Is There A Case For A Private Medical School In The Health Planning Of Sri Lanka?

Dr. Murali Vallipuranathan

Planning Human Resources for Health is vital for the development and efficient functioning of the health system of a country. As the issue of the private medical school in Sri Lanka has now become the hot topic of this country with more than 4000 doctors marched in a rally in Colombo against SAITM (South Asian Institute of Technology and Medicine) a private medical school a few days back and while President Maithiripala Sirisena has appointed an expert committee to solve this issue. I am writing this article to improve the awareness among the lay public and professionals. To make it easy to understand by everybody I am writing this article in the Frequently Asked Questions (FAQ) format:

Are we producing enough doctors in state medical faculties to cater the country’s needs?

Table 1 Number of medical graduates passed out from Sri Lankan Government Universities compared to the Population in Years 1991, 2001 and 2016 (2) Above statistics in Table 1 clearly shows that over the last 25 years period though the population has increased approximately by 24%, annual production of state medical graduates has increased approximately by 275% during this period. In addition significant number of graduates qualified in foreign medical schools join the workforce of Sri Lankan Health sector more than replacing the local graduates migrating to other countries. The doctor population ratio has improved rapidly during the last 11 years period (3), (4), (5) as shown in Table 2.

Table 2 Doctor per Sri Lankan population in years 2006, 2010 and 2014** Refers to doctors practicing Western Medicine employed in the Health Ministry (5)

* Refers to doctors practicing Western Medicine employed in the Health Ministry (excluding doctors attached to universities and private sector)- Source: Annual Health Bulletin 2014

Though our doctor population ratio is below the developed nations we are still doing well among the developing nations with similar economies and our health indicators are much better than other developing countries with better doctor population ratio. A study (6) conducted in 2006 showed that Sri Lanka had a doctor population ratio of 55.2 per 100,000 population above Bangladesh (23) India (51) Nepal (05) but below Pakistan (66) and Malaysia (67). At present the Ministry of Health struggles to give appointment to employ all the medical graduates applying for job. A study conducted in 2006 showed that among the medical practitioners registered with SLMC about 70% were employed with health ministry, about 3% with Universities, about 12% with private sector and about 15% overseas (2). Further expansion of medical graduates passing from state medical faculties may lead to unemployment of doctors in the government sector. In such situation instead of joining the private sector, doctors will start migrating to more lucrative countries overseas because western countries offer much better employment opportunities to Sri Lankan medical graduates when compared to private sector in Sri Lanka. In this context if we take India as an example with the largest number of 460 medical schools in the region with more than 50% of the medical schools are private still remains with a doctor population ratio below Sri Lanka but has become the largest exporter of doctors with around 47000 Indian doctors practicing in US and around 25000 in UK (7). Therefore unless the economy of the country improve to support better doctor population ratio with more employment opportunities and better remuneration, just increasing the production of medical graduates in the country will not improve the doctor’s population serving in this country.

Then what is the problem with medical manpower of this country?

We have too many doctors in Colombo and surrounding areas while very less doctors are located in rural and remote areas. Leaving aside the doctors attached to the major private hospitals and universities in Colombo, this District recorded the highest value of 182.3 doctors per 100,000 population while Nuwara Eliya District recorded the lowest value of 37.0 doctors per 100,000 population employed by the Health Department in 2015. The major problem in the health service provision of this country is maldistribution of health work force resulting in lack of equity. And like all other developing nations we have problem with brain drain of doctors migrating out of Sri Lanka. Are these problems going to be solved by setting up private medical schools in Sri Lanka? Are we going to stupidly believe that the wealthy parents paying around 10 million to get their children to become a doctor at private medical schools will allow their children to work in a remote place in Mullaitivu without electricity or in a remote place in the estates of Nuwara Eliya without proper transport? Research evidence also clearly proves that medical students graduated from private school less prefer to work in rural areas than the students graduated from government school (8). That is understandable because when the students made huge investments at their medical education they are keen to start earning at lucrative urban areas which result in growing inequity between urban and rural areas (9).

Why the medical fraternity is against the SAITM private medical school in Sri Lanka?

A medical faculty unlike other teaching institutions depends on the clinical and bedside teaching where the students have to see the real patients and gain clinical knowledge. Therefore a Teaching Hospital with adequate number of beds and patients attached to the medical school is mandatory for the proper training. Further the students should be exposed to all the mandatory disciplines such as Forensic medicine so that they can perform their duties as a full-fledged medical officer after completing their internship as in this example perform their medicolegal duties. Further their curriculum, criteria for recruitment of staff and admission of students should be transparent and maintain the highest standards (10). If the SAITM and their students wish to register with the Sri Lankan Medical Council and practice in this country respectfully then they should fulfill the above said requirements with transparency, honestly allow the Sri Lanka Medical Council to monitor that they maintain the high standards of training rather than manipulating the politicians to overrule the recommendations of the Sri Lanka Medical Council.

