Attention to trans-border health concerns traditionally has been concentrated mainly on public health issues (e.g., the containment of epidemics, disease prevention and treatment, reproductive health and infant mortality, substance abuse, famine, etc.) from a state-centric perspective under the guise of international health governance (IHG). Underpinned by the view that the nation-state functions as a container, national governments have been considered the appropriate scale of intervention and shouldered the ‘primary responsibility for the health of [their] people’, working together to protect their domestic populations from trans-border health risks (Dodgson et al. 2002: 8). It is within this framework that international bodies emerged in the 19th century to ensure vigilance over international health concerns by facilitating and managing intergovernmental cooperation. While the earlier regimes of IHG were characterised by a narrow biopolitical focus on protecting domestic populations from health risks that would threaten national prosperity made possible by industrialisation and heightened world trade, by the 1920s IHG began to be couched in a philosophy of humanitarianism, informed by the experience of setting up national public health systems that entailed the adoption of a vision of universal entitlement to health. Such notions of entitlement were actively projected and extended beyond national borders, applied in conjunction with the spread of Western-style development models for global prosperity. As a result, the World Health Organisation (WHO), established in 1948 as the UN special agency for health, set as its goal ‘the attainment by all peoples of the highest possible level of health’, with its underlying universalism being consistently reasserted in the years to follow (with the 1978 ‘Health for All’ Declaration of Alma Ata figuring most prominently). Prescribing standards for states to adopt into their national healthcare practices, the WHO’s ‘pledge to universality, however, has been strongly defined by the sovereignty of its member states’ (Dodgson et al. 2002: 11), along with their varying levels of governmental dedication, stability and resources.
In response to ‘deterritorialising’ neoliberal reforms in the form of deregulation and increased transnational flows of people, goods and services, the significant reterritorialisation of the pursuit and provision of healthcare over the last decades has called for the reconsideration of previous scales and modes of national/international intervention. In a report for the WHO, Dodgson et al.
(2002: 7-8) advance that IHG is no longer suited to the current globalised context because of the increased volume and influence of non-state actors in health governance, states’ own reduced capacity to provide for their populations’ health (which has, by extension, limited intergovernmental cooperation on health matters), the introduction/intensification of transborder health risks and the exacerbation of socioeconomic factors that negatively impact health. With IHG increasingly less relevant, Dodgson et al. (2002: 12) propose in its wake the post-national concept of global health governance (GHG), which recognises the ‘new fault lines and allegiances’ that have ‘emerged to form an increasingly complex milieu for health cooperation, with interests divided within and across countries and organisations’. As health has become increasingly bound up with a range of ‘global’ concerns, it has been extended into the political arena as an ‘integrated global public good’ providing benefits to and intersecting with the policy areas of security, trade, development, environmental protection and human rights. This, Fidler (2007: 5) argues, has made ‘global health governance something of a sentinel area for how governance in international relations develops generally in the early 21st century’.
While IHG sought to address the challenge of coordinating states’ behaviour as regards transborder health concerns, Fidler (2007) suggests that GHG is confronted with ‘open-source anarchy’ – a dynamic, unstructured and plural space of governance populated by state and non-state actors representing a broad range of interests and purposes engaged with rationalising and harmonising the terrains and subjects of global health. Non-state actors, like civil society groups, social movements, religious missions and philanthropic foundations (e.g., International Red Cross, the Bill and Melinda Gates Foundation, Médecins sans Frontières, etc.), have made significant contributions to the global health landscape with public health interventions complementing and sometimes challenging or marginalising national efforts, targeted often at trans- and sub-national levels. Furthermore, with the advent of WTO free trade agreements that framed health as a trade issue (e.g., the 1994 Agreement on Trade-Related Intellectual Property Rights (TRIPS) and General Agreement on Trade in Services (GATS)), the transnational private sector (e.g., pharmaceutical industry, multinational private hospital groups, etc.) has also become increasingly involved in GHG (e.g., influencing the production and availability of medicines, telemedicine, practice by foreign medical professionals, etc.). As the state’s relationship with its citizenry is recast, these non-state actors have increasingly picked up the slack left by the state as well as forging new terrains of their
own, revealing new ‘governance potential in the diversity of actors, interests, norms, processes, initiatives and funding streams’ (Fidler 2007: 4) reflected by the scripting of health as an essential factor in the domains of security, economics and universal rights. The spaces they constitute ‘do not represent a “spatial fix” that replaces the national economy’ – instead, their involvement in new forms of governance comprises ‘a composite of spatialities reaching back into and out from the webs and circuits of the nation-state’ (Larner and Le Heron 2004: 212, 227).
