which they or their family members had studied or lived previously. Having experienced a range of health systems in their lifetimes, they were thus better able to establish criteria for assessing and drawing comparisons between services as prospective healthcare consumers than those only familiar with the UK’s socialised National Health Service (NHS). Studies by Bochaton (2015) and Ormond (2015), furthermore, point to how effective migrants’ transnational social networks are not only for amassing sufficient treatment funds for patients and providing them with accommodation and transport before and after treatment but also for word-of-mouth promotion of the best medical professionals and facilities. In recognition of this, countries are seeking to develop ‘medical tourism’ by strategically targeting their diasporas, considered pioneering ‘early adopters’ capable of diffusing healthcare knowledge and innovative practices through their transnational networks. Indeed, several countries actively promoting themselves for years to the ‘average medical tourist’ described above have now begun to more explicitly acknowledge that their main markets from Global North countries are in fact predominantly diasporic in character (e.g., US-based people of Indian origin going to India (Connell 2011, p. 125); Germany-based people of Turkish origin going to Turkey (Turkish DirectorateGeneral of Health 2012, pp. 53-57); etc.) and to more aggressively target them. The underlying logic of destinations like these is well illustrated by a 2012 plan designed by the Trinidad and Tobago Coalition of Services Industries (Hellyer 2012, pp. 12-13): There are an estimated two million diaspora from the Southern Caribbean (mainly Trinidad and Barbados) living in the UK, USA and Canada. In most Caribbean countries, the estimate is there is the same number of diaspora as population nationally […]. Therefore it is reasonable to assume that the diaspora of Trinidad and Tobago is around 1.3 million people plus their offspring (sometimes two generations). Given that the 1.3 million diaspora (first generation) are now aging, the need for medical care (and expenses it involves) is growing, medical facilities in Trinidad and Tobago could explicitly target this segment. Therefore, [… t]he specific target for ‘Strategic Goal 3: Promotion of Medical Tourism to the Diaspora’ will be to attract 4000 new diaspora patients per year – 2000 from the USA, 1500 from Canada and 500 from the UK after 3 years. This target would mean less than 0.3% of first generation diaspora travelling to Trinidad and Tobago for medical treatment and, if second/third generation were included, less than 0.1%. 4
[However, t]he impact of 4000 diaspora patients, spending on average USD5000 per treatment, would generate USD20 million of revenue for private healthcare in Trinidad and Tobago. In this excerpt, we also see intentions by destination stakeholders to attract diverse segments of the diaspora. This not only includes first-generation migrants visiting friends and relatives (VFR) but also their second- and third-generation children and grandchildren who may have weaker links to these countries. The strategy of appealing to different age groups within the diaspora – both younger, economically-active migrants and older, retired migrants considering whether they will remain in their countries of settlement, relocate to their countries of origin or circulate between these and other countries in their transnational networks (Warnes and Williams 2007; Sun 2014) – is supported by the development of medical and allied care services that anticipate diasporic consumers’ diverse needs as they change and develop over the life-course. Indeed, more and more stakeholders are tapping into the rapidly-growing retirement migration market (and its return migration sub-market) by developing property and lifestyle opportunities that complement their on-going ‘medical tourism’ industry investments (see also Hall, this volume). Yet, developments must not only satisfy migrant retirees’ nostalgic yearnings for the ‘homeland’ but also meet the standards of healthcare and security to which they have grown familiar in their lives abroad. Notes a representative of the Jamaican Diaspora Canada Foundation (IMTJ 2013): I do not want to spend my twilight years in the cold. I would much prefer to spend it in Negril or Ocho Rios, but there are things you need to put in place. The fundamental right of every Jamaican is personal security, which is a problem in this country. Old people are afraid. When you reach 75 you want somewhere to come and retire that is sunny, where you can see a doctor and there is a clinic. We have the capacity to put those things in place. And there are also people in the diaspora who will come here and build those places, once the crime has been dealt with. Jamaicans will come any time, no matter what, but foreigners will not do that. Effectively, though they are considered ‘early adopters’, the tacit knowledge that migrants – positioned in their countries of origin as medical care and lifestyle-focused consumers – bring with them of experience with comparatively better-organised health and public security systems in their countries of habitual residence may also at times render them more akin to ‘mineshaft canaries’ than pioneers. ‘Medical tourism’ destinations seeking not only to attract diasporic patients, therefore, have much to learn from these ‘canaries’ about how to best attract others in their habitual countries of residence. At the same time, stakeholders in migrants’ habitual countries of residence are increasingly aware of their transnational health pursuits. Authorities and doctors in European Union (EU) countries home to peoples of non-European descent have begun to raise concern about