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Please cite as: Ormond, M. (2014, forthcoming) ‘Solidarity by demand? Exit and voice in international medical travel’, Social Science & Medicine.

Solidarity by demand? Exit and voice in international medical travel – The case of

Indonesia Meghann Ormond1

Abstract Globally, more patients are intentionally travelling abroad as consumers for medical care. However, while scholars have begun to examine international medical travel's (IMT) impacts on the people and places that receive medical travellers, study of its impacts on medical travellers' home contexts has been negligible and largely speculative. While proponents praise IMT's potential to make home health systems more responsive to the needs of market-savvy healthcare consumers, critics identify it as a way to further de-politicise the satisfaction of healthcare needs. This article draws from work on political consumerism, health advocacy and social movements to argue for a reframing of IMT not as a 'one-off' statement about or an event external to struggles over access, rights and recognition within medical travellers' home health systems but rather as one of a range of critical forms of on-going engagement embedded within these struggles. To do this, the limited extant empirical work addressing domestic impacts of IMT is reviewed and a case study of Indonesian medical travel to Malaysia is presented. The case study material draws from 85 interviews undertaken in 2007-08 and 2012 with Indonesian and Malaysian respondents involved in IMT as care recipients, formal and informal care-providers, intermediaries, promoters and policy-makers. Evidence from the review and case study suggests that IMT may effect political and social change within medical travellers' home contexts at micro and macro levels by altering the perspectives, habits, expectations and accountability of, and complicity among, medical travellers, their families, communities, formal and informal intermediaries, and medical providers both within and beyond the container of the nation-state. Impacts are conditioned by the ideological foundations underpinning home political and social systems; the status of a medical traveller's ailment or therapy; and the existence of organised support for recognition and management of these in the home context. Research highlights

Embeds international medical travel in travellers’ home health system struggles

Conceptualises international medical travel as a form of political engagement

Analyses the impacts of international medical travel on travellers’ home contexts

Provides evidence of political and social change at micro and macro levels

Offers novel insight into the impacts of Indonesian medical travel on Indonesia

Keywords Political consumerism, Healthcare advocacy, Health social movements, Medical tourism, Citizenship, Resistance, Indonesia, Malaysia

1 Corresponding author: Cultural Geography, Wageningen University, PO Box 47, 6700 AA Wageningen, The Netherlands. Email: meghann.ormond@wur.nl

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Exit and voice in international medical travel The patient emerges as not just a site for affliction, treatment and research, not just a site for interpenetrations on the part of powerful institutions and competing interests, but a site for examinations of sociality and morality, nature and culture, freedoms and duties, and for a constellation of inscriptions from human rights to consumer rights to legal rights to citizens’ rights.

(Landzelius, 2006, p.536) When it comes to individual and collective health, care and responsibility for them have assumed different territorialisations over time (Sparke, 2009). With the emergence of modern medicine and the modern nation-state, governments have often partially based their claim to legitimacy on ensuring quality healthcare access for their citizens and select resident non-citizens. In some cases, they have even assumed the role of principal provider. Over time, the pursuit, provision, organisation and regulation of health care have been taken for granted as unfolding largely within national and sub-national contexts. In the last decades, however, the retrenchment of social welfare, expanding healthcare marketization and the growth in access to medical, transport and communication technologies around the world have challenged health care’s national containerisation. Health care is enfolded into an ever-broader array of transnational flows and configurations of people, goods, services and ideas. Like the recruitment of foreign health workers, telemedicine and the overseas outsourcing of medical diagnostics and clinical trials, international medical travel (IMT) – ‘a growing industry that involves patients intentionally travelling abroad for non-emergency medical services’ (Snyder et al. 2011, p.530) – is symbolic of this increasingly global and private redistribution of medical expertise, experimentation, technology and governance (Petryna, 2002; Raghuram, Noxolo & Madge, 2009). Yet, paradoxically, the nation-state is so deeply entrenched as a naturalised container for health care that people travelling abroad for diagnosis, treatment and medication have been designated variously as engaging in ‘medical tourism’ and ‘medical exile’ (Inhorn & Patrizio, 2009; Kangas, 2010; Ormond, 2013c). Such terms indicate that the act of leaving their countries for care constitutes a transgression of normative boundaries delimiting appropriate spaces of care and responsibility. The ‘medical traveller’, then, is the transnational articulation of Landzelius’ (2006) ‘patient’ described in the opening quote above, constituted by and responding to an ever-broader array of competing claims and overlapping inscriptions.

