UN VISTAZO A LA AUTONOMÍA PROCESAL DEL TRIBUNAL CONSTITUCIONAL Y SUS LÍMITES.

I undertook purposive sampling, selecting sites throughout Malaysia and organisations that would allow me to make comparisons and discover variations among concepts and practices of care- provision (Strauss and Corbin 1998: 201, in Bryman 2008: 415). I did not include foreign patient-

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Though, for logistical reasons, it did not happen in the scope of research for the thesis, future research will be undertaken in Indonesia (the most important sending context in terms of volume).

consumers in Malaysia for several reasons. Ethically, they constitute a vulnerable group while hospitalised and in the special places (e.g., resorts, hotels, long-stay apartments, etc.) chosen for convalescence in Malaysia, and it is commonly held that one of the draws for seeking treatment away from one’s own country is the wish to ensure one’s privacy. Furthermore, studies of foreign patient-consumers’ experiences (see Kangas 2002, 2007; Ono 2008) generally trace them prior to, during and after their care pursuits over a lengthy span of time. This sort of scope was not economically feasible nor would it have helped me explore how ‘hosts’ and care providers conceptualise IMT and mobilise ‘Malaysia’ as an IMT destination. Therefore, prior to commencing the fieldwork in Malaysia, I undertook a preliminary Internet-based search in Malaysian newspaper articles, medical travel industry websites and press releases and official reports to compile an inventory of prospective interviewees spanning governmental bodies, professional organisations, civil society and private-sector interests throughout the country that held some type of published link to the development of IMT to Malaysia.

Once in Malaysia, I proceeded to send letters, emails, make telephone calls and visit the groups and institutions identified in the preliminary search. The number of non-replies, disconnected phone numbers and bounced e-mails to my initial interview requests is indicative not only of the precarious and ephemeral existence of many entities involved in IMT (e.g., from small- scale medical travel facilitators like Medical Service Coordination International to heavyweights like the nebulous National Committee for the Promotion of Health Tourism (NCPHT)), but also the number of references made in published materials to entities only nominally implicated in the industry and/or unwittingly associated with it (e.g., Malaysian Association of Tour and Travel Agents (MATTA) and Tung Shin Hospital) or that leverage the trendy terminology of IMT to attract media attention. The emergent status of IMT as a tool for development, therefore, translates into a relatively small yet dynamic constellation of proponents and promoters, spanning federal, state and urban governmental authorities, international and national professional associations, private and corporatised hospitals and specialist clinics, and medical travel facilitators in Malaysia. An even smaller number of vocal detractors – largely civil society representatives – exists. Furthermore, in light of IMT’s politically contested status as a state-endorsed driver for national economic growth, I had been advised by anonymous Malaysian insiders early on that it would be difficult to gain access to stakeholders, particularly government representatives, willing to discuss the development of an industry characterised as much by its fragmentation as by its glossy veneer. This was sometimes the case, with several requests for interviews with government officials declined. However, this was partially attributable to internal structural reorganisation within both the Ministries of Health and

Tourism during my period of fieldwork that produced a reshuffling of competencies, generating guarded reluctance and unwillingness to speak on the matter.

This preliminary Internet trawl, however, yielded many of the early interviews, permitting engagement from the start with multiple entry points to a range of actors variously involved with IMT (Valentine 1998: 116). Following this, contacts from interviewees, interview content and identifying linkages with the secondary data led to use of the snowballing technique to recruit other interviewees. Limited time and resources and the above-mentioned political sensitivity surrounding IMT restricted access to a number of interviewees and hindered my ability to undertake additional interviews with interviewees. Future research, however, will attempt to gather perspectives from a larger number and variety of interviewees throughout Malaysia – with special attention to international and domestic patient-consumers, health workers across the ranks, the health insurance industry and international transport providers – as well as to revisit many of this study’s interviewees to gain insight into the ever-shifting dynamics involved in the project of harnessing IMT.