the impacts of transnational healthcare pursuits not only on the health outcomes of ‘medical tourists’ and travellers but also on the health systems in their countries of residence more broadly. Similar to those outlined by Snyder et al. (2012) for Canada, their concerns include reduced continuity of care (e.g., a lack of records or communication between doctors in both countries) resulting in redundant or rival care (e.g., diagnostics, treatments and consultations), incomplete recovery or rehabilitation, the need to ‘repair’ health complications resulting from treatment abroad, the need to ‘repair’ trust between patients and providers in their country of residence and the need to undo ‘mixed messages’ (Nielsen et al. 2012; Sekerçan et al. 2014). At the same time, transnational care practices also are acknowledged to have the potential to supplement or even entirely replace care inaccessible or deficient in migrants’ habitual countries of residence due to financial, legal, cultural and linguistic hurdles (Nielsen et al. 2012; Stan 2015). Studies in Denmark and the Netherlands have highlighted significant transnational medical pursuits 5
by people of Turkish descent. Some 26.6% of first-generation Turkish migrants living in Denmark for three or more years and an impressive 19.4% of their descendants travelled abroad for at least some of their medical needs, compared with a mere 6.7% of Danes of non-migrant origin (Nielsen et al. 2012). 2 Meanwhile, in the Netherlands, some 21.3% of respondents of Turkish origin pursued healthcare abroad – more than double those of Moroccan origin (9.8%) – and more than half of all respondents of non-European descent aged 55 and over reported healthcare consumption in their countries of origin within the last 15 years (Sekerçan et al. 2014). Many of their healthcare pursuits in Turkey were considered to be motivated by disappointment with, and barriers to accessing, specific types of care in their habitual countries of residence. Health workers The conventional range of international skilled health workers’ (SHW) mobilities can be discerned by length of stay (Wendland 2012). Short-term stays have traditionally comprised medical students and volunteers from the Global North engaging in what Wendland (2012) calls ‘clinical tourism’, brief stints of less than one year in understaffed and under-resourced destinations in the Global South in order to experience ‘global health’ issues first-hand. Medium-term stays have usually involved SHWs mainly from the Global South spending several years in Global North medical facilities for postgraduate specialty training or, alternatively, SHWs principally from the Global North being deployed by humanitarian or missionary organizations on two- to three-year tours in especially needy areas in the Global South (e.g., Médecins sans Frontières). Finally, long-term stays, the most well-documented of all, have mostly included SHWs from the Global South who permanently migrate to the Global North. At first glance, these mobilities contrast with those described in the section above, where patients travel from one country to another in order to fulfil medical and other care needs. However, while studies of the globalisation of healthcare have largely attended separately to international patient and SHW mobilities, these can be quite intertwined and, together, have important and potentially novel repercussions on the people, places and health systems involved (Connell 2011). When it comes to short-term SHW migration and travel, Wendland (2012) notes that the frequent rotation of ‘clinical tourists’ from the Global North means that the new treatment approaches they introduce can quickly circulate within Global South host hospitals, clinics and communities. However, ‘clinical tourists’ introduce medical perspectives and solutions which, though feasible in the Global North, may be out-of-reach in material and human resource-poor contexts. For this reason, among others, short-term SHW mobility has been the target of critique. Yet, the international ‘medical tourism’ industry has generated two novel forms of short-term, circular SHW migration that appear to bring even fewer concrete benefits to the local communities in their destinations. Linked to growth in off-shoring ‘medical tourism’ practices meant to further minimise regulatory red tape and/or treatment costs, the first involves engagement in so-called ‘time-share’ medical practices, where doctors ‘purchase the right to be the only individual offering a service for patients from a specific geographic region (typically where their main practice is based) and the right to practice for part of each year in an off-shore medical facility’ (Snyder et al. 2015, n/p), and the second consists of doctors and nurses accompanying individual patients or groups of patients abroad in order to undertake their treatment. In making use of hospitals and clinical infrastructure that are independent and isolated from local healthcare staff and infrastructure in the destinations, neither of these forms offers potential for medical knowledge transfer or exchange. Those involved in the organisation and delivery of healthcare in Global South countries frequently receive part of their formal education and training abroad. This is what Wendland (2012) refers to as ‘medium-term’ clinical mobility. During their sojourns, these SHWs have learned about, experienced and practiced within health systems other than those of their countries of origin. This 2
Danish national health insurance covered non-chronic medical and pharmaceutical expenses for all persons with permanent residence in Denmark until 2008. The impacts today of the 2008 legislation limiting non-EU coverage on Turkish migrants’ healthcare pursuits outside of the EU remain unclear.
