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More than medical tourism: Lessons from Indonesia and Malaysia on South-
South intra-regional medical travel

Article  in  Current Issues in Tourism · July 2014

DOI: 10.1080/13683500.2014.937324

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This is a pre-publication version of the article published as: Ormond, M. and Sulianti, D. (2014) ‘More
than medical tourism: Lessons from Indonesia and Malaysia on South-South intra-regional medical
travel’, Current Issues in Tourism, DOI: 10.1080/13683500.2014.937324.

More than medical tourism:

Lessons from Indonesia and Malaysia on South-South intra-regional medical travel
Meghann Ormond1 and Dian Sulianti

Abstract
While scholars increasingly acknowledge that most contemporary international medical travel is
comprised of South-South flows, these have gone curiously unexamined. Rather, policy, scholarly and
media attention focuses predominantly on North-South flows of ‘medical tourists’. However, this
focus diverts attention from the actual and potential impacts of South-South intra-regional medical
travel flows in both their source and receiving contexts. As such, we present findings from a study
examining South-South intra-regional medical travellers’ motivations, preparations and practices to
better understand the social, economic and political situations that condition them and their effects
on the destinations that receive them. Our study of Indonesian medical travellers pursuing health
care in Malaysia draws on 35 semi-structured interviews with Indonesian patients, their companions,
medical staff and agents in both countries. From this, we suggest that South-South medical
travellers’ diverse socio-economic conditions shape decision-making and spending behaviour relative
to treatment, accommodation and transport choices as well as length of stay. We identify ways in
which informal economies and social care networks sustain the formal medical travel industry.
Finally, we observe how medical travel increasingly serves as a means through which chronic and
everyday health needs are met through temporary, visa-free intra-regional movement.

Keywords
Cross-border health care, medical tourism, intra-regional tourism, South-South migration, regional
alliances, development

Introduction
Ever larger numbers of people around the world are travelling abroad for medical care. In response,
the last 15 years have witnessed a rapid diversification of sites promoting ‘world-class’ care to them.
Identified by many governments as an economic growth catalyst, medical travel from the Global
North to the Global Southi (‘medical tourism’) in particular has formally entered many Global South
countries’ development agendas. Significant infrastructural and promotional investments are being
made in order to generate foreign exchange, improve existing tourism infrastructure and support the
private healthcare sector (Connell, 2013). Many of the Global South destinations promoting ‘medical
tourism’ are, however, at the same time important South-South intra-regional medical travel hubs
serving the needs of people from neighbouring countries with more limited resources. In fact, many
of the best-known destinations (e.g., Malaysia and Thailand) rely heavily on and are sustained by
intra-regional medical travellers, especially in times of economic crisis (Ormond, 2013b).
While scholars increasingly acknowledge that most contemporary international medical
travel is comprised of South-South flows (Connell, 2013), these – though with some notable
exceptions (see, e.g., Kangas, 2002; Lautier, 2008; Bochaton, 2011; Ormond, 2011, 2013a; Crush,
Chikanda and Maswikwa, 2012) – have gone curiously unexamined. Rather, policy, scholarly and

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

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media attention has been focused predominantly on North-South flows of ‘medical tourists’ (e.g.,
Canadian patient-consumers paying out-of-pocket for surgeries in India (Crooks et al., 2010)); North-
North flows (e.g., insured patient-citizens travelling between European Union countries for timely
care (Glinos et al., 2010)); and South-North flows (e.g., asylum-seekers purportedly ‘abusing’ the
United Kingdom’s National Health Service (Frith, 2006)). Hopkins et al. (2011: 186) justify the
disproportionate focus on North-South medical travel flows in particular by arguing that, though
‘oversimplif[ying] recent shifts in the global distribution of wealth and power’, it captures the
direction of medically-motivated travel ’that has raised the most concerns about health equity’.
Indeed, notwithstanding the local and national benefits that may accrue from greater foreign
exchange revenue and improvements in medical infrastructure, there are significant concerns that
North-South medical travel may also negatively impact Global South destinations by provoking or
aggravating increases in the rural/urban and public/private brain-drain of health workers as well as
diverting scarce financial resources from the public sector for investment in developing the private
sector (Hazarika, 2009; Connell, 2013).
Though vital to study, this predominant North-South focus privileges consideration of certain
power configurations (see Buzinde and Yarnal, 2012) and overshadows others, diverting attention
from the actual and potential impacts of South-South intra-regional medical travel flows in both their
source and receiving contexts. Such inattention has already been demonstrated with South-South
intra-regional tourism more generally. Thought to account for most of the world’s tourism, it has
been identified as a potentially powerful force for economic growth in Global South countries.
However, because South-South intra-regional travellers are often categorised as ‘budget tourists’,
many Global South governments pay little attention to intra-regional tourism, which is perceived as
‘far less glamorous’ (Rogerson and Kiambo, 2007: 229) than international tourism. Accordingly, as
Rogerson and Kiambo (2007: 229) suggest, ‘a so-termed “Northern bias” often pervades much
national tourism planning across the developing world’. This is found to lead not only policy-makers
but also scholars and entrepreneurs to neglect identifying and assessing both the benefits and
challenges of travel flows that do not conform to a North-South binary (Ghimire, 2001).
Much of the information available about international medical travellers’ experiences, Crooks
et al. (2010: 5) argue, is ‘heavily speculative or anecdotal in nature’ due to the phenomenon’s
novelty. Recent studies have sought to rectify this, shedding light on mainly North-South and North-
North medical travellers’ diverse motivations, preparations and practices (see, e.g., Lee, Kearns and
Friesen, 2010; Song, 2010; Solomon, 2011; Johnston et al., 2012). This work tells us that medical
travellers from the Global North go abroad to save significant amounts of money on un(der-)insured
necessary and elective procedures, to pursue what they perceive to be better quality care, to avoid
wait lists in their home health systems, to undergo advanced or controversial procedures and
treatments prohibited or unavailable back home, and to enjoy more culturally and linguistically
familiar and attentive care environments. It speaks to the often profound economically-, socially- and
politically-derived frustrations and barriers experienced in their interactions with home health
systems in the Global North as well as their negotiations with and dependencies on medical
providers and health systems abroad.
What, then, might South-South intra-regional medical travellers’ motivations, preparations
and practices say about the broader social, economic and political situations that condition them and
their effects on the destinations that receive them? In this article, we argue that a ‘Northern bias’ has
foreshortened our perception of the dimensions and complexities of international medical travel’s
diverse contexts and directionalities. Simply put, there is more to medical travel than ‘medical
tourism’. Here, therefore, we venture beyond ’medical tourism’ to learn from South-South intra-
regional medical travel. The scant extant research on South-South flows points to, among others, the
significance of shifting basic health needs in source and receiving contexts, webs of formal and
informal cross-border alliances, and a vast diversity of medical travellers’ socio-economic,
political/visiting and health statuses. Our own case study of South-South medical travel from
Indonesian to Malaysian Borneo builds on this body of work. Through the case study, we
demonstrate how Indonesian medical travellers’ motivations, preparations and practices are bound