Scholars have begun to address the impacts and question the benefits of IMT on its receiving contexts, destinations which are largely concentrated today in lower- and middle-income countries. Among the most pressing concerns for receiving contexts identified are the deviation of public healthcare funding and resources to the development of for-profit ‘medical tourism’ facilities, the crowding-out of locals, prioritisation of paying foreign patients’ needs, and rural-to-urban and public- to private-sector brain-drain of medical professionals (Hazarika, 2009; Ormond, 2014). By contrast, study of its impacts on medical travellers’ home contexts has been negligible and largely speculative. This void perhaps comes as a surprise, considering that IMT was heralded early on by proponents, particularly in the United States with its highly-privatised health system, as a ‘triumph of market democracy’ (Bennett, 1998, p.4). For proponents, healthcare consumers engaging in this ‘exit option’ wield significant power. Consumer demand for viable alternatives abroad that offer significant financial savings and more specialised service provision than the American health system’s dominant delivery models and practices (especially regarding hospital care) is seen as holding the potential to render home health systems more responsive to their patients’ demands. ‘Patients, like all consumers’, one study suggests, ‘will search for providers who offer them maximal value, and medical tourism is an explicit declaration about what patients value most’ (Horowitz et al., 2007, p.4).

Critics, on the other hand, have drawn on Hirschman’s (1970) distinction between expressing dissatisfaction with a good or service via the impersonal economic act of exit, where a consumer ‘uses the market to defend his [sic] welfare or to improve his position’ (15) by ceasing to purchase one thing and instead opting for another, and via the political act of voice, wherein citizens make

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demands openly rather than via ‘the anonymity of a supermarket’ (16). Chee (2010) and Pocock and Phua (2011), for example, argue that, when the middle class can ‘vote’ with their feet and pocketbooks by exiting their home health systems – whether predominantly socialised or privatised – as fee-paying patients abroad, they then have little incentive to exert political pressure for, or may even lose interest in, the improvement of their home health systems’ quality and accessibility for both themselves and their less internationally-mobile compatriots. Exit via the market, these scholars fear, may ultimately efface, erode or ‘paralyse voice by depriving it of its principal agents’ (Hirschman, 1970, p.51) because they no longer need to rely on political means to satisfy their wants and needs, thus undermining the voice of those unable to consume by de-politicising the satisfaction of want (Snyder, Dharamsi & Crooks, 2011; Streeck, 2012). Ultimately, critics argue, exit itself may cease to have its intended impact: ‘Although a patient exodus may cause the government to reconsider its policies, some governments may be content to see the problem exported overseas’ (Cortez, 2008, p.112; see also Pennings, 2002). Indeed, governments, employers and insurers are beginning to explore how to make effective use of IMT to further ‘outsource’ health care and reduce financial burdens and ‘care deficits’ back home (Ormond, 2014).

In this article, I depart from both IMT proponents’ focus on an ‘impersonal’ market-centred exit that substitutes or subsumes voice and its critics’ segregation of exit and voice by instead considering how exit and voice intertwine through IMT. This approach, I argue, permits a more nuanced look at the micro- and macro-level impacts of IMT on medical travellers’ home contexts. To elaborate on this argument, I first present its theoretical underpinnings which draw from work on political consumerism and health advocacy and social movements. Then, after engaging with the limited empirical work on domestic impacts of IMT, I apply this argument to Indonesian medical travel to Malaysia in order to flesh out additional areas of impact and types of engagement. I conclude by reflecting on how reconceptualising IMT as a political tool in this way can lead to promising directions for future research. Health, consumption, citizenship and mobility Though consumption as a political practice is hardly novel, its contemporary revitalisation has been argued to reflect a growing personalisation of politics and consumerisation of citizenship. These are thought to be characterised by ‘limited and easy-to-terminate individual commitments’ (Streeck, 2012, p.45) to single-issue politics without being driven by a sustained or coherent collective ideological foundation. Such critiques reflect popular discourse on consumption which has been shaped by simple binaries like ‘exit/voice’, ‘market/state’, ‘consumer/citizen’ and ‘individual/collective’ that pit self-interest against social justice and civic duty. Scholars and activists have begun to interrogate and complicate such binaries, however. They increasingly frame consumption not as a necessarily isolated, individualised endeavour but, rather, as embedded in macro and micro social and care practices that blur consumption with active (global) citizenship and concern for the self with concern for the other (Smith, 2005; Barnett et al., 2011).

Much recent scholarship in the social sciences has sought to explore the potential of consumer-based advocacy to work towards greater cosmopolitan acknowledgement and acceptance of responsibility for our positions in global commodity chains and recognition of our interdependency in political configurations (Massey, 2004). In a logic of ‘public virtue’ (Micheletti, 2003), acts of conscious consumption encouraging fair trade and environmentally-sound practices demonstrate care for the needs and demands of ‘distant Others’ as global citizens without necessarily benefiting consumers themselves directly, except by permitting them to express their values and commitments (Popke, 2006; Barnett et al., 2011). At the same time, many decisions and acts of purchasing are frequently rooted to the care of the self and/or of one’s family and immediate and imagined communities – ensuring the access, safety, quality, value-for-money, honest advertising and so on of what a parochially-defined ‘we’ consumes (e.g., access to generic pharmaceuticals, food safety, etc.). In a logic of ‘private virtue’ (Micheletti, 2003), then, such consumer-centred advocacy works in the interest of the consumer self and his/her intimate networks of ‘concrete Others’ and then, by extension, the interest of more distant or ‘generalised Others’ (Benhabib, 1986; Hilton, 2005).