My reliance on largely elite institutional gatekeepers implied that I had limited access to the doctors, nurses and other health workers directly engaged in caring for foreign patient-consumers ‘on the ground’. It proved difficult to get the permission of CEOs and public relations and marketing staff to move beyond the front-line and witness and discuss ‘everyday’ healthcare encounters in medical facilities. At the same time, however, the ability to hold interviews with these institutional elite – who are responsible for identifying and engaging with particular markets, creating policy and promoting IMT – indicated the social and political sensitivity and, at the same time, the prestige of engaging as a provider with IMT. These interviews also provided a wealth of valuable insight into the myriad types of less-obvious ‘everyday’ hospitality and care practices that take place in IMT provision both within and outside of the facilities themselves (e.g., outreach abroad to inform prospective patient-consumers of the availability and accessibility of care in Malaysia, arranging travel and accommodation for patient-consumers and their visiting family members, ensuring the presence of interpreters and local transportation, negotiations over pricing with families unable to cover the full economic costs of treatment and care, etc.). Keeping in mind the ways in which I was able to access interviewees, it is important to avoid reifying the authority and influence of the array of IMT proponents and detractors that I refer to herein as ‘stakeholders’ and ‘agents’. Recognising that those perceived to be ‘exercising power in a particular field may be a disparate, informal or even invisible network of people, dispersed across a variety of locations and professions’ (Smith 2006: 646) has helped me situate said ‘stakeholders’ within a context that renders their interdependencies and vulnerabilities more apparent.

Ultimately, single in-depth, semi-structured interviews, lasting between 40 minutes and three hours each, were held with 49 interviewees (see Appendix 2) representing the following types of institutions:

• Top-level executives and administrators (e.g., CEOs, directors, senior managers, board members and advisors) for governmental, private and not-for-profit bodies;

• Research, business development, marketing, policy, public relations and customer service executives and officers;

• Medical travel facilitators and • Medical professionals.

In recognition of the influence of place in conditioning the interview experience (Kesby 2007), interviews were most frequently held in interviewees’ private offices, closed-off meeting rooms or in urban public spaces selected by the interviewees themselves to ensure their comfort. This permitted us to talk without the interviewees needing to feel very concerned about whether their colleagues would overhear them. With the exception of a few cases in which recording was not permitted or where official commentary was sent to me by e-mail, the interviews were recorded and transcribed.19

Throughout the interview process, the subjectivities of both researcher and respondent proved integral to the knowledge produced. Since, as an interview develops, ‘we are constantly (re)producing “ourselves” so that researcher and interviewee may be multiply positioned during the course of an interview’ (Valentine 2002: 121, in Smith 2006: 647), I sought to be alert to both interviewees’ and my own multiplicity of positions engaged with or silenced in the research process. Studying in Scotland, having lived in Portugal for several years and coming originally from the United States, interviewees – oftentimes asking where I came from – received a not-so-simple answer that drew from these formative international experiences. Most all interviewees were in situations similar to myself – growing up in Malaysia and having studied abroad (e.g., Singapore, the UK, the United States, Australia, New Zealand, Hong Kong and Japan), working in many of these as well as the Gulf countries, and with family members spread across the globe. Still other interviewees were expatriates and transnational entrepreneurs of non-Malaysian origin seeking to tap into the country’s promise. It appeared that the harnessing of IMT as providers gave many an outlet for sustaining and building upon the linkages they had developed previously elsewhere.

19 With most all respondents being multilingual, English served as the lingua franca. Respondents were informed verbally and in writing about the scope and purpose of the study in which they were voluntarily participating. Some preferred to speak with anonymity, while others were comfortable with associating their names to their comments. In order to ensure the formers' right to anonymity, I have anonymised their comments in the thesis.

Yet, while at times our shared transnational trajectories generated rapport and respectful recognition of our varied engagements with IMT, I was at times explicitly identified by some Malaysian interviewees as representative of the European imperial and American hegemonic arrogance against which they were seeking expressly to situate both their institutions and themselves as Malaysians as responsive, more caring alternatives (see Valentine 1998). In conflating me with the ‘West’ more generally (e.g., ‘you in the West’) or specifically with massive institutions with ‘ageing technology’ like the British NHS, the ailing U.S. healthcare system and post-9/11 invasive anti-terrorism measures in the U.S. (e.g., ‘they don’t like your sniffing dogs’), these interviewees drew attention back to the ways in which I am perceived relative to the topic I am researching. As Gokariksel (2003: 41) notes, ‘Self-reflexivity during and after the fieldwork means thinking about how the relations between the researcher and research participants have been constructed and negotiated’. These experiences underscore how interviewees’ accounts were situated and co-constructed in the moment of the interview.