6
enables them to be able to bring home and potentially model good practices learned abroad, with many SHWs seeing themselves as ‘secular missionaries’ (Wendland 2012, p. 117). This type of brain circulation is especially prized in Global South countries’ ‘medical tourism’ industries, since foreign patients are widely believed to prefer doctors and nurses who have trained and practiced in the Global North (e.g., the USA, UK, Canada, Australia and Japan) or in their own countries. Indeed, several ‘medical tourism’ destinations – like India, Malaysia and the Philippines, which have large numbers of SHWs temporarily training and practicing in Global North countries – explicitly showcase these medium-term SHW mobilities in promotional materials in order to highlight their destinations’ world-class medical excellence and cultural competence (Ormond 2012, 2013; Walton-Roberts 2015). The Indian government, for example, places strategic value on Indian medical practitioners’ training and experience abroad, specifically as regards their potential to contribute to ‘private sector health provision in India, itself a generator of income for the country through the medical tourism that it has speeded up’ (Raghuram 2008, p. 183). SHWs’ medium-term sojourns, therefore, can constitute especially valuable sources of social, cultural and economic capital for their countries of origin. However, appreciation for SHWs’ experience in foreign patients’ habitual countries of residence cannot necessarily be taken for granted. Whittaker (2015), for example, notes that the ‘medical tourists’ and travellers from the Arabian Gulf countries she interviewed often expressed disdain for the Southeast Asians on temporary contracts who constitute the majority of SHWs in their home countries’ medical facilities, yet they would highly praise the local SHWs in the Southeast Asian countries in which they pursue medical care. Within a global context of severe SHW maldistribution and shortages, long-term international SHW migration has been described as a ‘perverse subsidy’ (Mackintosh et al. 2006) that disproportionately benefits recruiting countries in the Global North while depriving Global South source countries of valuable human capital in which they have heavily invested. The effects of this on ‘medical tourism’ were explicit in my study of Indonesians travelling across the border to Malaysia for medical care (Ormond and Sulianti 2014; Ormond 2015). Living in a poor, peripheral part of Indonesia, my respondents were frustrated by the emigration of their best and brightest health workers to the capital city, Jakarta, and outside the country’s borders. They decried the restrictions that the Indonesian government placed on recognising foreign medical education credentials for reducing the potential for Indonesian doctors trained abroad to return home and for foreign doctors to establish practices in their community. Thus, perceiving the local crop of Indonesian doctors to be inferior, they actively sought out alternatives in the form of distant regional missionary hospitals with a rotating staff of SHWs from the Global North or private hospitals in Malaysia and Singapore. Yet long-term SHW migration can affect ‘medical tourism’ development in many other ways. Connell and Walton-Roberts (2015, p.7) note that economically-motivated long-term SHW migration is far from a novel phenomenon: ‘In south India, the Philippines and small island states, migration of SHWs has occurred over more than one generation, resulting in a “culture of migration” that becomes pervasive, normative, nurtured, and enhanced by the presence of overseas kin’. This has led to the development of multi-generational diasporic networks of SHWs. However, migrant knowledge transfer or ‘brain gain’ is not necessarily hindered by the permanent settlement of SHWs abroad. Indeed, Opiniano and Castro (2006) have highlighted the role of migrant associations and professional diasporic organisations in both knowledge networks (e.g., the Transfer of Knowledge Through Expatriate Nationals (TOKTEN) and Balik Scientist programmes in the Philippines). Diasporic investment in ‘medical tourism’ industry developments is also increasingly significant, enabled by social networks bringing together local and diasporic knowledge and investment. The mobilisation of charitable financial contributions and business investments by diasporic Jamaicans for the proposed Negril International Hospital in north-western Jamaica developed to serve the medical needs of diasporic Jamaicans and non-Jamaicans ‘medical tourists’ alongside those of resident Jamaicans is one example of this (IMTJ 2013). Walton-Roberts (2015) also shows how Non-Resident Indian (NRI) investment in Indian private healthcare and education as well as migrant Indian brain-circulation at the managerial level have worked together to internationalise Indian hospitals and medical education, effectively making a significant impact on the country’s health system (see also Pandey et 7