2
up with local development concerns at home and abroad, get articulated through an array of non-
economic and informal care relations and services, and produce new rhythms and patterns of cross-
border travel. In so doing, we seek to broaden perspectives on international medical travel and its
diverse meanings.

What is known about South-South medical travel?

While Kangas’ (2002) study of Yemenis travelling to India has demonstrated that South-South
medical travel flows are not always necessarily intra-regional in nature, most – conditioned by
patient-consumers’ urgent needs, tight economic circumstances and travel limitations – do appear to
be. To our knowledge, however, no previous study has comparatively examined instances of South-
South intra-regional medical travel. In this section, therefore, we briefly profile three of the better-
documented destinations – South Africa, India and Thailand – in which the glamour of North-South
‘medical tourism’ has overshadowed the economic, social and political significance of South-South
intra-regional medical travel to look for differences and commonalities.
South Africa has been touted as one of the world’s top ‘medical tourism’ destinations, luring
customers from Europe and the Americas through a combination of discrete, affordable, high-quality
cosmetic surgery and a pre- or post-operative safari tour (Mazzaschi, 2011). Crush, Chikanda and
Maswikwa (2012) observe that, though most medical travel to South Africa is intra-regional, the
range of health-motivated movements within Southern Africa they encompass have been ignored in
studies of ‘medical tourism’ to South Africa. They identify two distinct South-South intra-regional
flows into the country. The first comprises middle-class Africans who recognise South Africa as a
continental hub for quality and affordable treatment for medically necessary procedures (e.g.,
reconstructive surgeries and chemotherapy) that is largely unavailable back home, due in part to
health worker brain-drain. Many of these medical travellers are covered by private health insurance
(70%); the remainder pays out-of-pocket (25%) or is covered by employers or governments (5%)
(Crush, Chikanda and Maswikwa, 2012). The second flow results from both sudden and sustained
regional health crises (e.g., a cholera outbreak in a neighbouring country without the necessary
supply of drugs to treat it) which, because they can generate public health emergencies in South
Africa itself, lead to organised public health responses to stem the spread of disease (e.g.,
distribution of free medicines to medical travellers with cholera). The HIV-AIDS pandemic in Southern
Africa also has overstretched domestic health systems, leading people to travel to South Africa for
diagnosis, anti-retroviral therapy (ART) and other medicines inaccessible at home. In light of the high
demand and large informal flow of patients from neighbouring countries, the Southern African
Development Community’s (SADC) 1999 Health Protocol has sought to formalise arrangements for
medical travel via bilateral health agreements. Nearby countries, however, struggle to reimburse
South Africa for treating their citizens.
With its large stock of highly-trained doctors, accredited ‘world-class’ hospitals and low-cost
surgeries, India has been aggressively promoted to un(der-)insured patients, insurers and employers
in the Global North since its National Health Policy enshrined ‘medical tourism’ as an economic driver
in 2002 (Smith, Martínez Álvarez and Chanda, 2011; Solomon, 2011). In response to the projection of
India as a ‘medical tourism’ destination, critical scholars like Hazarika (2009) and Sengupta (2011)
argue that India has overwhelming domestic health challenges of its own to resolve before opening
up to non-citizen others. Yet India has already been long perceived as a medical hub within South
Asia. Rahman (2000) estimated more than a decade ago that some 50,000 Bangladeshis annually
were satisfying their medical needs in the neighbouring Indian state of West Bengal alone. These
were largely lower-/middle-middle-income consumers that had money to travel to India but, unlike
their upper-class compatriots, not enough for more ‘desirable’ destinations like Singapore or
Thailand. Contrary to common belief about lack of availability at home and cost differentials
constituting the principal drivers for medical travel, only 15% of his respondents travelled to India
because treatments were not available in Bangladesh and the cost of treatment in both countries
was found by respondents to be comparable (Rahman, 2000). Physical and linguistic proximity, travel
ease (though a significant proportion would resort to entering India clandestinely), and perceptions