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Whether consumer-based or -centred, however, the strategic use of exit, voice and loyalty in the form of boycotts, demands on producers and providers, and selective shopping (i.e., ‘buycotts’) challenges commonly-held views that consumers are manipulated, passive buyers. It instead highlights consumer-based and -centred agency directed towards both market and state actors. It furthermore recognises the multiple sites and types of actors involved in political consumption, de-territorialising political activity from conventional institutionalised settings and encompassing a broader range of forms of engagement and motivation. Marketplaces are increasingly recognised as potent political arenas in which some excluded from or disillusioned by conventional political practice can ‘make choices among producers and products with the goal of changing objectionable institutional or market practices’ (Micheletti, 2003, p.12).

Health has emerged as a particularly powerful frame for mobilising personal frustrations into ‘collective challenges to medical policy and politics, belief systems, research and practice’ (Brown et al., 2004, p.52). Yet, because of the traditionally central role of the nation-state in healthcare provision and regulation, healthcare consumer-based and -centred advocacy has been held in less esteem than advocacy in which people deploy a rights-based approach to health predominantly as citizens in order to demand accountability from the state (de Ceukelaire, de Vos and Criel, 2011). With late modern states redistributing their previous responsibilities by privatising healthcare provision and governance, however, Kearns and Gesler (2002, p.143) find that there has been a ‘symbolic shift in the locus of health care from the world of the service user to the world of the consumer’. This shift individualises responsibility (e.g., by assigning greater self-responsibility for one’s health and awareness of health risks to oneself and their impacts on others) less mediated by government regulation and enforcement. It also functions as a means of making service providers more responsive to the variegated needs of citizens-as-consumers (e.g., efficiency, personalisation, responsiveness and choice) (Barnett et al., 2011).

As noted earlier in the Introduction, there is considerable concern that encouraging citizens to reframe their relationship to health as individualised consumers and engage in international medical travel (IMT) fundamentally conflicts with, and may seriously undermine, public health interests and the common good within both their home and receiving contexts (Blume, 2006). There are growing calls for medical travellers themselves to work to mitigate these potential negative impacts. The rationale here is that, with IMT, as with tourism more generally, the physical, political and social distance that is thought to limit consumers’ sense of responsibility to distant or generalised Others in the commodity chain gets reduced (Fennell, 2006; Popke, 2006). This in theory potentiates new forms of approximation and care-full engagement. As a form of consumer-based advocacy, therefore, Snyder, Dharamsi and Crooks (2011) call for the development of ethical consumption guidelines for medical travellers in order to bring to light labour and environmental conditions in medical travel destinations.

Recent work on responsible tourism, however, suggests that consumers who consider themselves ‘responsible’ at home often ‘disregard such notions of responsibility when booking holidays, and instead choose holidays based on financial considerations and convenience’ (Sin, 2011, p.167). Applying this lesson to IMT, the potential for medical travellers’ recognition and appreciation of their impact on their hosts appear to be less than optimal. Medical travellers’ emotional and corporeal vulnerability, anxieties and (comprehensible) inward-looking focus prior to and during their treatment abroad, on the one hand, and the practice of keeping medical travellers in hermetically-sealed environments, on the other, work to keep the ‘less-developed worlds’ in which many hospitals are located out of the hospitals themselves (Kingsbury et al., 2012; Ormond & Sothern, 2012). While there is certainly scope for introducing more ethical consumer-based advocacy practices in IMT, therefore, their importance and feasibility may be obscured and their reach limited by medical travellers’ own preoccupation, desperation and indignation with what they perceive as injustices and deficits in their own home contexts (see Adams et al., 2013).

It is therefore medical travellers’ home contexts on which I would like to focus as a potentially more productive site for IMT to effect meaningful change via consumer-centred advocacy. Five principal drivers ‘push’ people outside of their home health systems for care: being ‘priced out’

