The IRMs in our studies were found to engage in two key types of bricolage behaviour that are explained in the findings that follow. First, ‘within-system bricolage’ enacted by IRMs to help them access and navigate existing formal health and care systems within the public and/or private sectors. Second, ‘added-to-system bricolage’ that was supplementary to and filled gaps in health and care provision that was otherwise unavailable through formal routes (Phillimore et al. 2019). Our analysis include the challenges that led our respondents to bricolage, and indicates the multidimensional nature of bricolage solutions within and across local and transnational spaces using multiple economic, social and legal resources.
For British and Japanese nationals, public healthcare systems are the normative approach to addressing a healthcare need; however, in Spain and Malaysia, public healthcare systems were not universally available and accessible to the IRMs. The retired British migrants in Spain (‘British’ from here onwards) who received a state pension were entitled to free public healthcare in Spain via EU citizenship rights. Whilst retired Japanese migrants in Malaysia (‘Japanese’ from here onwards) are entitled to use public healthcare services (for a fee), quality concerns led them to elect for private healthcare funded primarily through private insurance (Kohno et al. 2016b). Both groups of IRMs encountered challenges in accessing and/or navigating these ‘formal’ healthcare services and so responded through ‘within system’ bricolage activities involving the creative mobilisation of resources to make these services more accessible.
A key challenge for all of our participants was language barriers when seeking health/care related information and in medical appointments, as few spoke the local language. Language barriers were dealt with in a multitude of ways, including ‘getting by’ using hand gestures, personal translation tools (e.g. google translate) and writing down symptoms before appointments. However, such improvisation only got them so far and subsequently IRMs employed interpreters, or where these were too expensive, utilised free local services. For the British, a crucial resource were voluntary organisations, including a volunteer interpreter service that operated in Costa del Sol hospitals run by Spanish-speaking (mostly British) volunteers. The British also utilised other British-run voluntary organisations (e.g. Age Concern España, the Royal British Legion) for translation, but also for transport to hospital appointments, as Anne explained:
[Volunteer] will be picking me up and taking me to the hospital … They take me to [and translate at] all my hospital appointments. (Anne, 74, British)
In Malaysia, many of the Japanese spoke English but they did not speak Malaysian and so often had to use interpreters in medical settings. Interpreter services were often included in private hospital charges, but for the Japanese the main challenge was navigating private healthcare insurance systems. Unlike Spain, which has a plethora of British-run voluntary organisations, Malaysia has few voluntary organisations to support Japanese IRMs. Instead, the Japanese turned to their wider social networks for advice and information, including other IRMs and younger Japanese expatriates who were working as doctors, nurses, care workers and translators. Through these relationships, they were able to access health and care related advice, and obtain help to arrange medical insurance, book medical appointments and access care facilities. Ongoing personal relationships with MM2H agents, who had supported the Japanese when they first moved, were a crucial source of health and care advice, and provided translation at and transport to hospital. As Reika explained:
The visa agent helps us to do everything we need, taking us to find a condominium and going to the hospital. (Reika, 66, Japanese)
Social clubs, most notably the ‘Japan Club of Kuala Lumpur’ and the ‘Second Home Club’, also acted as a safety net for newly arrived Japanese IRMs, with our observations showing that they particularly support enrolment in medical insurance, and provide ongoing health and care related information. A ‘health support line’ was also established by a Japanese IRM, which provides Japanese language information on health and care services in Malaysia:
When my husband became sick, the ‘[health support line]’ I am a member of, I call there and ask which hospital has a urology department. This system, it helped me a lot. (Masako, 70s, Japanese, Focus Group)
Another key challenge for some participants was an inability to access formal (public or private) healthcare services due to age and/or financial barriers. Some of the Japanese found that when their health insurance policy lapsed post-migration, their deteriorating health and age led to increased premiums and so they were unable to afford to continue their cover. Similarly, a small number of the British were unable to access public healthcare because they were under state pension age and/or were not legally resident in Spain. Some of the British purchased private healthcare insurance, but in a similar scenario to the Japanese, pre-existing medical conditions and age meant costs were often unaffordable. In this scenario, the British and Japanese elected to make ‘out-of-pocket’ cash payments for private healthcare services. This option resulted in considerable cost, anxiety and led to the IRMs limiting their use of healthcare services. In a focus group, Hiroshi (73, Japanese) who was unable to renew his healthcare insurance due to the substantial cost explained, “I was always very wary of how much they were going to bill us. We will try not to go to hospital as much as we can”. Julia (53, British) is under state pension age and does not work so is not entitled to public healthcare. She stated ‘I’ve got no health cover … [so] we try not to get ill’.