al. 2004). Her study indicates that not only migrant SHWs but also migrants with other forms of experience in the healthcare industry – like management, sales and marketing – also bring new approaches and practices to the business of healthcare in their countries of origin as a result of their own migratory sojourns (e.g., ‘medical tourism’ facilitators like IndUSHealth and MalaysiaHealthcare.com). At the same time, the ‘medical tourism’ industry has been championed by international and national development organisations and government bodies for its potential to reduce the effects of long-term international SHW brain-drain. First, it is held to be able to help stem brain-drain by providing a greater number of more lucrative and better-resourced employment opportunities within SHWs’ home countries (Connell 2011). 3 Second, it is used to legitimise investment in educating more SHWs in ‘medical tourism’ destinations. However, such logic rarely takes into account the length of time necessary to produce a sufficient number of competent nurses and medical professionals with the specialisations most in demand by ‘medical tourists’. In light of this, destinations increasingly look to both diasporic and non-diasporic migrant health workers to either permanently or temporarily fill in the gaps. The ‘medical tourism’ industry has been used to justify governments’ return migration campaigns targeting, among others, senior medical specialists practicing abroad in order to benefit from their knowledge, experience and prestigious foreign credentials. The Malaysian government’s Returning Expert Programme (REP), for example, offers attractive fiscal incentives to senior Malaysian SHWs and permanent resident status to their nonMalaysian family members. In my 2012 study of Malaysian medical specialists who regularly work with ‘medical tourists’ 4, the significance of migrant SHWs’ tacit knowledge transfer is explicit. Embrained, encultured and embedded knowledge are particularly well-illustrated in the following excerpt from an interview with a Malaysian specialist who returned to settle in his hometown: I have overseas qualifications, and a specialist qualification obtained overseas seems to be more sought-after than a specialist trained locally […]. So, there seems to be confidence when you are trained in […] a first-world country, trained in Australia. […] People like us have an advantage. The other thing I realised is that the Australian system, which is the only system I can speak of, helped us a lot in terms of communication skills. [… It] really emphasises communication, and my seniors – Australian-Italians, AustralianGreeks and Australian-Maltese – were very smart people with a very high EQ [level of emotional intelligence]. They were my role models, showing me how to communicate with patients, showing me how to manage difficult situations. So, it was through them that I managed to develop my soft skills. When I got back, it wasn’t a problem launching a private practice. I could take it on right away. I think that the Australian medical education taught us to have a holistic approach: you treat a disease, you treat a person – you don’t treat a number. The patient is not a number – you call the patient by their name. We also can see that Global South ‘medical tourism’ destinations are increasingly turning to migrant SHWs from both the Global North and South to fulfil their care labour needs. Snyder et al. (2015) point to growth in long-term international migration by SHWs between Global South countries. Low-wage Indian doctors, nurses and technicians, for example, are being hired to cover 75% of the staffing needs in Health City Cayman Islands facilities. Matsuno (2009, p. 13), meanwhile, found that foreign nurses accounted for 40% of all nurses in Malaysian private hospitals but only 2% of all nurses country-wide. Furthermore, the growth of hospitals and care homes not only in the Global North but also the Global South has created new labour demands not only for SHWs but also 3
While there is little doubt that internal brain drain is exacerbated by the privatisation of healthcare, of which the ‘medical tourism’ industry is symbolic, further research needs to be done on the specific types of human resources required for medical tourism in order to substantiate such claims. 4 See Ormond and Sulianti (2014) and Ormond (2015) for study details.