3
of better service, bedside manner, specialties and facilities in India were most important in decision-
making. While the improvement of medical service quality within Bangladesh is held as the principal
route for stemming Bangladeshi medical travel, Rahman (2000: 37) acknowledges the difficulties the
country faces and advocates closer interaction between Indian and Bangladeshi professionals and
collaborative ventures in the short run. Khatun and Ahamad (2013) also push for improved
collaboration in this area among member-states of the South Asian Association of Regional
Cooperation (SAARC).
Thailand is today one of the world’s most successful ‘medical tourism’ destinations, with
Bangkok’s Bumrungrad Hospital widely held within the global industry as the institutional model to
emulate (Connell, 2006). Yet, again, most medical travel to Thailand is South-South and intra-
regional. Within the Greater Mekong Subregion, for example, Laotians living near the border with
Thailand frequently turn to Thai health providers for primary through to tertiary care due to Laos’
health system’s real and perceived deficits (e.g., trained personnel, facilities, equipment and
medicine shortages) (Bochaton, 2011). Poor rural Laotians are cared for by debt-burdened public
Thai hospitals at the border at subsidised cost on human rights grounds (Thailand’s Border Health
Master Plan 2005-08). This has become a politically sensitive issue, with hospitals ‘seeking to put the
brakes on neighbouring Laotian patients without the means to pay’ (Bochaton, 2011: 14). Private
Thai hospitals, on the other hand, habitually charging higher prices for foreigners than locals, work to
attract wealthier urban Laotians. The volumes of Laotian private patients are so financially significant
that some Thai hospitals will go to great lengths to sustain their patronage and loyalty. Meanwhile,
Laotian authorities downplay the pursuit of care in Thailand as a ‘trendy’ phenomenon that has
‘unpatriotic’ and ‘subversive’ undertones. Placing the Laotian public health system at risk, they plan
to develop costly private healthcare alternatives within Laos in order to stem the flow of valuable
healthcare custom into Thailand. Yet, because Thai hospitals take for granted the steady stream of
Laotian patients, Bochaton (2011: 13) suggests that, unlike the government’s boosterism for
attracting medical tourists from the Global North, ‘it would be difficult to imagine the Thai
government developing business strategies for private Thai hospitals to attract Laotian patients’.
These three brief case studies present a number of themes useful for conceptualising South-
South intra-regional medical travel. First among them is the relevance of the epidemiological
transition. Growing numbers in the Global South face lifestyle diseases (e.g., some forms of diabetes
and cancer, etc.) yet their home health systems (where they effectively exist) continue to be
primarily engaged in struggles to manage fundamental public health concerns (e.g., reducing hunger
and infant mortality, controlling contagious disease, and improving sanitation and water supplies)
and may not have sufficient means to address personal health needs beyond those that concern the
overall public good. With home health systems significantly underfunded and unable to retain skilled
health workers (brain-drain), better-resourced systems in neighbouring countries may be (perceived
as) comparably better off in spite of their own difficulties.
Second, as a result of growing numbers of supranational regional alliances and trade
agreements, source and receiving contexts are increasingly interdependent, though their willingness
and capacity to commit to greater integration and harmonisation may be negligible (Timothy, 2003).
Home health systems struggling with controlling public health concerns on their own may generate
overflows in which people independently pursue treatment when thought to be accessible abroad.
Though an array of social actors in destinations habituated to intra-regional medical travellers may
take these flows for granted and perhaps even exploit them, destinations are also vulnerable to
shifting social, economic, political and epidemiological conditions in the source contexts. Diverse
social actors may work actively on both sides of the border to manage or even stem medical travel
flows. However, others in both source and receiving contexts – connecting via formalised
government-to-government agreements and/or marketised links between consumers and private
providers – are clearly establishing an ever-broader array of formal and informal cross-border care
networks.
Third, South-South intra-regional medical travellers cannot be lumped together into a single
homogeneous category. Travellers’ very diverse socio-economic circumstances and political/visiting

4
statuses condition their ability to travel as well as their selection of medical destinations (e.g.,
distance from home and type of facility), treatments, length of stay and who accompanies them.
While cost differentials between home and elsewhere in the Global South may be a factor for some,
other significant drivers are the sheer availability and perceived quality of equipment, medication
and skilled professionals in destinations. The Global South’s increasingly mobile emerging middle
classes play a particularly powerful role in shaping healthcare consumption both at home and
abroad, leading to greater cross-border competition for them as well as shifts in relations of care and
responsibility between states and their subjects as citizens and consumers.

