Statistics

In addition to published documentation, I also gathered published and previously unpublished statistics on foreign patient numbers and revenue in Malaysia and other countries promoting themselves as IMT destinations. However, a series of caveats must be addressed here in order to contextualise my analysis and use of this type of data in the thesis.

IMT industry stakeholders repeatedly note that the lack of standardised terminology, absence of unified methodologies for data collection and poor reporting practices constitute a ‘risky trap’ that inhibits countries from publishing their IMT figures and stymies productive international comparison on industry growth (Whittaker 2008). Even the most ‘reliable’ sources on world-wide IMT figures to date produce figures that are light-years from one another. Two large-scale independent studies the first of their kind were released in 2008 by the Deloitte Center for Health Solutions and McKinsey & Company. Deloitte (2008c: 7), defining ‘medical tourism’ broadly as ‘the act of travelling to another country to seek specialized or economical medical care, well being and recuperation of acceptable quality with the help of a support system’, found that roughly 750,000 Americans alone travelled abroad for medical care in 2007 and predicted that the industry would ‘experience explosive growth’ (2008c: 4). Meanwhile, McKinsey generated highly conservative estimates of only 60,000 to 85,000 patient-consumers globally (Ehrbeck et al. 2008: 2), with ‘medical travel’ confined to non-resident foreigners that enter a country specifically for treatment by McKinsey (Ehrbeck et al. 2008: 2).

In the absence of a global industry-wide standardised system, therefore, a disparate range of practices are used to produce figures on the dimension of IMT. These then repeatedly get reported in the media and academic literature without being sufficiently problematised, making it ‘unclear whether their numbers are accurate or just another marketing device to generate “buzz”’ (Turner 2007a). Most often released as rounded figures not discriminated below the national level, they construct a false vision of objectivity and legitimacy, while at the same time privileging the methodological construction of a homogeneous ‘national’ territory of care (see Table 2.1). These

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The results of a cursory content analysis of the articles during the above-mentioned period (see Appendix 4) demonstrate, particular nomenclatures have come in and out of fashion over time, indicative of shifting conceptualisations within the Malaysian and international industries of how IMT flows were constituted and what they – as ‘tourists’ or ‘travellers’, as ‘health-seekers’ or pursuing ‘medical’ intervention – meant and to whom. The term ‘healthcare travel’, for example, only came into more common usage in 2009, coinciding with the launch of both the Malaysia Healthcare branding exercise and the Malaysia Healthcare Travel Council (MHTC). While ‘health tourism’ was favoured by government policy documents until 2009, both ‘health tourism’ and ‘medical tourism’ have been used interchangeably in media coverage since 1998.

figures tell us little about which foreign patients are counted, how they are counted, which bodies are responsible for reporting, the level of reporting and the politics behind their dissemination.

Table 2.1 Foreign patient figures among select Asian IMT destination countries (2002-2008)

2002 2003 2004 2005 2006 2007 2008 India 150,000 450,000 Korea 10,000 16,000 40,000 Malaysia 84,585 102,946 174,189 232,161 296,687 341,063 374,063 Singapore 210,000 230,000 320,000 374,000 410,000 348,000 370,000 Thailand 600,000 1,280,000 1,000,000 1,400,000 1,500,000

Sources: India - Whittaker (2008), Health-tourism.com (2009a); Korea - IMTJ (22/10/2009), Vequest and Valdez (31/10/2008); Malaysia - APHM (2008); Singapore - Hospitals.sg (28/01/2009), IMTJ (27/10/2010), Yap (2006); Thailand - Whittaker (2008), Health-tourism.com (2009b)

Which patients are counted depends on the intention of the quantification exercise. In Malaysia, data collected for the purpose of describing the volume of medical travellers do not sufficiently discriminate. The practice lumps all foreigners receiving care from a set of 35 private hospitals endorsed by the MOH for IMT together, irrespective of whether they have purposely come to the country in pursuit of medical care, whether they have fallen ill while in the country and sought care out of necessity, whether they are primarily residing in Malaysia or abroad, whether they are conventional tourists or migrant workers, and so on. This blurry definition of ‘foreign patient’ in Malaysia encompasses all patients holding foreign passports, complicating attempts at better understanding the dynamics of the IMT market.