Despite these short comings how the SAITM student won the case?

The root cause of the legal debacle was the positive recommendation given to the Faculty of Medicine of the Kotelawala Defense University (KDU). The SAITM student was able to win the case against the Sri Lankan Medical Council (SLMC) at the Court of Appeal by proving the mala fides because the SLMC had positively recommended the KDU which was having lesser facilities than the SAITM. Leaving aside the circumstances of positive recommendation given to the KDU during the white van regime period (11), if the SLMC is to win the case at the Supreme Court, it has to reevaluate and if necessary rescind the status of positive recommendation granted to KDU. Now 8 years after the end of war the role of the KDU need to be seriously reconsidered. I have treated several Sri Lankan students from KDU who claim to have no family connection with armed forces but enrolled to KDU by solely paying the tuition fees. On the other hand what is the rationale for selecting only children of armed force members by lowering the Z score cut off marks? Is not this procedure violating the fundamental rights of other intelligent students who worked hard, scored high Z score and could not enter medical faculty because their parents are not in armed forces? Should not this concession be extended to the child of a dedicated doctor at a remote station working 24 hours on call without replacement than the children of members of armed forces who have been enjoying their fortune at Laya Hotels, other profitable business ventures the military has undertaken after the end of the war and at UN peace keeping missions? At least we should consider allowing the children of dedicated members of parliament to get this concession so that they can stop their illegal transactions of selling the vehicles imported under duty free permit concession (12) to pay for their children at SAITM and other expensive medical colleges overseas.

Why the SLMC, GMOA and other professional bodies have not protested vociferously earlier?

One of the unfair allegation levelled against SLMC, GMOA (Government Medical Officers Association) and other professional bodies that they have not warned in advance and thereby allowed hundreds of students to join SAITM and their parents to spend their hard earned money on a venture whose collapse would frustrate their costly investments (13). During the previous white van regime period SLMC faced serious threats for its stand of not to compromise the high standards of medical education. If we look at the timeline in October 2011 Dr. N. J. Nonis the Registrar of the SLMC was assaulted (14), in November 2011 Prof. Lalitha Mendis President of the SLMC was compelled to resign (15) and in August 2012 a hand grenade was thrown into the house of Dr. Lalantha Ranasinghe a Council member of the SLMC (16). It is not surprising to see that the same elements manipulated the threats against the SLMC members in the past are now capable of staging a shooting incident in SAITM issue (17).

What should be done in the future?

My recommendations to solve the need of medical practitioners to the country could be:

Bonding of students selected to medicine to serve for 5 years in this country (6) as it was in 60’s and 70’s or else they have to return the course fees. A student who received free medical education at the state university from the tax payer’s money of this country has a moral obligation to serve this country and particularly the area people from which he or she was selected. The bonding solution when applied to the free Postgraduate training provided by the Ministry of Health has successfully reduced the brain drain.
Either have a scheme for the persons selected from a district for university entrance to come back and work a mandatory period or make a post intern list selecting the difficult areas/stations so everybody have to work in the difficult station at some stage of their career. Additional incentives should be provided to retain doctors in these stations.
Allocate resources in equitable manner not only health sector but also in all other sectors and develop all districts in an equitable manner. Improve the salary and other facilities to doctors in Sri Lanka so that they would give up the migration ideas.
Allocate more percentage of GDP to health and create more employment opportunities in health sector.
Recognizing the value of the precious life of the patients in the hands of properly trained doctors World Health Organization has clearly recommended highest level of transparency in an accreditation system operating within the legal framework of the country (18). It further elaborated that the legal framework must secure the autonomy of the accreditation system and ensure the independence from the government, the medical schools and the profession. It must authorize the accreditation body to set standards, conduct periodic evaluation and confer, deny and withdraw accreditation (18). Therefore in Sri Lanka private medical schools may be allowed to function provided only if the existing regulations are amended to allow the independent accreditation body Sri Lanka Medical Council to monitor without any pressure from the government and maintain the highest standards of medical education without any possibility of manipulation by the politicians.
KDU should stop enrolling students to medicine because the admission criteria of KDU students giving merit to the position of the parents infringes the fundamental rights of other students entering state medical faculties by their self-merit. Further this admission policy of concession to armed forces degrades all other dedicated civil employees playing more vital role in the development of the country in the absence of war.