States themselves are fundamental actors in this ‘deterritorialisation’. Governments ‘choos[ing] to trade health services to achieve their national health objectives’ (Shimazono 2007), committing to GATS to varying extents, partially surrender sovereignty over healthcare regulation in exchange for a stronger stake in the ‘flat world base-map’ of global healthcare (Sparke 2009b; see Adlung and Carzaniga 2002; Shaffer et al. 2005). These commitments are structured around four principal modes of service supply: Mode 1 – Cross-border supply, Mode 2 – Consumption abroad, Mode 3 – Commercial presence and Mode 4 – Movement of natural persons (see Table 4.1). While most clearly reflected in Mode 2 (Consumption abroad), the IMT industry is articulated through all of these modes, namely the existence (or lack) of restrictions on entry and practice by foreign healthcare providers (Mode 4); restrictions on foreign direct investment in health and other related sectors (e.g., insurance, education and telecommunications) (Modes 1, 2 and 3); and domestic regulatory, infrastructural, financial, capacity and human resources constraints (Chanda 2002; García-Altés 2005: 263).
Since 1994, Malaysia has committed to varied extents to the above four modes in the domains of health services, business and financial services, private higher education and certain professional activities (Blouin et al. 2006: 30; Mahani 2005). While from the outset the government did not limit market access for services carried out under Modes 1 and 2, the same was not true for the more sensitive terrains covered by Modes 3 and 4. The establishment of individual or group practices by foreigners was not permitted. The presence of foreign suppliers was possible for large hospitals, pending an economic needs test and on the condition of joint venture so as to limit foreign participation and ensure Malaysian (particularly bumiputera) shareholding. The heaviest restrictions were on the movement of foreign labour in order to protect Malaysian jobs, limited to intra- corporate transferees and medical professionals for whose specialities the country was in dire need (Khoo 2009: 4). Such was the situation during the time I was undertaking fieldwork in Malaysia in late 2007 to early 2008, when struggles with the direct impacts of restrictions on Modes 3 and 4 were clear. Managing the chronic shortage of medical and nursing professionals, for example, led to intensive investment in the development and retaining of Malaysian human resources and acquisition of new technology (e.g., the in-country proliferation of nursing schools and a
government-sponsored incentives programme to lure back Malaysian professionals living abroad). The Malaysian government’s reticence with regard to further liberalisation stemmed not only from protectionism but also served as a critique of the uneven character of liberalisation. For Tan Lee Cheng, spokesperson for the MOH’s Corporate Policy and Health Industry Division, the solution hinges on reciprocity:
This is globalisation, a bilateral trade issue. If you want a share of our market, you should open your market to us, too. But a lot of the first-world countries are not offering healthcare services as part of liberalisation. (Tan interview, 17/01/2008)
Table 4.1 International trade in services – the four modes of supply Modes Supplier/consumer
relation
Types of health-related
services Examples present in Malaysia Mode 1:
Cross-border supply
The service crosses the border, while the supplier and consumer remain in different countries
Analysis of laboratory samples, diagnosis and clinical consultation via telemedicine,
teleconferencing, teleconsultation, tele- education, etc.
