By Harendra de Silva –

Vidyajothi Prof Harendra de Silva

Let me first reiterate that this is my personal opinion and not the official view of the SLMC.

In Economics, Return on Investment (ROI) is a ratio between net profit and cost of investment. A high ROI means the investment’s gains compare favourably to its cost. As a performance measure, ROI is used to evaluate the efficiency of an investment. In economic terms, it is one way of relating profits to capital invested.

In Healthcare ROI, It incorporates more than money saved or earned; it must take into account both qualitative benefits such as improved patient safety and improved two way relations with patients and mental health. It eventually saves on health expenses e.g. Immunization will reduce immediate expenses of treating diseases in addition to long term consequences of e.g. chronic lung disease following TB, Measles, Pertussis and also mortality. e.g. ROI on Preventing Obesity and reduction in NCD will reduce morbidity and mortality. 

ROI in Education is considered as an investment in human capital. HUMAN CAPITAL can be described as knowledge, abilities, skills and Attitudes of an individual, acquired through education, training and experience. it ultimately changes behaviour patterns positively, which would help the latter to be more productive and improve his earnings. e.g. Improved Literacy increases immunization and increases quality of life that invariably saves personal & state health costs. e.g. Knowledge and skills would increase productivity, hence earnings, quality of life, hygiene and consequently benefit the person monetarily, health-wise and the country as a whole.

Since the birth of the “open economic” policy; For three decades (now 4 decade) the application to the relevant higher education policies have faltered by focussing on student intakes and unemployment. Basically, we operate as a “state-owned monopoly in a “closed economic model’, resulting in a continuous loss of competitiveness locally as well as globally! Mainly due to so called ‘political sensitivities’ i.e that’s where the votes are! (Ref. UGC Publication 2012 Re-creating and Re-positioning of Sri Lankan Universities to meet Emerging Opportunities and Challenges in a Globalized Environment 2012, Edited by Ranjith Senaratne and Sivanandam Sivasegaram. Policy reforms in higher education: transforming Sri Lanka into an education hub. Sirimal Abeyratne and Upul Lekamge) 

Unfortunately, the Postgraduate Institute of Medicine is also a Monopoly of postgraduate education in medicine. In the meantime; many countries in Asia including Bangladesh has progressed far beyond us! If Sri Lanka wishes to be one of the emerging economic giants in the region and at the global level, it has to introduce a series of educational policy reforms to achieve its goal in becoming a “knowledge hub”, primarily eyeing on international demand for University education similar to many other countries.

Although Sri Lanka could boast of net primary enrolment ratio and adult literacy ratio, these achievements make little sense in the context of globally competitive knowledge and skills. Many countries in the region which in the past lagged far behind Sri Lanka have advanced in higher education by surpassing Sri Lanka. We as a country has not invested on Logical and Critical thinking and analytical skills. We still have a population though ‘Educated’ that believe in non-scientific beliefs including supernatural powers. 

Becoming a knowledge hub and a global economy, we need to invest on human resources. Apart from just literacy, quality of education, logical and critical thinking of students and hence the community, IT skills, and other technical skills are necessary. Have successive governments invested enough? to achieve a society with logical and analytical skills?? Are we taking the correct approach? educational methods include knowledge based i.e. ability to reproduce, vs. logical thinking patterns e.g. Australian entry to medical school would/may include English/Chinese/…, mathematics, biology, logic and compulsory community service is often mandatory, while we are harping on Biology, Chemistry and Physics only. How can a country develop without innovative and logical thinking? We believe in: supernatural powers, timing elections on supernatural predictions by politicians, followed by similar behaviour by the “educated” which shows that conventional educational achievements do not mean much.

Although we boast of a high literacy rate illogical belief’s without understanding scientific evidence has detrimental effects on our health, nutrition and economy. We believe in not bathing when ill while drinking water!! We don’t eat milk rice for lunch because, coconut milk is a ‘cold’ food: but we eat rice with potato curry made with coconut milk; for lunch; we don’t substitute rice for pittu, hoppers, or roti for lunch without realizing that it is all made of rice flour; when we say that diarrhoea is caused by indigestion, people stop eating and stops focussing on the infective nature to prevent spread and it also causes malnutrition. This illustrates how illogical we are although in a highly literate and ‘educated’ country!

In 2017 more than 250,000 sat for A/L and (64.38 %) were eligible for university education but only 31,415 (19.25%) enter the ‘free university’ system (MOE data). in spite of tough competition and the issue of area-based Z scores that may discriminative to some students?