8
for lower-wage, oftentimes less formally trained care-givers (e.g., orderlies, home care providers, etc.). Yet scant scholarly attention has been given to the locals and migrants employed in such jobs, though they are essential for ‘medical tourism’ industries. Finally, Snyder et al. (2015) also highlight the long-term settlement of so-called ‘black sheep’ or maverick SHWs from the Global North in Global South countries whose regulatory environments may facilitate medical practices unregulated elsewhere (e.g., experimental stem-cell therapies) or leave legal problems unresolved in their home countries unacknowledged. These recruitment and settlement strategies are opening ‘medical tourism’ destinations up to new directionalities of flows of tacit knowledge around health, illness, impairment and treatment with the potential to challenge standards and practices in local medical facilities and households. Conclusions Due to a dominant shared imaginary of who the ‘average medical tourist’ is and what he/she needs and desires, many ‘medical tourism’ industry stakeholders have been slow to – or perhaps still have yet to – acknowledge the actually-existing diversity of people pursuing and receiving medical care outside of their usual countries of residence. For a long time, this conceptual blind spot has effectively precluded much of the potential of knowledge transfer by migrant patients to the developing ‘medical tourism’ industries in their countries of origin. Yet we are beginning to see greater awareness among stakeholders in both migrants’ habitual countries of residence and other countries in which they choose to receive medical treatment of their practices, to the extent that migrants have become recognised by some as bellwethers for broader ‘medical tourism’ populations and trends. Migrants’ diverse medical pursuits have underscored the need for policymakers and industry stakeholders to pay attention to the nuances of migration temporalities, employment statuses, integration trajectories, transnational social networks and stages of the life-course and how these in turn impact on engagements in (transnational) healthcare practices by economic migrants, refugees, international students, expatriates, retirement migrants, etc. (Ormond 2014; Stan 2015). Furthermore, the tacit knowledge that migrant patients, their families and communities have of different health systems, facilities and medical professionals puts them in a particularly unique position to assess the advantages and disadvantages of receiving treatment and care in different places. Migrant health workers, meanwhile, bring another set of skills and knowledge to developing ‘medical tourism’ industries not only through return migration and brain circulation but also through diasporic professional knowledge transfer and investment. However, as with migrant patients, policymakers and industry stakeholders also have had – and continue – to work to eliminate another conceptual blind spot: namely, the existence of a much broader range of transnational health worker mobility existing both before the emergence of ‘medical tourism’ development plans and resulting from them. While destinations have banked on harnessing certain migrant skilled health workers’ (SHW) tacit knowledge to benefit the industry, a range of other entrepreneurial migrants with varied non-medical experience of healthcare operations have also recently come on to the scene, seeking to implement good practices and business models acquired elsewhere in their countries of origin. Still, other contributions by migrants – especially those engaging in care work considered ‘unskilled’ – have largely passed under the industry radar in spite of the growing relevance of care-giving in rapidly ageing societies around the world. In sum, migrants are not only knowledgeable workers but they are also knowledgeable citizens, family members and consumers. Tapping into their diverse tacit healthcare knowledge can bring a range of stakeholders in countries of origin great insight, at both macro and micro levels, not only into how to improve on local healthcare delivery but also how to effectively respond to the needs and interests of ‘medical tourists’ as well as a range of travellers and migrants enfolded in developing ‘medical tourism’ industries. References 9
Blackler, Frank (2002). ‘Knowledge, knowledge work and organizations’, in Chun Wei Choo and Nick Bontis (eds), The Strategic Management of Intellectual Capital and Organizational Knowledge, New York: Oxford University Press, pp. 47–62. Bochaton, A. (2015). ‘Cross-border mobility and social networks: Laotians seeking medical treatment along the Thai border’, Social Science & Medicine, 124, 364-373.