Educational twinning programme between Tun Hussein Onn National Eye Hospital and Birla Institute of
Technology & Science (India); Provision of consultative assistance by the Mayo Clinic (US) to Normah Medical Specialist Centre Mode 2: Consumption abroad Consumers move to the supplier’s location and consume the service there On-site consumption of medical and dental care
Sumatrans and Americans receiving medical care in Penang’s private hospitals
Mode 3:
Commercial presence
The supplier enters the country of consumption and establishes a commercial presence there Foreign investment in hospital operation, medical and dental services and management of healthcare
KPJ Healthcare Group’s pursuit of endorsement by Harvard Medical International; Shareholding by Parkway Group (Singapore) in Gleneagles and Pantai Group hospitals; Management of Prince Court Medical Centre by Vamed (Austria) Mode 4: Movement of natural persons The temporary cross-border movement of labour into the country of consumption
Migration of healthcare personnel from one country to another, whether as a result of intra-corporate transfers, self- employment or salaried labour International ‘expertise-transfer scheme’ at Prince Court Medical Centre; Debate over whether Malaysia should permit Japanese doctors to practice in the country at the request of the Japanese expat community
Source: Herman (2009: 3); UNESCAP (2007: 9)
The situation has since changed. Binding commitments to the 1995 ASEAN Framework Agreement on Services (AFAS) and other regional and bilateral FTAs, along with further autonomous liberalisation, led the Malaysian government to withdraw the 30% bumiputera equity rule for services in 2009 in the areas of health, social services, tourism, transport, business, IT and financial services in order to ‘strengthen our [Malaysia’s] economy to face the increasing challenges of
globalisation’ (MITI 2009). Furthermore, in the scope of the AFAS, liberalisation designed to improve regional efficiency and competitiveness has extended beyond GATS commitments to foster greater regional cooperation and integration in preparation for the future ASEAN Economic Community (AEC) to be formed in 2015, with signatories obliged to undertake ‘complete’ liberalisation of the services sector by 2010 so as to render the region a ‘more level playing field’ and more stable venue for investment (Reuters 16/12/2008). Within the scope of Mode 3 (Commercial presence), the 51% limitation on ASEAN participation switched at the start of 2010 to permit 70% ASEAN equity for healthcare and tourism (MITI 2009). As for Mode 4 (Movement of natural persons), AFAS signatory member-states have entered into Mutual Recognition Arrangements (MRAs) to ensure equal national treatment for service suppliers in ASEAN, facilitating market access by, and therefore the mobility of, registered and certified professionals engaged in engineering, architectural, surveying, accountancy and nursing services as well as medical and dental practitioners through the official recognition of their qualifications (Khoo 2009: 3).
In the midst of such major change, a significant disconnect exists between governments, directly engaged in the trade negotiation process, and local healthcare stakeholders ‘on the ground’, with many coming belatedly to realise that their work has been recast as a service industry subject to international trade relations. This is illustrated by former Malaysian Medical Association President (2007-2009), Dr Khoo Kah Lin’s (2009: 4-5) observations:
International trade in services is a relatively new development as compared to trade in goods and it is inherently different from goods trade: it is intangible, is governed through complex rules and regulations, and its cross-border trade can be provided through different modes of supply. Services cover a very diverse and large number of sectors and sub-sectors, they are under the purview of numerous government agencies and ministries, and some of them may not have (or probably even need) a regulatory framework in place. Healthcare is an even more unique service facing tremendous challenges as it is being transformed into ‘another service industry’ with all its connotations… A number of packages of liberalisation commitments have been scheduled, MRAs have been concluded, and a number of other works are well underway. These negotiations and legislation have been conducted over many years with minimal lukewarm input from the stakeholders of healthcare delivery [in Malaysia].