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by prohibitively expensive medical costs and insurance premiums; a lack of medical expertise and equipment; a limited supply and/or restrictions on qualification for treatments and procedures; a desired procedure’s unregulated, experimental status; and the moral polemics certain sought-after procedures may cause at home (Ormond, 2014). These obstacles speak to real and perceived deficits of home health systems as well as a range of broader socio-economic, cultural and political negotiations taking place in medical travellers’ home contexts. Consequently, I want to suggest here that exiting via IMT can be productively reconceptualised not as a ‘one-off’ statement about or an isolated event external to – but rather as one of a range of critical forms of on-going engagement (voice) embedded within – ‘fields of contention’ (Crossley, 1999, in Landzelius, 2006, p.530) in medical travellers’ home contexts over health(care) access, rights and recognition. These fields of contention – which, with IMT, expand by becoming more transnational – encompass a range of sites, types and directionalities of collaboration and negotiation between people living with illnesses and impairments, their care-givers, health workers, government institutions, media, and voluntary and commercial bodies with heterogeneous interests (Brown & Zavestoski, 2004). Exiting an unresponsive home health system can assume different forms (e.g., complementary and alternative medicine (CAM) and hospice care (Pagán & Pauly, 2005; Broom, 2012)) of engagement and be partial, complete, temporary or permanent in nature. IMT is generally temporary: people return home after their treatments and, even if they go abroad frequently for additional care (see Ormond & Sulianti, 2014), they eventually re-engage, at least partially, as patients, consumers and citizens whose exits and re-entries are ‘voiced’ and heeded, managed and condoned differently by family, friends, communities, healthcare providers and policy-makers back home. What is known about the domestic impacts of IMT? Before engaging with the above approach in my Indonesian case study, I first wish to situate it relative to the scant but instructive extant work addressing IMT’s domestic impacts. Focusing on source contexts in the Global North, scholars have suggested that domestic impacts of international medical travel (IMT) and responses to them are heavily contingent on the political, social, cultural and economic conditions of medical travellers’ home contexts.

First, impacts speak to the ideological foundations underpinning home health systems and shaping users’ solidarity with them. Snyder, Crooks and Johnston (2012), for example, found that Canadian medical travellers who believed that they were ‘driven’ abroad by what they found to be ‘unethical and inequitable aspects of healthcare provision within Canada’ (41) were ‘largely dismissive of [home health] system-level concerns’ (44). However, while they may not initially recognise their potential to adversely impact their home health systems, it is suggested that they may more easily acknowledge this and assume greater responsibility relative to their fellow Canadian health system users because they are part of a socialised system, as opposed to those coming from privatised systems where health is not considered a social good. As such, Snyder, Dharamsi and Crooks (2011) and Adams et al. (2013) call for raising Canadian medical travellers’ awareness of their responsibility to minimise inefficient or abusive use of collective home health system resources upon return. Good patient-citizens’ responsibilities to their home country include properly following prescribed therapeutic regimes and selecting reputable facilities and doctors abroad in order to reduce the possibility of medical complications and of passing on hospital-acquired infection once back home (Hall & James, 2011).

Second, IMT serves as a comparative tool that travellers leverage when demanding change at the micro and macro levels within their home contexts upon return. Snyder, Crooks and Johnston (2012), for example, identify the potential for Canadian medical travellers to enjoy being healthcare consumers abroad and return home with market-based expectations that do not correspond to what Canada’s more socialised system may offer. Yet IMT may also have the opposite effect: producing greater appreciation for and investment in medical travellers’ home health systems. Seear et al. (2010, p.18) note, that experiencing

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a poor level of hygiene and lack of contemporary equipment in Chinese hospitals… some patients have formed a view that if SCT [stem cell treatment] were available in Australia, many of these discomforts and disadvantages could be avoided. In this sense it is possible that adverse experiences may actually serve to strengthen a commitment to SCT and to advocacy efforts for the increased availability of treatments [in Australia.]

Medical travellers’ expectations also may be altered even prior to embarking on their journeys. Direct-to-consumer medical advertising, which has facilitated the growth of IMT, for instance, enables radically increased contact between patient-consumers and specialist providers that flattens conventional doctor-patient hierarchies and challenges medical gate-keeping traditions (Lunt et al., 2010; Seear et al., 2010).

Finally, the literature suggests that domestic impacts of IMT depends on the legal, social and medical-ontological status of a medical traveller’s illness, impairment or desired therapy and the existence of organised support for recognition and management of these in his/her home context (Brown et al., 2004; Landzelius, 2006). Seear et al.’s (2010) Australian respondents – people living with chronic degenerative diseases and their informal care-givers – pursuing stem-cell treatment abroad, for instance, are frustrated by what they perceive as their own country’s ‘backward’ regulatory limitations. These travellers’ successful mobilisation of support by family, friends and local communities in Australia through fund-raising, care-giving and media coverage before, during and after costly stem-cell treatments abroad, they suggest, may play a meaningful role in raising awareness and changing everyday political views on controversial issues like stem-cell treatment and research within their broader communities. Domestic impacts of Indonesian medical travel While the bulk of international medical travel (IMT) takes place between countries of the Global South, policy-makers, entrepreneurs and scholars alike have neglected identifying and assessing both the benefits and challenges of travel flows that do not conform to a North-South binary (Ormond & Sulianti, 2014). The same can also be said about the directionalities of consumer-centred health advocacy and political consumerism. In this section, therefore, I seek to expand the scope of these bodies of work by considering the influence of Indonesian medical travel on Indonesia itself.