Some of these IRMs responded by creatively utilising their transnational citizenship rights to access public healthcare provision from the home country. Legal frameworks are a recognised bricolage resource (Baker and Nelson 2005) and for the British, this involved retaining UK residency and returning to the UK for any planned healthcare treatments whilst using the European Health Insurance Card (EHIC) in Spain (to access free emergency healthcare). Retaining UK residency involved keeping an address in the UK at their own property or using a son/daughter/friend’s address. Julia explained that when in Spain, she uses her EHIC card and a ‘pay-as-you go doctor’ costing ‘150 euros a year’. She also explained that she had retained an address in the UK at her father’s house to access the British NHS:
I do need [medical treatment] at the moment, so I’m going to have to try and prearrange it through my GP in England...via my fathers. (Julia, 53, British)
However, she goes on to recognise that travelling back and forth is only possible whilst she is healthy, and that her low income means this is not an option in the long-term. Similarly, some of the Japanese retained an address in Japan so that they could continue to use the Japanese health insurance system. To enable ongoing residency in Japan, a small number of participants were living in Malaysia as tourists rather than through MM2H, and so moved back and forth, in other words did ‘visa runs’ every 90 days:
I did not even apply for MM2H and continue visa runs and stay in Malaysia for maximum 270 days a year. I registered my Malay host family’s address to the embassy. When I go to the hospital, I use my [credit] card. (Tetsuo, 63, Japanese)
These examples of bricolage show how IRMs utilise and combine their legal and citizenship rights to access healthcare in the home and host countries. As prior research notes, IRMs can and do exploit the structural and legal gaps of their transnational lives by ‘picking and choosing’ the optimum healthcare provision available to them (Ackers and Dwyer 2002; Oliver 2017). This is a key example of ‘transnational care bricolage’ that involves the utilising and combining of legal, social and economic resources across national borders to access public healthcare. Some of the British who were legally resident in Spain also used their British citizenship rights to apply for exportable UK disability benefits, including Attendance Allowance. Some found that applying for the benefit from Spain a challenging process and so obtained help from a British voluntary organisation to complete the paperwork.
Whilst some of the IRMs retained residency in and returned temporarily to the home country to access healthcare, others spoke about return migration as a more permanent solution to their health and care challenges. Returning to access the more developed welfare system of the home country is a common strategy enacted by IRMs to address health and care needs in later life or if a health crisis arises (Giner-Monfort et al. 2016). Returning was a more common strategy for the Japanese than the British, which may be partly explained by the British having access to free healthcare in Spain, whilst the Japanese were likely to face increasing (private) healthcare costs as they aged. Furthermore, whilst the UK has a means-tested social care system (Thorlby et al. 2018), the introduction of long-term care insurance in Japan in 2000 led to almost universal care for those over 65 and may influence the decisions made by the Japanese to return once care needs arise, as Hanako explained:
My husband is 75. I have to persuade him to return to Japan in the next few years for the time when we need care. (Hanako, 68, Japanese)
These examples of within-system bricolage involve the combination of multiple resources to access formal healthcare services from the home and host countries. These same resources can however also restrict bricolage, particularly transnationally, with for example frequent travel and the retaining of an address in the home country being dependent on IRMs having sufficient economic, health and social resources in the first place.
