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.
* 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.
- de Silva, N. et al., (2008). How many doctors should Sri Lanka have?. Ceylon Medical Journal. 53(3), pp.93–98. DOI: http://doi.org/10.4038/cmj.v53i3.249
- Prof. A. H. Sheriff Deen, Why this fuss over SAITM? SLMA Newsletter, December 2016 P2-3