Our case study

These three observations have shaped the design of our case study, where we examined Indonesian
medical travel to Malaysian Borneo. 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 increasingly coming to the fore are not being adequately addressed and managed.
Outside of the country’s capital, Jakarta, medical specialists, technicians, equipment and facilities are
sparse. Given the dearth of quality health care throughout much of Indonesia, a growing middle
class, the advent of more affordable cross-border transport and greater political ease in crossing
borders, at least one million Indonesians are estimated to travel abroad for care each year (IRIN,
2009; Lee, 2012; Bhatt, 2013; Ormond, 2013a,b; Smith, 2013). Due in part to the currency
devaluation during the 1998 Asian Financial Crisis, growing numbers of lower- and middle-income
Indonesians began entering neighbouring Malaysia for medical care because, in addition to being
accessible linguistically and geographically, it became more affordable. Cognizant early on of this
trend and needing to fill beds emptied by local patients who reverted to the public healthcare system
during the crisis, certain Malaysian private hospitals began to promote themselves to Indonesians. By
2007, nearly four-fifths of all international medical travellers to Malaysia were Indonesian (APHM,
2008). However, while the number of Indonesian medical travellers in Malaysia is very high, their
average length of stay and healthcare consumption has been found to be lower than that of medical
travellers of other origins (Oon et al., 2007; Musa et al., 2012; Yeoh et al., 2012). Malaysian
governmental and private sector authorities are keen to reduce dependency on the Indonesian
market via diversifying the market in recent years (IMTJ, 2010). Spectacular investments in hospitals
in the Malaysian capital, Kuala Lumpur, are being undertaken with non-Indonesian medical travellers
in mind.
In spite of these developments, the majority of medical travel to Malaysia remains far less
‘spectacular’ and far more ‘everyday’ (Ormond, 2011). Indonesians, pursuing everything from
primary to tertiary care, continue to dominate medical travel to Malaysia. However, because they
mostly receive outpatient medical care, Indonesians spend less on average per patient than medical
travellers from further afield whose inpatient ratios are higher (APHM, 2008). Yet Oon et al. (2007:
12) have found that Indonesians are also more likely than other medical travellers to be repeat
visitors and that they spend at least double what the average leisure tourist spends daily in Malaysia.
This underscores not only the enduring economic relevance of Indonesian medical travel for Malaysia
but also the significance of its varied distribution throughout the country. Indonesians travel in
particularly heavy numbers to the Malaysian states of Penang (hosting 66% of Indonesian medical
travellers), Melaka (22%) and Sarawak (5%) for health care (APHM, 2008). These are places that
share both established and developing social, cultural, linguistic, economic and transport links with
specific parts of neighbouring Indonesia (e.g., the island of Sumatra in the cases of Penang and
Melaka and Indonesian Borneo in the case of Sarawak). This is partly attributable to these areas’
participation in the Indonesia-Malaysia-Thailand Growth Triangle (IMT-GT) and the Brunei
Darussalam-Indonesia-Malaysia-Philippines East ASEAN Growth Area (BIMP-EAGA), two cross-border
regions established by the Association of Southeast Asian Nations (ASEAN) to foster economic
development that – like the Economic Community of West African States (ECOWAS) and the East
African Passport – have facilitated personal, temporary intra-regional mobility (Ormond, 2013b).

5
 Our case study focuses on middle-class medical travel to private Malaysian hospitals in
Sarawak’s capital, Kuching, from the cities of Pontianak and Singkawang in the Indonesian Borneo
district of West Kalimantan, the principal source of medical travel to Kuching (see Figure 1). While
Sarawak officially received only a small proportion of the approximately 340,000 foreign patients
reported to have received care in Malaysia in 2007, like Melaka (where around 90% of foreign
patients are Indonesian), it relies heavily on Indonesians (84%) (APHM, 2008). In fact, most of the
550,000 Indonesians travelling to Sarawak in 2011 are believed to have gone for medical treatment
(Lee, 2012), significantly increasing Sarawak’s weight relative to other principal Malaysian
destinations and questioning the accuracy of official national medical tourism figures. Sarawak’s
unique strength as a destination is that it can be accessed from Indonesia not only by air or sea but
also by land, allowing lower middle-income medical travellers from West Kalimantan the opportunity
to access care more easily than the other key Malaysian destinations. This transnational study site
within the BIMP-EAGA, therefore, gave us access to Indonesian medical travellers with a range of
socio-economic conditions.