Unlike the previous regime, I have my highest regards and faith on His Excellency Mr. Maithirpala Sirisena who had played a genuine role in all health related issues of this country including curbing drug menace (19), smoking (20) and even asbestos use (21) without any conflict of interest. I am confident that he is capable of ensuring a free hand to Sri Lanka Medical Council to maintain the highest standards of medical education in this country despite the affiliations and nefarious manipulations of other politicians who have vested interest in this issue.

*Disclaimer: Author Dr. Murali Vallipuranathan is a visiting lecturer at the Universities of Jaffna and Colombo. He was the President of Jaffna Medical Association in 2014/15 and have wide experience in this issue by holding positions in several professional bodies. Though he has been serving as a Senior Specialist in Health Planning at the Management, Development and Planning Unit, of the Ministry of Health he claims the technical opinion expressed in this article to improve the public awareness is his private opinion and in no way reflects the official position of the Ministry of Health in this issue.

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Latest comments

Nimal / March 10, 2017

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It’s a good idea to turn as many doctors as possible and it could lead to a multibillion Rs venture and the Private sector expanding it with private money.
In the private sector funded and educate doctors could be sent abroad to work where they will remit their incomes to SL.
Our Moda ambuday type leaders have no vision.

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Dot / March 10, 2017

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Health planning in Srilanka this is a timely article written without bias and I condone almost every word of it . ..yes did he ever exist for the people I like to add my thoughts too ..Have we built up a society that is sensitive to the needs of rural regions? .Not only health facilities but educational ?A lopsided development is apparent .Rural students are given concession in the admission scene and quite rightly so for the distant areas lack the educational facilities that would help these students to achieve to the maximum ..But the buck stops there for the adult who come out of our Higher leaning institutes do not wish to go to the backward areas for they do not want their progeny faced with the same situation as they did the mental agony of not seeing the marks but the benevolent officialdom …So can we point the finger at them ?Most of us migrated to the cities for the same reason .Some even left the country for better wages and a better working environment . The solution lies with the government to provide educational institutions of the same standard as the Urban centers and the hospitals in par with the Metropolitan .. may be!. A more equitable division of resources would help to achieve the ratio of medical personnel co-related to the population .. More concentration of high rise residing people in Colombo would mean a lucrative demand concentrated in the city and ultimately the neglect of those in far away places and the double jeopardy of the sick having to spend on the arduous trek to cities and channeling experts . the cost to them is much more than a urban rich .The Government should budget to fund the needs of the people rather than the needs of the MPs and Ministers who desire to lead a life of luxury on the budgetary allotments .Much much more work has to be done to make a Medical graduate feel that the health system is working with them to provide for needs of he people ..

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K A Sumanasekera / March 10, 2017

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Yes indeed.

Otherwise how can the Yahapalana enforcer Rajitha get a MBBS for his DIL?..

Wonder whether it is MBBS or more up market MD, like in the States?..

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Gayan kodithuwakku / March 10, 2017

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Good information with balanced way…

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kp / March 10, 2017

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Yeah, I stopped reading this as soon as the personal attacks against members of the armed forces started raining down. I’m by no means a nationalist ‘ape ranaviruvo’ type, but to pretend the armed forces personnel are the only ones that have been involved in misappropriation of state property is laughable, coming from someone in a profession that goes on strike at the drop of a hat and wants new cars at the taxpayer’s expense every couple years. You’re a hypocrite too, good doctor. You just seem to have your head up your own behind when it comes to seeing your community’s faults.

This is a perfect example of why we need a (well-regulated) private medical college in this country: if nothing else, to break the stranglehold these type of hypocrites have on the healthcare system of the country, holding patients ransom for their own petty agendas. He speaks of problems with distribution- ignoring the fact that a lot of these doctors in outstation areas are more concerned with running their private practices, sometimes smuggling government drugs out of hospitals for their clinic pharmacies. Is this a joke, or has this guy just woken up from a nap?

As for the person of questionable sanity commenting under the name of ‘Nimal’- apparently this government is bad whether it decides to keep SAITM on or not. A government can’t ‘send’ people abroad to work- this isn’t Soviet Russia where one stroke of a pen can exile people. This is the same backwards logic every government uses when they try to appeal to skilled Sri lankan labour abroad to return to the country to ‘help develop the nation’, without first fixing the problems that caused the brain drain to begin with. People will go if they want to. Leave the government out of it. This socialist bs has ruined people’s capacity to think, and every problem now requires government intervention. Like they say, when all you have is a hammer, every problem looks like a nail.

I don’t know who should be shot up the backside for all this- the misinformed ignorants that protest at everything yet expect the government to magically come up with solutions, or us for reading this drivel.