Bookman, Milica Zarkovic and Karla R. Bookman (2007). Medical Tourism in Developing Countries. New York: Palgrave Macmillan. Casey, V., V.A. Crooks, J. Snyder and L. Turner (2013).’” You’re dealing with an emotionally charged individual…”: an industry perspective on the challenges posed by medical tourists’ informal caregiver-companions’, Global Health, 9(31). Connell, John (2011). Medical Tourism. London: CABI. Connell, J. (2013). ‘Medical tourism in the Caribbean Islands: a cure for economies in crisis?’, Island Studies Journal, 8(1), 115-130. Connell, J. and M. Walton-Roberts (2015). ‘What about the workers? The missing geographies of health care’, Progress in Human Geography. doi:10.1177/0309132515570513
Crush, J. and A, Chikanda (2015). ‘South–South medical tourism and the quest for health in Southern Africa’, Social Science & Medicine, 124, 313-320.
Faist, T. (2008). ‘Migrants as transnational development agents: an inquiry into the newest round of the migration–development nexus’, Population, Space and Place, 14(1), 21-42. de Freitas, C. (2005). ‘Health has no Borders: Cape Verdean Immigrants in the Netherlands and the Transnational Quest for Health Care Across Europe’, International Journal of Migration, Health, and Social Care, 1(1), 19–36. Hanefeld, J., N. Lunt, R. Smith and D. Horsfall (2015). ‘Why do medical tourists travel to where they do? The role of networks in determining medical travel’,.Social Science & Medicine, 124, 356-363.
Hellyer, Mark (2012). ‘Draft National Strategy for Medical Tourism’, Trinidad and Tobago Coalition of Services Industries, available at http://cnsc.org/download/trade_in_services/Trinidad%20and%20Tobago%20%20Medical%20Tourism.pdf (accessed 30 April 2015). IMTJ (2013). ‘Jamaica argues it is ready for medical tourism’, International Medical Travel Journal, 4 Oct., available at http://www.imtj.com/news/?entryid82=428628 (accessed 30 April 2015). Mackintosh, M., K. Mensah, L. Henry and M. Rowson (2006). ‘Aid, restitution and international fiscal redistribution in health care: Implications of health professionals' migration’, Journal of International Development, 18(6), 757-770.
Matsuno, A. (2009). ‘Nurse migration: The Asian perspective’, ILO/EU Asian Programme on the Governance of Labour Migration Technical Note, available at http://www.ilo.org/wcmsp5/groups/public/---asia/---robangkok/documents/publication/wcms_160629.pdf (accessed 30 April 2015). Mitchell, Kathryn (1996). ‘In whose interest? Transnational capital and the production of multiculturalism in Canada’, in Rob Wilson and Wimal Dissanayake (eds), Global/Local: Culture and the Production of the Transnational Imaginary, Durham: Duke University Press, pp. 219–54. Nielsen, S.S., S. Yazici, S.G. Petersen, A.L. Blaakilde and A. Krasnik (2012). ‘Use of cross-border healthcare services among ethnic Danes, Turkish immigrants and Turkish descendants in Denmark: a combined survey and registry study’, BMC Health Services Research, 12(1). doi:10.1186/1472-6963-12-390 Opiniano, J.M. and T.A. Castro (2006). ‘Promoting knowledge transfer Activities through diaspora networks: A pilot study on the Philippines’, in Clay Wescott and Jennifer M. Brinkerhoff (eds), Converting Migration Drains into Gains: Harnessing the Resources of Overseas Professionals, Manila: Asian Development Bank, pp. 73-97. Ormond, Meghann (2012). ‘Claiming “cultural competence”: The promotion of multi-ethnic Malaysia as a medical tourism destination’, in C. Michael Hall (ed.), Medical Tourism: The Ethics, Regulation, and Marketing of Health Mobility, Abingdon: Routledge, pp. 187-200. Ormond, Meghann (2013) ‘Harnessing “diasporic” medical mobilities’, in Felicity Thomas and Jasmine Gideon (eds), Migration, Health and Inequality, London: Zed Books, pp. 150-162.