Figure 1 (Map of the study region) about here

We used convenience sampling to conduct a total of 35 semi-structured interviews in

February 2012 with four Kuching public- and private-sector medical specialists familiar with
Indonesian patients, six private hospital administrators in Kuching and Pontianak, six Indonesian
medical travel agents as well as 19 Indonesian medical travellers from West Kalimantan accompanied
by their family members and friends (an additional 24 people). Interviews with doctors and
administrators took place in Pontianak and Kuching. Those with agents took place in Pontianak,
Kuching and en route between the cities. Interviews with Indonesian patients and their companions
took place while travelling to Kuching (see Ormond, 2013a) and in two anonymous cooperating
Kuching private hospitals (denoted herein as Hospitals ‘X’ and ‘Y’). To access the largest possible pool
of Indonesian medical travellers in Kuching, many patient and companion interviews were performed
on weekdays when medical travel agents bring Indonesians to Kuching. Since patients constitute
vulnerable research subjects, we restricted our sample to outpatients capable of independent
decision-making (see Table 1). Respondents received study information and provided verbal consent
prior to commencing interviews. Responses have been anonymised. Patients and companions were
asked to describe what led them to pursue medical care in Kuching and their preparations for and
experiences of, first, travelling to and back from Malaysia and, second, the care sought out and
received in Malaysia and Indonesia. Doctors, administrators and agents were asked about their
experiences with Indonesian medical travellers. Interviews were digitally recorded, transcribed and
translated from Bahasa Indonesia where necessary, then thematically coded deductively and
inductively. The next two sections present the main themes.

Table 1 (Indonesian patient respondents) about here

Motivations for medical travel

Medical travellers’ discontent with, and mistrust in, Indonesian medical care is linked to limited
availability and access to – as well as the perceived inferior quality of – medical specialties, service
and bedside manner, resources for diagnosis and treatment, and medication in West Kalimantan.
Seeking to spend less money, obtain accurate diagnoses and experience rapid results, some medical
travellers went directly abroad, completely bypassing local healthcare providers. Among those who
sought local treatment first, however, several ultimately went to Kuching because they did not think
they were making fast-enough progress with their treatment regime or medical needs and concerns
were not taken seriously by doctors back home. By contrast, the professionalism and bedside
manner of Kuching doctors were repeatedly praised:

6
 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. (R7)

This excerpt reflects how many patients and companions wanted greater say in managing their
health and used medical travel to achieve this. Like Rahman’s (2000) Bangladeshis travelling to India,
dissatisfaction with health care back home was linked not only to questions of material availability
but also to disdain for a hierarchical medical culture that sees patients not as demanding consumers
but rather as passive recipients. The significance of this exodus is not lost on one Indonesian private
hospital director interviewed:

It’s important to change the paradigm about patients [in Indonesia] – patients must
come first. It’s important to improve services for patients, and this will change the whole
system. […] 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.

This and other Indonesian hospital administrators were also frustrated. Enabling doctors and
hospitals to provide the standard of care that more Indonesians have grown to expect abroad (e.g.,
reduced waiting times for specialist consultations and diagnostics and longer consultations), they
argued, would necessitate a radical overhaul of the Indonesian health system.
Medical travellers mainly attributed the difficulty in accessing care to a human resource
problem: recruiting and retaining quality doctors is a difficult task in Indonesia and even more so in
peripheral areas. Indonesia-trained doctors were considered inferior to those trained abroad. Yet
foreign-trained Indonesian doctors were thought to have little incentive to practice in West
Kalimantan due to wage differentials and obstacles to credential recognition. Travellers’ local
doctors, in turn, were often criticised for being more occupied with treating symptoms than with
identifying ailments and curing them. Some patients travelled to Kuching in search of more accurate
test-supported diagnoses. Though doctors in Pontianak diagnosed one respondent’s tuberculosis
correctly, they did not detect his diabetes. His mistrust of those doctors shaped how he advised his
sister to handle her Indonesian medical records:

We can’t be sure about the accuracy of diagnoses in Pontianak. […] I showed the
specialist [in Kuching] my medical records [from Pontianak] but, for my sister’s case,
though we have brought her records from Pontianak, we don’t plan on showing them to
the specialist [in Kuching]. We want to get a second opinion and compare the diagnoses.
She will do blood tests and, based on the results, we will know about her illness. (R13)

Local doctors were also criticised for prescribing ineffective (dosages of) medication and making
patients return too frequently for monitoring and follow-up visits and to refill their prescriptions:
‘The local doctors [in Pontianak] treat their patients by experimenting with all kinds of antibiotics.
They provide low doses, making it harder to cure an illness’ (R17). Others found that Indonesian
doctors would resort more quickly to invasive techniques, like one respondent with oral nerve pain
whose local dentist extracted his teeth instead of opting for less-invasive options like drug therapies
more common in Malaysia (R19).
Alert to the limited local pool of specialists and lacking or outdated equipment and finding
themselves unable to adequately address their patients’ needs, some local doctors make referrals to
Jakarta hospitals, where specialties and well-equipped public and private hospitals are more
plentiful, or even abroad to Singapore or Kuching. However, this occasional deference to foreign

7
providers is rarely reciprocated. Government-to-government and ASEAN-level provision and
compensation agreements facilitating cross-border care – such as those that exist between Botswana
and South Africa (Crush, Chikanda and Maswikwa, 2012) and Libya and Tunisia (Lautier, 2008) – are
absent. However, some Indonesian hospital directors, themselves doctors, suggested that
communication with Malaysian doctors treating Indonesian patients must improve in order to
strengthen continuity of care across borders. Yet Malaysian doctors interviewed perceived the
distance between them and their Indonesian counterparts more difficult to bridge. This sentiment is
captured below by a Malaysian medical specialist in private practice:

Right now, economically, Indonesia has moved forward but unfortunately the medical
field is still lagging behind. […] Indonesia says, ‘We are very good. We don’t need your
help’. […] It’s a pride thing – it’s very difficult [for us] to go in and say, ‘We’re going to
help you’.