A further challenge is how ‘foreign patients’ are counted once it is decided who is being counted. Along the most standard lines, the Malaysian private hospitals reporting to the Association of Private Hospitals of Malaysia (APHM) record individual patient/hospital episodes, meaning that patients are counted each time they go to a hospital and not by how many staff they see during that time. Meanwhile, Southeast Asian IMT destinations have been quick to pick apart the impressive though polemically inflated foreign patient figures of their competitor, Thailand’s premier IMT facility, Bumrungrad Hospital (which, by extension, inflates the national figures) (2008 Medical Travel World Congress proceedings). Instead of counting individual patient/hospital episodes, Bumrungrad counts the number of patient/medical staff contacts.21 Neither of these approaches allows for conclusive figures on the absolute number of foreign patients because it does not control for repeat hospital episodes or visits by the same patient. These sorts of categorisation practices account for the difficulties in quantifying the phenomenon.

21 In other words, an individual patient is counted each time he/she meets with hospital staff – meeting with a gastroenterologist counts as one, meeting with a radiologist counts as two, and so on.

Compounding the inconsistencies in data-gathering are irregular and inadequate reporting practices. Methods of gathering data on IMT are highly variable, taking place at the level of the medical institution providing care and, depending on the destination country, potentially upon declaration of visitors’ intentions to pursue medical care at immigration control points when they enter a country (e.g., Singapore). In Malaysia, the APHM is charged with compiling statistics from the 35 IMT hospitals, collecting information on the origins and number of foreign in- and out- patients, the procedures undertaken and the revenue generated. In practice, however, hospitals’ lax reporting practices have meant that IMT data is far from complete (see Appendix 7). Reporting practices are slowly improving year on year, possibly due to increased pressure by APHM and warnings by the MOH that the facilities risk being dropped from the official list if they do not submit data regularly (Chua 19/07/2004) (see Table 2.2). Plans to make IMT a success have been reportedly under threat due to the hospitals’ practices since foreign patient data is considered crucial for the MOH to craft its marketing strategy (The New Sunday Times 20/02/2005). As an anonymous Malaysian governmental tourism representative (interview, 24/01/2008) observed,

Everybody is so secretive and not willing to share! That’s why when we, at the Ministry and marketing levels, have a difficult task in getting figures. But not figures alone, because we must get data on the original countries and the kind of treatments. They keep it to themselves! This makes it very difficult for us to know in which part of the world we can promote certain kinds of treatment and which parts of the world on which to concentrate more. If we don’t have this information flow, then how are we going to promote health tourism?

To date, there exists no manner to legally enforce reporting, though there have been discussions about putting forth legislation to require it.

Table 2.2 IMT-endorsed hospitals reporting data to APHM on foreign patients and revenue generated22 Year 2002 2003 2004 2005 2006 2007

Patients 19-22 19-21 19-20 19-25 27-28 29 Revenue 10-14 n/a 11-13 13-16 20-23 23-25

Source: APHM (2008) Note: See Appendix 7 for a list discriminated by contributing hospital.

The politics behind the dissemination of figures constitute yet another obstacle. Most authorities promoting their countries as IMT destinations are wary of publishing their figures. While authorities in other countries do not possess centralised databases and/or do not choose to release this information publicly, the APHM and the Singapore Tourism Board go against the grain by compiling and releasing annual figures. The limited statistics on IMT in Malaysia included in this

22 The range indicates that the number of hospitals reporting varied from month to month. Furthermore, while hospitals have been more forthcoming with data on foreign patient numbers, they remain more guarded regarding the revenue they generate.

thesis were provided by the APHM, individual medical facilities and state-level government representatives, thus countering the paucity of statistics released by the government media outlet, Bernama (overall national figures), and published in Tourism Malaysia’s Key Performance Indicators

yearbook (overall national figures disaggregated by foreign patients’ country of origin). None of these statistics, however, are to be taken at face-value. Considering the role of foreign patient statistics in the production and circulation of knowledge about IMT, the way in which they came about and the stories they are used to tell merit deeper consideration and reflection, since ‘[t]echniques of enumerating, tabulating and correlating’ constitute cultural projects in their own right (Shurmer-Smith 2002: 97).

In spite of the multiple pitfalls of IMT statistics, I have opted to include them – if cautiously – herein in order to illustrate how such data is employed to (re)present the Malaysian industry’s growth and success, given the immense explanatory authority of such comparative quantitative techniques in the globalising healthcare economy. They are employed not only to tout political successes but also as a platform upon which to base future development policy (see Chapters III and IV). As such, through the gathering of statistical data from a range of sources, I have sought to deconstruct the unified national image of Malaysia as an IMT destination produced through the release of national-level statistics by presenting the data disaggregated by region and by listing the individual hospitals that have contributed their figures since the early 2000s.23 While the reliability of figures themselves are questionable, the broad regional trends they indicate do correlate with the claims and challenges that emerged in the interviews undertaken with stakeholders.

23 _{Note that the APHM, having provided much of the statistical data, has expressly requested that I not publish} the foreign patient-consumer revenue generated by each of the contributing hospitals and I have honoured their wishes.