The Indonesian government is working to improve access to basic health care and reduce the incidence of contagious and preventable disease among its 250 million people (Aspinall, 2014). However, Indonesia’s epidemiological transition has meant that lifestyle diseases (e.g., some kinds of cancer and diabetes) increasingly coming to the fore are not being adequately addressed and managed (Eeuwijk, 2006). Outside of the country’s capital, Jakarta, medical specialists, technicians, equipment and facilities are sparse. However, Indonesians affected are not engaging in conventional collective civic action to protest their dissatisfaction with the poor condition of healthcare financing, infrastructure and human and material resources. Rather, each year, at least one million Indonesians – hailing largely from the country’s growing middle class – are making use of more affordable international transport and greater political ease in crossing borders to satisfy their health needs and demands in neighbouring countries like Malaysia and Singapore (IRIN, 2009; Lee, 2012; Bhatt, 2013; Ormond, 2013a,c; Smith, 2013). National commentators have suggested that ‘[l]ittle can be done to limit the practice [of Indonesian medical travel] as the government struggles to provide access to health care for average Indonesians who are financially weaker and generally in greater need’ (Hulupi, 2006). The Indonesian Medical Association (IDI) has admitted, ‘We cannot blame people for seeking treatment overseas’ (in Gunawan, 2007). Yet, at the same time, Indonesians engaging in IMT are increasingly being criticised for ‘jumping ship’ by Indonesia’s top politicians who, ironically, themselves routinely pursue medical care outside of Indonesia (Sulaiman, 2012).

In keeping with the conceptualisation of IMT as a temporary exit practice embedded in ‘fields of contention’ (Crossley, 1999, in Landzelius, 2006, p.530) around health(care) access, rights and recognition, this study was designed to focus not only on the perspectives and actions of medical travellers and their care-giving companions but to also bring attention to other types of social actors

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involved in challenging conventional medical order, authority and identity. Private hospitals in Peninsular Malaysia’s states of Penang and Melaka received most Indonesian medical travellers in 2007, hosting 66% and 22% respectively, followed by the East Malaysian state of Sarawak (5%) and the Kuala Lumpur greater metropolitan area (3%) (Association of Private Hospitals of Malaysia, 2008). As such, for this case study I draw from empirical material from two periods of qualitative fieldwork in these areas to examine the domestic impetus for and impacts of so many Indonesians going abroad each year. In the first period, 50 Malaysian private hospital representatives, medical travel agents, private- and public-practice doctors and members of civil society were interviewed over six months in 2007-08 in Penang, Melaka and Kuala Lumpur. The second period spanned six weeks in 2012 and was sited in Kuching, Sarawak’s capital and home to the state’s main private hospitals, and Pontianak, home to over half a million people, a significant source of medical travellers to Kuching and the capital of the Indonesian Borneo district of West Kalimantan. Convenience sampling was used to conduct 35 semi-structured interviews with outpatient Indonesian medical travellers and their travel companions, Indonesian and Malaysian medical specialists, private hospital administrators and medical travel intermediaries. Prior to commencing interviews, respondents received study information and provided verbal consent. Patients and companions were asked to describe what led them to pursue medical care abroad as well as their preparations for and experiences of it. Doctors, administrators and intermediaries were asked about their experiences with medical travellers. All interviews were digitally recorded, transcribed, translated into English from Bahasa Indonesia where necessary and then thematically coded both inductively and deductively. All responses have been anonymised. Reluctant exit Regardless of the type of ailment that led them to pursue care in Malaysia, the Indonesian health consumers and travel companions interviewed repeatedly claimed to feel let down by their home health system. Lacking or inadequate medical infrastructure and equipment, poor-quality pharmaceuticals, inaccurate diagnoses, a shortage of skilled human resources, and medical professionals’ poor management of and communication with their patients topped their list of complaints (Ormond & Sulianti, 2014). Yet, while IMT is a notably common practice among middle-class residents in their local communities, many indicated remorse about needing to temporarily exit the Indonesian health system. As the excerpts below demonstrate, several respondents regretted that their money should leave the Indonesian economy and end up in the coffers of providers abroad:

People are forced to come here [to Malaysia]. It’s about our lives. We already spent money on local health treatment [in Indonesia] without being cured. The situation makes it difficult for Indonesia to develop its health services.

(Indonesian medical traveller in Malaysia, a small business owner in his 60s) It’s such a loss for the Indonesian government because most of the patients at [this private Kuching hospital] are Indonesian. The cost of chartering a car from Pontianak to Kuching is approximately IDR 3.5 million [USD 300]. That amount of money, if the local medical service is good, should be spent at [a private Pontianak hospital].