Ultimately, Indonesian travellers are left to negotiate care across two very different health systems
largely on their own. Still, echoing Bochaton’s (2011) description of Laos’ simultaneous emulation of
and antagonism with Thailand, top Indonesian officials have announced plans to improve the
national health system’s infrastructure, human resources and financing mechanisms expressly to
stem the leakage of valuable healthcare custom (Bhatt, 2013; Aspinall, 2014). However, when and
the extent to which peripheral West Kalimantan might benefit remain unclear.

Preparing and undertaking medical travel

Upon deciding to leave West Kalimantan, medical travellers were faced with selecting the location,
medical facilities and doctors to consult; deciding on the need for an intermediary agent; and
managing financial, work and family care responsibilities. Seeking medical care in Kuching was
perceived as a routine practice. While it was some travellers’ first time to pursue diagnoses or
treatment themselves in Kuching, all those interviewed had been there previously on business, to
visit friends and relatives, or to shop and engage in other leisure pursuits. This suggests its intra-
regional hub status for more than just medical care. Many had previously accompanied family
members and friends to the city for care. Yet Kuching was not the sole care option. Several related
experiences in which they or their family members pursued care in Jakarta or Singapore.
Acknowledging Singapore as the most expensive option, travellers generally felt that they would save
both time and money by pursuing care in Kuching instead of Jakarta because, though they found
diagnostic and treatment costs to be similar in both places, Kuching was perceived as more easily
accessible due to lower travel costs made possible by economical cross-border land transport and
tolerable journey durations. This was especially so among those living in rural areas poorly served by
roads. However, some – like one who prefers that both she and her elderly father receive medical
care in Kuching but sends her children for check-ups in Singapore (R4) – actively pursue care for
themselves and their loved ones in multiple sites based on perceptions of where specific expertise is
concentrated.
Like Bochaton’s (2011) Laotians, Indonesian travellers were heavily reliant on family and
community to pursue care abroad. Conversations with family, friends and neighbours were the main
sources of encouragement and medical and travel information on Kuching as a medical destination
as well as specific private hospitals, doctors and medications: ‘We already knew about Kuching
before my sister came here [to live]. People have been coming to Kuching for medical care for a
dozen or so years, decades actually’ (R6). The most cost-conscious were encouraged to head to the
lowest-cost hospitals or to ‘shop around’ for the best quality-to-cost ratio. Indeed, once in Kuching,
travellers were not especially loyal to one particular private hospital but, rather, would move
between them. Rarely travelling on their own, most visited Kuching with family, friends and
neighbours sometimes also in pursuit of medical care. Within a group of travellers, if travelling
without a medical travel agent, different members were likely to go to different private hospitals
depending on their needs (e.g., a woman visited a specialist in Hospital ‘X’ while her mother had

8
surgery in Hospital ‘Y’ (R6)). Malaysian doctors and medical travellers alike suggested, however, that
patients were more loyal to specific medical specialists, routinely returning for follow-up
consultations and recommending them to their friends and family. This is attributable not only to
their medical expertise but also to their linguistic ability (e.g., Chinese-Malaysian doctors using
particular Chinese dialects with older Chinese-Indonesians) and other soft skills.
Given our recruitment of medical travellers for this study, though several did not use medical
travel agents, most did. Those using agents did so either due to a self-confessed lack of familiarity
with the details involved in pursuing medical care at a specific medical facility or due to the
convenience of turning the many logistical details over to someone else. Three types of agents,
sometimes overlapping, were identified. First, each of the three private hospitals in Kuching has
official local representatives with offices in Pontianak that register customers, schedule their
consultations and testing, and provide the hospitals with customers’ records and stated complaints.
These may also provide facilitated payment options (e.g., allowing patients and their families to
settle Malaysian hospital bills in Indonesian currency or transfer additional funds) and transport to
and from Kuching (e.g., transport ticket purchase, own transport services, etc.). This type may receive
a combination of base salary and commission from the hospitals for each customer served. Second,
numerous commission-based agents arrange not only transport and accommodation but also –
though they do not have medical training – may conduct the initial triage of customers’ ailments
themselves, identifying what they deem to be the appropriate specialist for their ailments,
registering them and accompanying them to the consultations, even interpreting for doctors and
their patients:

I got [Agent X] to have a look at my medical records. He sent me to [Dr X in Kuching]. He

also chose a specialist for my sister. Since we lack information about specialists here [in
Kuching], we depend on [Agent X]. (R13)