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- Nimal / March 11, 2017
  
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  Kp
  If the people have their own money to educate their children in private collages will take the pressure out of the government medical schools. More doctors we have is the better and as above any doctor has a chance to work abroad and they are bound to remit some exchange to SL,if they have settled or not.
  If that person is not a doctor by an office worker then the chances of working abroad is diminished and the foreign exchange earnings will be nil. Something is better than nothing.
  Sadly I can see a bit of envy and jealousy here where some don’t like the private enterprise land.
  
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SJ / March 10, 2017

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Very clearly and reasonably stated.
Thanks

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Adrian / March 10, 2017

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Instead of Private Medical Colleges, why not contribute the same funds and expand state medical colleges so that students with adequate merit could enter and serve the society. Being called Doctor is not a decoration. It is a dedication and sacrifice. It needs skill and insight. Don’t try to buy degree for money. Those who have money can educate their children in many other fields, not in a field that become a noose to the society.

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Ex GMOA / March 10, 2017

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‘Precious lives of patients’- surely that is not what all these hypocrites are planning. Pros and cons don’t matter here if the SLMC under the Medical Ordinance are not helping new med schools to come up to a sufficient level of competence at MBBS degree. Not all can get here, but if they do, they will definitely polish themselves during internship, as every doctor knows. GMOA does not want efficiency in SAITM as it is a threat to their future practice and money “No competition please” is their wish, but it will not happen by destroying others, but by improving themselves. So defamatory lies are on media and web. Pl. credit us with brains to see through these mountains of lies. Executive Govt. has no option but carry out the Judicial verdict. No intellect in GMOA but only flex muscles. Thankfully, there are unbiased teacher consultants. This endless wastage of time, energy, finances in suggestions must stop. Give SAITM verdict/internship.

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Kautilya / March 10, 2017

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Well articulated with evidence.

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Theva / March 10, 2017

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Thrown the light in right direction for people like me , given balanced view and the flaws on privatizing medical education. Children from rural areas not keen to go back to their villages to serve knowing the difficulties they gone through. They thrive f better for their family. Many specialists serve in rural areas leaving their kids to be in urban areas to get better education. There is no work life balance until their retirement age. There should be focus on developing all the districts to avoid frustrated kids with high Z score could not achieve their dreams.
The author clearly given his view by increasing the institutions with out proper training facilities will leave the profession in deep hole. Well written article to give clear insight into this burning issue of private medical education. Your non-biased view in helping the public aware of this issue is commendable.

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Malar / March 10, 2017

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It is not appropriate to compare the total number of doctors to the population. You need to exclude the specialists. It is wise to compare General practitioners to number of population.

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Nuwan / March 11, 2017

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Good article. I’ve seen a video where Vijitha Herath said, SAITM is a problem created by SB, MR and NF.
Unsurprisingly, this is another example of current government perpetuating crony-capitalism of the previous regime without an iota of shame.
I’ve seen many a times parents trying to push their kids through to government employment with the help of politicians. SAITM does exactly the same. Just a bit more money involved.

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- Nuwan / March 11, 2017
  
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  Remember Sajin Vass flying school. Thank god he didn’t change sides to MY3. Otherwise today’s debate would have been allowing those unqualified pilots to fly UL flights.
  
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K.Pillai / March 11, 2017

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There was this recent assassination attempt on the CEO of SAITM. If the SAITM courses are anything like that, there is a clear case to shut it down.

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K.Pillai / March 11, 2017

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Thank you Murali Vallipuranathan for enlightening us laypersons, on aspects of SAITM.

The world over, businesses are there for making wealth for the wealthy – competition bridles this a bit – repeat “a bit”. In Lanka business is particularly ethic-less, ruthless and very much depend on political connections. SAITM has no competitors. Political connections will ensure its monopoly. It may go the way as to how a certain politician did a law examination paper in an air-conditioned room and got 98%.

Murali pointed out private medical study in India but the large number of such institutes will up to a point ensure quality.

Un-controlled quality controlled doctors will tarnish the reputation of the Lankan university doctors chosen by UGC on merit. The protest by the doctors is understandable. Maithripala is simply buying time by appointing this so-called expert committee.

Indications are that SAITM is for the class who go to Singapore to treat a headache. This class has the money to fly to Singapore specially converted business class seats for a heart by-pass. Singaporeans fly to Lanka for such operations because it is very very much cheaper.

Will Lankans accept an Avant-Garde Institute (of course a fictitious name) to produce the higher rung Police and Army personnel? (White-van maintenance will be an essential part here)

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Rameshkumar Thevarajah / March 12, 2017

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Thanks, a well written article.

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