(Husband of an Indonesian medical traveller in Malaysia, a housewife in her 30s) Unlike Snyder, Crooks and Johnston’s (2012) Canadian respondents for whom the general reliability and robustness of their socialised home health system was taken for granted, these middle-class medical travellers – experienced private healthcare consumers in Indonesia that would rarely, if ever, consider turning to under-equipped and -funded public health providers for care – were very conscious of the broader social and economic impacts of IMT on their struggling national mixed-provider health system. Respondents’ comments suggest a sense of nationalism and civic responsibility for improving their national health system by acting in the capacity of consumers,

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identifying their medical expenditure abroad as – though necessary to improve their personal health and secure their families’ welfare – a significant economic leakage that could have made a difference if ‘invested’ in an Indonesian system that showed signs of improvement. However, reflecting a chicken-and-egg situation, most are unwilling to trust Indonesian healthcare providers for little but the most basic of ailments until there are real signs of improvement. Revelation and mobilisation upon return Seeking to spend less money, obtain accurate diagnoses and experience instant results from medical treatment and medication, some Indonesian respondents opted to go directly abroad, bypassing their local providers completely. Among those who sought local treatment first, however, several ultimately pursued care in Malaysia because either they did not think that they were making fast-enough progress with their treatment regime or their medical needs and concerns were not thought to be taken seriously by doctors back home. By contrast, Indonesian medical travellers spoke effusively about how much better the Malaysian health system was than the one out of which they felt they were driven:

I think that 90 percent of patients here [in a Kuching private hospital] come from Indonesia – especially from Pontianak. We understand why. Doctors here [in Kuching] are more open, honest, and explain to us whether illnesses can be cured or not. They will keep us informed – giving us the percentage of likelihood for a cure, giving us all the information we need. They are clearer and more open – friendlier, more familiar. They will inform us about everything. Our local doctors in Pontianak sometimes hide the truth from us. That’s the weakness of local doctors in Pontianak. They are not open with patients – they don’t want to be open with us. [… They] will not answer our questions. Sometimes I have been ignored by the doctors.

(Indonesian medical traveller in Malaysia, a small business owner in her 40s)

Malaysia was overwhelmingly framed by respondents as a promised land of reliable diagnoses, treatment and medication on which they believe an improved Indonesian system should be modelled.

As Smith’s (2013) account of Indonesian medical travel out of post-tsunami Aceh demonstrates, the contrasts medical travellers experience are often profound:

When they return from Malaysia and tell others of their encounters with ‘friendly’ and ‘intelligent’ Malaysian doctors, Acehnese depict the disparities between the Indonesian and the Malaysian health care systems as a form of injustice. As medical travel becomes more accessible to poor and middle-class Indonesians, the regional health disparities that have long been noted in statistical reports are becoming increasingly apparent to ordinary people.

Yet, without significant recourse to the internet and with post-Reformasi civil society only beginning to mature, medical travellers instead direct their narratives of contrasting healthcare experiences in Indonesia and abroad to their intimate networks of ‘concrete Others’ (Benhabib, 1986): family, friends, neighbours, colleagues and religious communities. It is in these localised networks that Indonesian medical travellers actively articulate what they perceive as the most significant failings of their home health system and spread information about how to access viable alternatives abroad.

Not limited to sharing frustrations and practical information, these networks are also mobilised materially, financially and emotionally to facilitate IMT for those within them. Money for travel and treatment is raised within these networks and contacts with extended family and friends of friends in Kuching are given. As evidenced in the following excerpt, some medical travellers also take it upon themselves to assist others:

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Many people suggested that we come to Kuching because they said that the medical treatment here was good. The guy over there [a neighbour who drove her son, sister and husband to Kuching for her husband’s treatment] had the experience of falling ill and being cured here [in Kuching]. […] We weren’t sure about coming to Kuching, but after we heard about it through word-of-mouth, we decided to come, especially after he [the neighbour] shared his experience of getting sick and being cured here.

(Wife of an Indonesian medical traveller in Malaysia, a civil servant in his 50s) For-profit medical travel guides have also emerged out of these informal support networks. Those using the experienced guides invest great trust in them, turning to them to provide transport and organise accommodation, suggest an appropriate specialist for their specific condition, provide linguistic interpretation in consultations with doctors when necessary, or even lend money when the cash they bring with them runs out (Ormond, 2013a). Notes one Pontianak guide, who was once a medical traveller himself:

I saw patients look for treatment here in Pontianak but they couldn’t get it. […] So, I thought I’d start the business. It’s not simply profit-oriented but also has a social mission. […] I was interested in this business because I wanted to help people.