The last agent type informally transports customers to, from and sometimes within Kuching,
competing with licensed transport operators for custom. Those not using an agent tended to be
seasoned medical travellers; had friends and family in Kuching on whom they could rely; wished to
avoid the extra fees charged; or desired greater independence in selecting facilities, doctors,
transport and accommodation.
Diagnostic, treatment and medication costs were widely regarded by medical travellers as
similar across Indonesia and Malaysia. Care in Kuching, however, entails the additional burden of
transport and accommodation costs as well as sometimes temporarily closing their businesses or
taking leave from work or care responsibilities to go abroad. Yet all travellers found the additional
financial burden to be worth it: ‘Nothing is free here [in Kuching] but it’s still better than having
medical treatment [back home] and not being cured’ (R6). Few could quickly, from one day to the
next, travel to Kuching for their medical needs, however. Before travelling, they budgeted for
consultations, treatment and medication as well as transport, lodging and food. As credit cards are
rare and since only some hospital-linked agents offer facilitated payment and money transfer
options, cash payments are predominant. Travellers thus required time to amass the estimated
amount and exchange currency before leaving Indonesia.
Numerous hotels, guesthouses and private homes available for rent by day, week or month,
amenable to travellers’ tight budgets and located near the private Kuching hospitals, are
proliferating. Many economical cross-border coach services compete with one another and freelance
medical travel agents for patient-consumers’ custom. In order to foster greater connectivity within
the BIMP-EAGA region, Indonesian and Malaysian low-cost airlines have even added new routes and
additional flights to respond to medical travel demand (Ormond, 2013a). To minimise costs,
however, all but one traveller interviewed opted for land transport (e.g., cross-border economy
coach services, shared vans and taxis, etc.). Furthermore, all stayed in low-budget accommodation
(e.g., economical hotels, privately-rented homes or guesthouses owned and run by Indonesian
agents) or at family and friends’ homes. Flexibility was important. Several secured accommodation in

9
Kuching only after learning from their doctors how long they needed to stay for testing and
treatment. Notes one traveller who arrived the morning of the appointment,

My luggage is still in the car because we haven’t booked a hotel yet. We’re waiting for
the results of my husband’s blood tests […] If treatment wraps up today and we get the
supply of medication, we might go home tomorrow – that’s the original plan. If the
doctor says that we can go home, then we will go home straight away. (Wife of R18)

Given the weight of respondents’ financial burdens, praise for the quick turn-around time for test
results and their analysis by doctors as well as comparatively quicker post-operative recovery times
in Malaysia was commonplace. Indeed, while some took advantage of their free time between
appointments to go shopping and visit the sights, most intended to stay in Kuching only as long as
medically necessary.
Travelling with family and friends to Kuching allowed patients to both receive and – for those
travelling with others pursuing medical care at the same time – provide logistical, physical and
emotional support to one another. However, such support also came at a cost. Several travellers
were small business-owners, allowing them greater flexibility to travel. One, a garage owner,
commented, ‘Luckily I run my own business. If I worked as an employee, it would be hard to ask
permission from my boss every time I have to come here [to Kuching]’ (R13). Yet, small business-
owners were also conscious of the income they were losing by temporarily closing in order to
address their healthcare needs abroad:

We arrived yesterday, and we plan to go home tomorrow if everything goes well. […]
We are busy back at home. […] If I go for medical care, I have to close the cafe because
my son won’t be able to handle it [during the busy times on his own]. (R19)

Those responsible for young children made alternative care arrangements ahead of time. One
traveller managing a chronic condition that takes her frequently to Kuching for appointments notes,

I hired a nanny to look after my kids, so whenever I go [to Kuching] I don’t have to worry
about them. […] They are getting used to me being away. It was hard at first, but they
adapted. […] I prepare everything for them before I leave for Kuching. (R4)

Because Kuching serves as a primary destination for their more serious and chronic medical needs,
many travellers shuttle routinely back and forth between Kuching and West Kalimantan. Negotiating
with their doctors about phasing follow-up appointments across periods of several months, they get
larger amounts of prescription medication to last them longer so that they can reduce the number of
trips and fit them more easily around care and work commitments back home. As Exworthy and
Peckham (2006: 275) observe, willingness to travel for medical care is conditioned ‘not simply [by]
travel distance but [also] travel time, costs, social dislocation and spatial perceptions’.

Discussion and conclusions

Policies in both the Global North and South are increasingly favouring the development of
promotional campaigns, travel infrastructure and attractions that interest and engage higher-
spending tourists over lower-spending tourists (e.g., backpackers). Like cultural tourism (Bendixen,
1997), North-South ‘medical tourism’ is widely perceived by destinations to deliver higher-status
tourists that stay longer and spend more than conventional leisure tourists and South-South intra-
regional medical travellers. Considering that the bulk of international medical travel remains South-
South and intra-regional in character, however, we have sought here to de-centre this dominant
North-South focus. Our review of extant empirical work on this topic and cross-sectional examination
of Indonesian medical travel to Malaysian Borneo offers scholars concerned not only with ‘medical
tourism’ but also migration and development in the Global South novel insight into South-South