As the previous section highlighted, IRMs engaged in bricolage activities to access and navigate existing formal healthcare services. However, we also identified some health and care needs that could not be filled through existing service provision. Whilst the majority of IRMs in our studies referred positively to medical services, participants found that there was little or no community based care, including hospital aftercare, district nursing services, palliative care and domiciliary care (e.g. personal care such as help with washing/dressing). In Malaysia and Spain there is a cultural expectation that family members provide reablement and long-term care (León 2010; Samsudin et al. 2019), and very few IRMs have family living nearby (except a spouse who was often themselves elderly so unable to provide care). In Spain, Social Services are more developed than in Malaysia, but in both countries services are limited and patchy due to familial expectations and language/cultural barriers that restrict access where they do exist. Subsequently, no IRMs in our studies had accessed public community-based care. Participants found that they were discharged from hospital as soon as they were ‘medically well’ and as British retiree Geoff (aged 85), who had recently been in hospital explained, ‘the operation was fine … the aftercare was virtually nil’. IRMs therefore found they had to develop ‘added-to-system’ bricolage (Phillimore et al. 2019) solutions outside of formal care systems to address their needs.
At a local level, there is a strong sense of community among IRMs in Spain and Malaysia, characterised by friendships, social clubs and reciprocal exchange (Hall and Hardill 2016; Ono 2015a). This community was utilised as a resource to fill care gaps. Social clubs in Malaysia and voluntary organisations in Spain helped IRMs to organise and even provided informal community-based support. Judy explained how, when her husband was discharged from hospital late one night, she phoned a voluntary organisation for help:
It was about one o’clock then they released him, and I was like “Crumbs, what am I going to do”? So I actually rang the [voluntary organization], and they sent somebody down for me … it’s an extended family to us. (Judy, 73, British)
Friendships with other IRMs were also utilised for help and care in the home. Ruby, a British IRM (79, widowed) explained that in the absence of any aftercare, a friend had lived with her for 2 weeks after being discharged from hospital following a hip operation. Her friends also provided practical help in the home on a more ad-hoc basis (e.g. shopping, food preparation). Support between friends was multi-directional and inclusive, for example Ruby went on to explain how she used a ‘buddy system’ established by a voluntary organisation where small groups of IRMs who live alone, call each other every morning and evening to ‘check-in’. As Ruby explained, it was designed to ensure “you made it through the night or day because sometimes you can go the whole day and not speak to anybody”. These locally based ‘community-making’ bricolage practices often operated as mutual support networks based on reciprocity and offered a safety net by bringing together multiple local resources to bridge, fill and add to gaps in formal care and support (Olsson and O’Reilly 2017). In Malaysia, Japanese IRMs established the voluntary organisation Otasuke Man Club, that provided mutual assistance, particularly for new arrivals (Ono 2018; 2015a). Mitsuyo (60, Japanese), a founding member, explained, “everyone starts by being helped and later on they will help other retirees.”