10
Ormond, Meghann (2014) ‘Medical tourism’, in Alan A. Lew, C. Michael Hall and Allan Williams (eds), The Wiley-Blackwell Companion to Tourism, Malden, MA: John Wiley & Sons, pp. 425-434. Ormond, M. (2015). ‘Solidarity by demand? Exit and voice in international medical travel - The case of Indonesia', Social Science & Medicine, 124, 305-312. Ormond, M. and D. Sulianti (2014). ‘More than medical tourism: Lessons from Indonesia and Malaysia on South-South intra-regional medical travel’, Current Issues in Tourism. doi:10.1080/13683500.2014.937324 Pandey, A., A. Aggarwal, R. Devane and Y. Kuznetsov (2004). ‘India’s transformation to knowledgebased economy–evolving role of the Indian diaspora’, Washington, DC: World Bank, available at: http://info.worldbank.org/etools/docs/library/152386/abhishek.pdf (accessed 30 April 2015). Raghuram, Parvati (2008). ‘Thinking UK’s medical labour market transnationally’, in John Connell (ed.), The International Migration of Health Workers, Abingdon: Routledge, pp. 182–198. Şekercan, A., M. Lamkaddem, M.B. Snijder, R.J. Peters and M.L. Essink-Bot (2014). ‘Healthcare consumption by ethnic minority people in their country of origin’, The European Journal of Public Health, cku205. Snyder, J., V.A. Crooks and R. Johnston (2012). ‘Perceptions of the ethics of medical tourism: comparing patient and academic perspectives. Public Health Ethics’, 5(1), 38-46. Snyder, J., V.A. Crooks, R. Johnston, K. Adams and R. Whitmore (2015). ‘Medical tourism's impacts on health worker migration in the Caribbean: five examples and their implications for global justice’, Global Health Action, 8. doi:10.3402/gha.v6.27348 Stan, S. (2015). ‘Transnational healthcare practices of Romanian migrants in Ireland: Inequalities of access and the privatisation of healthcare services in Europe’, Social Science & Medicine, 124, 346-355.
Sun, K.C.Y. (2014). ‘Transnational healthcare seeking: how ageing Taiwanese return migrants view homeland public benefits’, Global Networks, 14(4), 533-550. Temenos, C. and E. McCann (2013). ‘Geographies of policy mobilities’, Geography Compass, 7(5), 344-357. Turkish Directorate-General of Health (2012). ‘Evaluation report on medical tourism in Turkey, 2012’, Department of Health Tourism, Republic of Turkey Ministry of Health, Ankara, available at http://www.saglikturizmi.gov.tr/admin/content_img/general/big_images/VY8HA0NDoT.pdf (accessed 30 April 2015). Walton-Roberts, M. (2015). ‘International migration of health professionals and the marketization and privatization of health education in India: From push–pull to global political economy’, Social Science & Medicine, 124, 374-382. Wang, D. (2014). ‘Activating cross-border brokerage: Interorganizational knowledge transfer through skilled return migration’, Administrative Science Quarterly, 60(1), 133-176. Warnes, A. M. and A. Williams (2006). ‘Older migrants in Europe: a new focus for migration studies’, Journal of Ethnic and Migration Studies, 32(8), 1257-1281. Wendland, C.L. (2012). ‘Moral maps and medical imaginaries: clinical tourism at Malawi's college of medicine’, American Anthropologist, 114(1), 108-122. Whittaker, A. (2015). ‘”Outsourced” patients and their companions: Stories from forced medical travellers’, Global Public Health, 10(4), 485-500.Williams, A.M. (2007a) ‘International labour migration and tacit knowledge transactions: a multi‐level perspective’, Global Networks, 7(1), 2950. Williams, A.M. (2007a). ‘International labour migration and tacit knowledge transactions: a multi‐ level perspective’, Global Networks, 7(1), 29-50. Williams, A.M. (2007b). ‘Listen to me, learn with me: International migration and knowledge transfer’, British Journal of Industrial Relations, 45(2), 361-382. Williams, A.M. and C.M. Hall (2000). ‘Tourism and migration: new relationships between production and consumption’, Tourism Geographies, 2(1), 5-27. Williams, A.M. and V. Baláž (2008). ‘International return mobility, learning and knowledge transfer: a case study of Slovak doctors’, Social Science & Medicine, 67(11), 1924-1933. 11