He built up his business decades earlier by driving local Indonesians to a remote non-profit, foreign-run missionary hospital, a respected facility once widely perceived as the best hospital in West Kalimantan in spite of its distance from the district’s major population centres. Once Kuching private hospitals became recognised in the cross-border region for their range of medical specialties and technology, however, he began taking Indonesians there instead. In identifying and responding to his community’s need for quality health care, he sees himself as a social entrepreneur. Improving Indonesians’ health from afar? Malaysian doctors’ and hospitals’ openness to Indonesian medical travellers as consumers has been received by some Indonesian authorities not as a supportive, collaborative act but rather as the patronising flexing of political and economic muscle by a more ‘developed’ country. Malaysia is seen here as keen to poach Indonesian doctors’ and hospitals’ ‘rightful’ patients instead of demonstrating solidarity with their citizens through more conventional humanitarian aid avenues that recognize nation-states as the most appropriate venues for ensuring the welfare of their populace (Ormond, 2013c). Sensitive to territorial claims over who should be caring for whom, Malaysian for-profit providers have learned to refine how they frame their services so as to avoid being perceived as over-stepping:

We say that we are always here to offer alternatives to your people. You should go to your doctor first. However, if you want a second opinion or a procedure that is not available in your country, then come here [to Malaysia].

(Private hospital marketing representative, Melaka)

While acknowledging their complicity in the industry of IMT, private Malaysian providers interviewed also tended to see what they individually did as helping to relieve some of the burden on a health system too poorly-equipped to respond effectively to the needs of all Indonesians:

All of us [Malaysian doctors] do this [treat Indonesian medical travellers] because they come over for whatever is not available [in Indonesia]. On the country-to-country level, it’s Malaysia saying, ‘Why not? So many millions of Indonesians! We can set up so many private hospitals!’ It’s purely medical tourism – nothing more than that. But obviously, on the individual level, some doctors go the extra mile, saying, ‘I will help you. If you can’t afford it, I will waive the fee’ – these kind of things on humanitarian grounds. It’s

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kind of individual; some doctors have the heart to go the extra mile, while some look at it from a purely profit-oriented point of view.

(Malaysian medical specialist in private practice, Kuching) To further demonstrate good will, some Malaysian private hospitals have also begun to demonstrate their promotion of the welfare of both the communities in which they are located and those from which their Indonesian customers hail through corporate social responsibility (CSR) measures. With a view to developing a positive reputation and consolidating relationships within the different Indonesian communities in which they operate, for example, Kuching’s three private hospitals donate used equipment to the abovementioned West Kalimantan missionary hospital. However, because the equipment is antiquated and does not satisfy the hospital’s actual needs, such efforts were criticised by some respondents as empty public relations gestures. Separate from the hospitals’ donations, a group of Christian medical specialists from Kuching also volunteers in an individual, private capacity at the missionary hospital, though their support is restricted to medical training due to Indonesian law prohibiting foreign doctors from treating patients without holding its national certification. Support efforts do exist elsewhere, such as one private hospital in Melaka that funds skilled health worker training in order to reduce shortages in Indonesia. Notes one of the hospital’s marketing representatives:

Many think that we are just being opportunists, going in and taking whatever we can from Indonesians. But we need to be a responsible corporate body, to show some responsibility and initiatives to help them.

Undertaken in good faith or not, however, private Malaysian volunteer and charity-based approaches to ameliorating Indonesian health care such as these remain erratic, temporary and fraught by restrictions, reducing their effectiveness in satisfying locals’ health needs. Improving Indonesians’ health from within? The large annual outflow of Indonesian medical travellers has attracted the Indonesian government’s attention. In 2010, the Indonesian Ministry of Health announced that curbing medical travel was key to the development of the national health system. It was, they suggested,

time for the people of Indonesia to obtain health services with international standards, eliminating the need for Indonesian citizens to pursue medical treatment abroad. In addition to meeting the demands of the community, this effort will also reduce the flow of sizeable amounts of Indonesian foreign exchange overseas.

(Kementerian Kesehatan Republik Indonesia, 2010)

To stem flows in West Kalimantan, public and private hospitals are seeking to improve their reputations relative to providers in Malaysia and Singapore, the most popular destinations for Indonesian medical travel, and to instil greater faith in local doctors and health care. The public Regional General Hospital Soedarso in Pontianak, for example, recently invested IDR 8 billion (USD 660,000) in order to acquire much-needed diagnostic and monitoring equipment like magnetic resonance imaging (MRI) and computed tomography (CT) scanners to serve the district in part ‘so that people no longer need to leave West Kalimantan for medical treatment abroad’ (Dr Gede Sanjaya, in Rakyat Kalbar, 2012).