10
intra-regional medical travel that – due to its growing scale and diversity – cannot be overlooked or
dismissed.
Due largely to economic and political conditions in both their source and receiving contexts,
South-South medical travellers’ motivations, preparations and practices may differ significantly from
those of their North-South ‘medical tourist’ counterparts. However, before we summarise our
study’s key insights, we wish to emphasise that application of the insights below to North-South
flows would also help to de-homogenise dominant conceptualisations of ‘medical tourism’, broadly
characterised so often and in particular by Global South policy-makers, developers and media
channels as capable of affording great luxury (but see, e.g., Hayes (2014)).
Travellers’ socio-economic diversity – In light of a pervasive ‘Northern bias’ (Rogerson and
Kiambo, 2007: 229), Ghimire (2001: 107) observes that ‘government investments in accommodation
and other visitor facilities do not [tend to] reflect the interests and motivations of the bulk of [South-
South] regional visitors’. Such an approach is short-sighted. Cole (2008: 282) notes that lower-
spending tourists, like the Indonesian medical travellers discussed here, create demand for
inexpensive accommodation as well as ‘a parallel structure of transport, restaurant and support
services’ that ‘due to lower capital requirements […] are more likely to be locally owned, resulting in
greater economic benefit for and more participation from the local community’. South-South intra-
regional medical travel flows, therefore, have significant potential for generating a meaningful type
of economic development that looks and performs differently from that for which ‘medical tourism’
is typically celebrated. Global South governments wishing to see their citizens benefit from
international medical travel therefore are enjoined to look beyond investing in big hotels and fancy
hospitals and to consider how spending actually occurs and who actually benefits from it.
To our knowledge, however, only one study to date has tracked international medical
travellers’ spending behaviour: Musa, Thirumoorthi and Doshi’s (2012) cross-sectional survey of a
small sample of foreign inpatients in Malaysia’s capital. While pioneering in its objectives, the
published results do not disaggregate the expenditure profiles of North-South and South-South
inpatients, and broad categories like ‘accommodation’ and ‘shopping’ obscure how, where and when
spending occurs. Indonesian travellers’ variety of strategic money-saving behaviours described in our
study indicate the necessity for more nuanced analyses that consider different tiers and types of
accommodation, transport, and medical and non-medical goods and service consumption. These
would better reflect the socio-economic diversity of South-South travellers as well as enable insight
into local and national economic impacts and leakages.
Everyday informal economies and social care networks – Most ‘medical tourism’ studies have
focused on international medical travel’s articulation through largely corporate nodes within the
formal economy. By contrast, few have examined its imbrication in everyday informal economies of
care (but see, e.g., Scheper-Hughes (2000) on underground organ transplantation and Casey et al.
(2013) on unpaid care-giving companions). Our Indonesian respondents have underscored the
significance of non-economically-based care relations (e.g., friends and relatives providing ‘free’
accommodation and care-giving) as well as the flourishing informal economy (e.g., unlicensed agents,
the purchase of prescription medication in Malaysia for family and friends in Indonesia, etc.)
underlying international medical travel practices. There is also significant South-South intra-regional
short-stay business travel (Rogerson and Kiambo, 2007) in countries’ entry/exit statistics, much of
which is characterised by small-scale ‘suitcase trading’ (Ratha and Shaw, 2007). Future research into
formal and informal small-scale cross-border entrepreneurship and care practices would improve our
understanding of how formal and informal care economies are made possible by medical travel flows
and make medical travel flows possible.
Travel frequency – With middle classes emerging throughout the Global South and the rapid
growth of lifestyle diseases have come new demands on home health systems’ human and material
resources. At the same time, in recent years, bi-lateral and intra-regional agreements have facilitated
the temporary, visa-free movement of many between Global South countries. With countries unable
to effectively respond to the healthcare needs of their people, South-South intra-regional medical
travel is ever-more banal. As our Indonesian respondents observed, medical costs in Indonesia and

11
Malaysia are held to be similar. With cost differentials – so key to North-South ‘medical tourism’ –
irrelevant, other factors like geographic and cultural proximity, cross-border support networks, and
confidence in the quality of diagnoses, treatment and medication are foregrounded.
Correspondingly, intra-regional medical travel becomes a feasible way to manage chronic health
needs, with people commuting on a routine basis for treatments, check-ups and refills. However,
research on international medical travel to date, again partly due to the ‘Northern bias’ focused on
long-haul journeys for expensive treatments and surgeries, has not yet considered the impacts of
frequent, short-distance and typically outpatient ‘medical commuting’ (e.g., requirements for
different types of health workers and expertise). Furthermore, while intra-regional tourism has been
identified and promoted by regional bodies (e.g., ASEAN) to improve connectivity and foster mutual
benefit across borders, the emergence of de facto ‘transnational health territories’ (Bochaton, 2011:
16) as we have seen here resulting from intra-regional medical travel is underexplored.
To conclude, there is more to international medical travel than ‘medical tourism’. The findings
from our South-South intra-regional medical travel case study suggest that there is valuable
analytical and practical potential in re-framing international medical travel – regardless of its
directionality – in ways that draw attention to the powerful role that it plays not simply as an
industry but also as a social force with a transformative capacity in both source and receiving
contexts (Higgins-Desbiolles, 2006). This reframing requires more cross-sectional studies that reflect
and consider international medical travellers’ diverse geographic, socio-economic and political
situations as well as longitudinal studies that trace the pre-, mid- and post-medical travel experiences
of patients, their companions and their range of formal and informal care providers.

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i
With the use of ‘Global North’ and ‘Global South’, we seek to acknowledge the spatialities of socio-economic
unevenness but also to avoid the linear progression implied in terms like ‘developed’ and ‘developing’.

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