Social networks were typically centred around the IRMs national/ethnic community, so whilst they helped to maintain a sense of national and cultural identity, it has been argued they may also serve to limit integration into the wider society (Olsson and O’Reilly 2017; Oliver 2017; Hieda et al. 2013). The majority of the IRMs in our studies therefore spent much of their time with other Japanese/British people, but this did not mean there was no local integration. The British referred to Spanish and Scandinavian friends and the Japanese spoke about friendships with Malaysians. Such cross-cultural exchange was more common among the Japanese, and included cross-generational and reciprocal relationships with younger Malaysian families. Saori explained that her local friends acted like family and offered care and support during times of need:
We feel that a couple [Chinese Malaysian wife and Philippino husband] are like our daughter and son in Malaysia. They take care of us much more than our real children. (Saori, 63, Japanese)
Saori’s experience highlights the importance of proximate support networks, especially during times of crisis when family living at a distance cannot be there. She did also maintain strong ties with her four children in Japan and many of the other IRMs referred to the emotional, practical and even financial help they received from children either virtually using video conferencing (e.g. Skype, FaceTime) and social media or through occasional visits. However, Saori’s experience and also prior research suggests that virtual support and care between children and their ageing parents is not a direct substitute for proximate care (Baldassar 2014; Kilkey and Merla 2014). Subsequently, some Japanese and British participants planned to return to live with children in the home country. For example, Sandra (80, British) explained how she was building an annex to her daughter’s house in the UK to which could return if her husband dies. Similarly, Eriko explained that she does not want to stay in Malaysia on her own after her husband dies and so plans to return to her daughter in Japan:
We will be staying in Malaysia for the time being, but when my husband dies, I am not going to stay alone in Malaysia. I will go back to Japan, to my daughter’s place. (Eriko, 70, Japanese)
Alternatively, those without close family relationships or who did not want to return often combined local and transnational resources to access care and support. Harriet explained that whilst her son wanted her to move back to the UK, she felt that Spain was her home. Therefore, her son visited from the UK when she came out of hospital, but when he left, he helped her to find locally based care:
When I had the first operation, I needed a bit of care and help, and my son came over, and he said “We’ve got to get you some help when I go back. You can’t walk yet … you’ve got to have a bit of help” (Harriet, 79, British)
Harriet and her son found that neither public Social Services nor informal (unpaid) local care solutions were sufficient to fully meet her needs and they had to turn to formal (paid) care services. Private Spanish care services were unfeasible due to language barriers (i.e. care staff rarely speak any English) and so they turned to the British community.
Within the IRM communities in Spain and Malaysia, private care markets have emerged that operate outside of existing statutory and local private provision and cater specifically to the needs of IRMs. In Spain, British people have set up residential/nursing homes and domiciliary care services with (mostly) British staff. Harriet started using a British-run care company who now visit every morning to help her get dressed/washed, and also take her to the hospital. Similarly, in Malaysia, private care facilities that cater to the needs of older Japanese retirees have been established, although in contrast to the British have involved cross-national collaborations between the Japanese and Malaysian communities. For example, a Malaysian GP established a nursing home for Japanese IRMs, where younger Japanese expatriates in Malaysia worked as staff and Japanese retirees helped as volunteers. The nursing home met the care needs of Japanese migrants for a short period, but in the long-term there was insufficient demand for the nursing home and it closed down. This indicates the fragility and fluidity of IRM communities (Oliver 2017) with bricolage often being for the purpose of ‘making-do’ in the short-term and in response to challenges as they arise (Phillimore et al. 2019).
Such private care services can be very expensive and many of our participants did not have the financial resources to pay for long-term care. Therefore, low-cost care arrangements have emerged within the IRM communities. For example, in Spain, Vera (80, British) cares for her husband with Alzheimer’s and explained that she was unable to access any care from Spanish Social Services due to long waiting lists and language barriers. She pays a British care company to help her for a few hours per week, but she needed respite care when she returned to the UK (her husband’s health means he cannot travel) and the high cost of paying the care company for 24/7 care led to her asking her British friends if they knew anyone that could help. A ‘friend of a friend’ suggested another British person who, for a small fee, stayed with her husband whilst she was away. Similarly, observations of the Second Home Club in in Japan found Toshiki (65) asked volunteers and other IRMs to help him arrange a Filipino domestic care worker to provide care for his elderly mother who lived with him in Malaysia. This creative combination of resources therefore allowed Vera and Toshiki to address their multiple care needs outside of any formal care systems.
These examples indicate the importance of community for IRMs as they navigate across and between formal and informal health and care services. We found examples of the informal and formal working in tandem, with voluntary organisations in Spain working closely with British care services and in some cases even paying the care costs for those on low incomes. In Malaysia, the Japanese IRM community was often used as a platform to launch and promote support services again indicating the intersection of the formal and informal health and care sectors.