Yet the Indonesian doctors and hospital officials interviewed argue that acquiring up-to-date medical equipment and resources is only part of the solution. In order to reduce Indonesian medical travel, it would be necessary to profoundly overhaul the Indonesian health system to enable doctors and hospitals to provide the standard of care that more Indonesians have grown to expect due to their experiences abroad (e.g., reduced waiting times for specialist consultations and diagnostics and longer consultations):

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It’s important to change the paradigm about patients – patients must come first. It’s important to improve services for patients, and this will change the whole system. Patient-centred care. […] Malaysia and Singapore already have patient-centred care, and this will begin in Indonesia, too. The hospital will have to follow up with the patient.

(Indonesian private hospital director, Pontianak) Therefore, while there are plans underway to improve the national health system’s infrastructure, human resources and financing mechanisms in order to keep Indonesians in Indonesia (International Medical Travel Journal, 2010; Bhatt, 2013), it remains unclear when, and the extent to which, peripheral regions like West Kalimantan will benefit from such an overhaul.

It is, nonetheless, patent that Indonesian medical travel has made important political, social and economic impacts in Indonesia. The large and unrelenting number of those going abroad each year for care has drawn such public attention to some of the principal obstacles to accessing quality diagnoses, treatments and medicines for ailments increasingly common among the growing Indonesian middle class that medical travellers have become simultaneously a target of condemnation and reconciliation by national government and public and private healthcare providers (see, e.g., Rakyat Kalbar, 2012). It has mobilised local communities not only to share information about alternatives abroad but also to provide a strong, flexible and mobile base of material, financial and emotional support and guidance for those opting to use IMT to address their health concerns. It has even generated a handful of more or less successful and genuine attempts by providers in Malaysia, both at the corporate and individual levels, to mitigate the deficiencies of the Indonesian health system and thus diminish the need for Indonesians to travel abroad for medical care. Conclusion In an attempt to re-politicise the satisfaction of want through market means (Streeck, 2012), this article has conceptualised international medical travel (IMT) not as a way to individually and permanently exit an unresponsive home health system but rather instead as embedded in medical travellers’ existing home health contexts and struggles. By drawing from literature on political consumerism and health advocacy and social movements, I have sought to demonstrate here how IMT can serve as a consumer-centred advocacy tool to voice concern and engage with transnational ‘fields of contention’ (Crossley, 1999, in Landzelius, 2006, p.530) over health(care) access, rights and recognition. Through a review of extant literature addressing the domestic impacts of IMT and by offering up a case study on Indonesian medical travel, I have shown how IMT, as an act of temporary exit, may effect domestic political and social change. I argue that this is accomplished horizontally through altering the perspectives, habits, expectations and accountability of, and complicity among, medical travellers, their families, communities, formal and informal intermediaries, and medical providers both within and beyond the container of the nation-state. These findings effectively challenge and complicate conventional conceptualisations of medical travellers as atomised and de-politicised consumers concerned only with improving their own individual wellbeing. They further demonstrate how multiple sites and social actors with heterogeneous interests influence medical travellers’ awareness of disparities and injustices and assist in mobilising and sustaining acts and relations of solidarity.

This article has focused mainly on how IMT is used by loose configurations of citizen-consumers without a strong collective self-awareness who are unable to access affordable treatment or medicines; face a lack of available trained health workers, facilities, equipment, biological resources and medication; or are challenged by a procedure’s limited availability in their home contexts. It would be productive, therefore, to examine how IMT is and can be used within other fields of contention in health and health care. For example, how might IMT be undertaken by people encountering limitations because of who they are within their home societies draw attention to their specific health needs and their exclusion from political agendas and medical research? Consider here

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women in ‘reproductive exile’ (Inhorn & Patrizio, 2009) who are excluded from qualifying for certain types of fertility treatments due to definitions of ‘appropriate’ age, marital status or sexual preference (Pennings, 2002; Whittaker, 2010) or uninsured immigrants in socio-economically and politically precarious conditions (Horton & Cole, 2011; Ormond, 2013b). Furthermore, IMT is used to access therapies and procedures that remain unregulated or highly restricted back home by patients whose conditions give them little hope but to turn to experimental or controversial procedures. Take, for example, people living with Parkinson’s disease or muscular dystrophy that go abroad for stem-cell therapies unregulated at home in spite of official warnings that benefits are unproven and therapies may in fact prove harmful (Seear et al., 2010; Song, 2010). Given these medical travellers’ comparative openness to unregulated or experimental therapies, then, how might their use of IMT facilitate transnational partnering with scientific researchers, doctors and political allies abroad? Finally, consider the growing number of people undertaking cosmetic surgery abroad in the context of a societal ‘pathologisation’ of ageing (Landzelius, 2006; Holliday et al., 2013). How does IMT get used to further or even author ontological claims about medical travellers’ (perceived) ailments and impairments? There is significant scope for future research on IMT’s embedment in consumer-centred health advocacy at local, national and global levels. References Adams, K., Snyder, J., Crooks, V.A. & Johnston, R. (2013). Promoting social responsibility amongst

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