As we saw in this chapter’s introduction with the issues raised by participants at the 2008 Medical Travel World Congress, as healthcare goes increasingly ‘global’ and more consumers pursue medical care outside of their countries of residence, IMT discursively transcends conventional state-centric conceptualisations of the terrain of healthcare pursuit and provision. This has resulted in a dearth of governance suited to this branch of trans-border health concerned less with the well-being of national populations and more with that of individual transnational patient-consumers. The current
challenge, therefore, is seen as coming up with effective governance of this fluid ‘flattened’ terrain of globalised health. Because national governments have been careful in outwardly displaying their involvement in the development of IMT (see Chapter III), this industry specifically demonstrates the relevance of non-state and transnational private sector actors in shaping the contours of GHG. It has led Cortez (2008: 73-74) to make the radical claim that the IMT industry has developed ‘almost entirely independently of lawmakers and regulators’, with market interests driving the development of private sector-led mechanisms for industry governance.
It is perhaps no surprise, then, that ‘global healthcare’, which requires the ‘open-source anarchy’ that Fidler (2007) observed, has become the newest term in vogue to describe the ‘new political space’ (Kickbush, in Sparke 2009b: 134) that encompasses what has been variously referred to as ‘medical/health tourism’, ‘cross-border care’, ‘healthcare/medical outsourcing’ and ‘international medical travel’. Its conscious promotion by global industry groups signals a significant shift in the discursive contours of the transnational movement of individual foreign patient- consumers, from one that initially conceptualised it as a temporary patch while imbalances in national healthcare systems get resolved (what Josef Woodman (interview, 17/06/2008), author of
Patients Beyond Borders and CEO of the Healthy Travel Company, calls the ‘Band-Aid effect’) to something that now reaches beyond the individual scale and grows increasingly more pervasive, lasting and institutionalised. A recent influential Deloitte Center for Health Solutions report goes as far as describing this private sector-led ‘global healthcare’ spatial imaginary as ‘a manifestation of globalisation and a natural stage in the lifecycle of the healthcare industry’ (Deloitte 2008c: 7, emphasis added). It embraces the pioneering individual medical traveller as well as the insurers, employers and governments sending those in their care abroad for cost-effective treatment; the transnational expansion of medical institutional subsidiaries and the enhanced possibilities of cross- border referrals; and the material and virtual networks necessary to provide equipment and pharmaceuticals, ensure follow-up care and transfer medical records – all the resources and infrastructure necessary to make the industry function as seamlessly, as borderlessly, as possible. Therefore, while other monikers of the medical travel phenomenon inherently imply flows across the borders of sovereign nation-states, the rhetoric of ‘global healthcare’ instead undertakes the ‘political bull-dozing work’ (Sparke 2009b: 137) necessary to evoke the utopian, flattened playing field celebrated in Friedman’s (2006) bestseller that ‘helps him [Friedman] naturalize neoliberal norms and pro-market reforms as the only options available for governance in a flat world’ (Sparke 2009b: 137).
Cortez’s (2008) earlier suggestion that market-based governance has emerged in domains where national regulators and policymakers fear to tread eclipses the significant multifaceted
linkages between the private sector and governmental authorities in the form of public-private partnerships that have fostered and facilitated the liberalisation of healthcare services and expanded flows of patient-consumers, providers, capital and goods. The nation-state’s gradual retreat from its role as principle healthcare provider has left it instead to assume the role of regulator and intermediary of private sector healthcare provision, entailing involvement in multi- level transnational regulation that, far from rendering the nation-state less powerful, rescripts elements of nation-states that ‘can be plugged into new global arrangements while retaining linkages to their previous national functions’ (Porter 2008: 2). Indeed, as we have seen in previous chapters, the national governments of many medical travel destinations (e.g., Barbados, Cuba, India, Malaysia, the Philippines and Singapore) actively collaborate with the private sector in the promotion and regulation of ‘global’ medical travel (Caballero-Danell and Mugomba 2007). Yet, healthcare provision has so long been articulated within national confines that it has proven particularly difficult to harmonise across borders, meaning that the mechanisms and scale of harmonisation are being constantly re-configured. For this to occur, such paths require adherence to what Levi-Faur (2005) calls ‘regulatory capitalism’ which, on the heels of deregulation, demands extensive state re-regulation linked to other technologies and scales of regulation (e.g., self- regulation, corporate compliance systems, etc.).