Overall, these varied interview encounters offered valuable insight into how the industry stakeholders I interviewed constructed their target foreign patient-consumer markets and their respective needs and concerns, as well as into the lenses through which they construct the providers and systems with which they see themselves competing. At the same time, however, endorsement from the Prime Minister’s Economic Planning Unit (EPU) and my visiting researcher affiliation with the University of Malaya also sometimes seemed to put me in an odd in-between position, with some interviewees being at greater ease with my research objectives due to their familiarity with these institutions, facilitating or enabling access to official data and interviews, particularly with state and quasi-state authorities. Furthermore, I conducted interviews at the same time as three different major international consulting companies were undertaking studies on IMT, meaning that some interviewees had been interviewed already multiple times prior to meeting with me and sometimes would align my research with that of the consulting companies – their answers at times feeling well-rehearsed.

I loosely employed an interview schedule with three sets of questions, covering the general development of the IMT industry in Malaysia, changes in the pursuit and provision of medical care and the overall customer base (see Appendix 3). The same interview schedule was used with all interviewees as a point of departure to prompt open-ended responses and discussion. To begin, I first asked interviewees to tell the story of how IMT to Malaysia began and what prompted the industry to emerge as a response. I sought to trace interviewees’ normative constructions of the IMT industry’s development, paying attention to the landmark events, practices and values they identified as having significantly shaped its contours. Interviewees were asked to describe how their

institution fits within this process and the factors driving institutional interest in developing and promoting IMT to Malaysia. The identification of linkages and networks with which the respondent’s institution is engaged served as a way to get interviewees to point out the players they deemed pivotal to the industry, who and what they consider to be authorities in the field, and the alliances and disconnects they identify as relevant to their progress. They were then asked to identify the strengths, weaknesses, opportunities and threats (SWOT analysis) for the broader industry as well as their own institutions’ engagement with IMT. Specifically, I posed questions concerning the overall effects of IMT on the public and private divide in the national healthcare system that have been critically addressed in media coverage and academic literature. These included IMT’s potential to exacerbate rising healthcare costs and privatisation, brain-drain (public/private, rural/urban and domestic/foreign) and influence on the quality of healthcare provision and access to it by local patient-consumers. These narratives demonstrated the discursive processes through which the stakeholders negotiate their position in healthcare in relation to others as part of ‘the ethical problematisation of consumption’ (Barnett et al. 2008).

The second set of questions addressed the changes taking place in the provision and pursuit of medical care in an increasingly globalised context. Questions were posed about the consumption of healthcare, particularly how patient-consumers acquired health knowledge and advocated for their health interests. Interviewees were asked to reflect on the influence of medical technology and developments in biomedicine on the ways in which medical professionals and patients understand ‘health’ and the ways in which it is pursued. They were asked to comment on the extent to which they feel the impact of international political relations and trade agreements (e.g., GATS, ASEAN, etc.) on healthcare practices. Interviewees were also asked to identify how they see IMT articulating with the Malaysian government’s overarching development ideals in light of IMT’s enshrinement as a driver for national economic growth and development. I sought here to identify overlaps and disjunctures between visions of development at a range of scales and stakeholders’ everyday practices that accept, appropriate, coincide with or resist them.

The patient-consumers fuelling IMT to Malaysia were discussed in the final set of questions. Interviewees were asked to estimate the number of medical travellers handled by their institutions and how they were counted and categorised. They were then asked to list and discuss the reasons that foreign patient-consumers might go abroad for medical care. Issues addressed included facilitated transnational mobility, the quality of Malaysian healthcare, combinations of care with conventional types of tourism and the compulsion to sidestep obstacles perceived to inhibit care ‘back at home’. Rationale for the targeting of particular patient-consumer segments (e.g., East Asia, Middle East, ASEAN, North America, etc.) at the national and institutional levels was solicited. I then

queried them about the means used for attracting foreign patient-consumers (e.g., television and Internet advertising, brochures, special trade missions, trade fairs, etc.) and if/how these techniques are adapted to the different segments targeted. Interviewees were asked to reflect on the effectiveness of these methods and how they have evolved over time. Had they identified different needs and concerns (e.g., language barriers and the satisfaction of dietary needs, religious needs, cultural specificities, etc.) among the segments they pursued? If so, what were the means they had at their disposal for catering to these (e.g., interpreters, religious guidance, halal food/medication, rooms equipped to accommodate accompanying guests, same-sex medical staff, etc.)? These questions were posed in order to examine how foreign patient-consumers and their needs get imagined and these constructions are deployed by stakeholders to further their interests and develop niche market positioning.