In this environment more than 20,000 go to universities abroad, 3,000-4,000 to local private institutes affiliated to foreign universities and about 108,000 though eligible cannot pursue further education nor has any other avenue to further education!! Although education is a basic human right, the majority are denied ‘freedom of education’ in alternative studies (as opposed to free education). 

In 2019, the SLMC has issued 734 Eligibility certificates for students to study medicine in 18 Universities abroad. Some individual universities received 60 to 244 certificates, which raises different issues of standards of education in these universities to accommodate huge numbers from Sri Lanka alone. Websites revealed course fees of 11 million to 25 million or more for each course of 5 or 6 years. Assuming that there are 750 medical students entering foreign medical schools every year. At any given time, there will be 5 (or 6) times this number (minimum 5x 750) in foreign medical schools. Assuming that the average annual fees are 3 million Sri Lankan rupees (total 15 mil for 5 years). The total foreign exchange lost per year is Rs. 11.2 Billion. This is not taking into account those who did not collect eligibility certificates and universities with higher fees as well as 6-year courses. We are considering only 750 and not the estimated 20,000 others who go for other courses where the course fees are likely to be less than medical courses. The foreign exchange lost will be astronomical. Even other courses conducted in Sri Lanka affiliated to foreign Universities would include foreign exchange. The SLMC has issued 244 eligibility certificates to one university in Belarus. To accommodate this huge number far in excess to any Sri Lankan Medical intake would be in addition to other foreign countries and local graduates which casts doubts on standards of teaching. Checking the Internet, I found 12 agents for this university spread across the country! There are agents all over, some are doctors, others affiliated to organizations, some are former – SLMC officials!! no wonder this is a prolific business!!

Gunaruwan, et al, 2016, (Education Service Delivery Economics Of The Sri Lankan State University System: Cost Competitiveness, Concerns And Strategic Opportunities). Sri Lanka Journal Of Business Economics; Vol 6 (2016) estimated the Cost of Medical Education in Sri Lanka and confirmed that the State university system is capable of, competing with international universities in producing medical graduates. The university system although riddled with bureaucracy, is cost-effective to meet the local demand and is internationally marketable, thus making it a true knowledge-hub, paving the way to earn foreign exchange to the national economy. Malaysia and India are targeting 200,000 International students while in Australia education of international students generated a record $20.3 billion in “export” income for Australia in 2015/16 and 28 Billion A$ in 16/17. International education remains Australia’s third largest export – just behind iron ore and coal. Recent reports indicate that the Australia’s economy may collapse in the wake or the Corona virus epidemic since there would be a drop in Tourists and students. Our Intellectuals (THOSE WHO are left!) are treasures! The government and the people have invested in their education!! Why don’t we make use of this resource to earn foreign exchange??? Sri Lanka exports our university teachers to Malaysia and other countries!!!! So that Malaysia can earn foreign income through them, including from Sri Lankans student who study there!!!! There are approx. 50 sri Lankan medical students in one Malaysian university alone: the cost is approx. Rs. 25 million per person for 5 years = 1,250,000,000 for 50 students. There are 5 Sri Lankan professors teaching there as well. 

Taking a point of view of a ‘devil’s’ advocate and risking stirring a hornet’s nest? Is it possible to prevent the massive foreign exchange loss by converting some of these medical colleges to fee levying schools and more importantly attract foreign students thus saving and earning foreign exchange, provided proper standards are met? But would ‘medical professional territorial protectionism’ allow such progressive steps? Would governments succumb to short term political benefits as history has proven previously????

Although not visible there are fee levying systems in existence. E.g. Under the Bhutanese/ SAARC agreement, we have approximately there are 130 foreign students:

In addition, there are 37 expat students paying 12,000-12500 US$ per year in 2 state Universities. Under act no. 17 of 2018, former SAITM students are paying 2,587,500/= to the KDU. The KDU also takes fee levying foreign students at the rate of 6500 US$ per year. In addition, we already have state of the art university hospitals that are underutilized i.e. the KDU and the Neville Fernando Hospital. Which means we have clinical space that can be used. Since we already have schemes for foreign students and we undoubtably have competent staff, all we have to do is to use the existing Universities and the administrative system to recruit foreign paying students. The staff should be recruited through a competitive and transparent system. There would be major protests by students in the free state sector who entered on a Z score on a area basis ONLY if fee levying local students are admitted!! This is because: Sri Lankan fee paying students entering on high entry criteria would be direct competitors in their career but not the foreign students who will not work here!?? We have to understand that those students who strike, face water cannons, baton charges or smoke bombs are not spontaneous reaction but manipulated like puppets by student Unions, and in turn manipulated by local political currents and possibly international influence. 

In terms of Postgraduate education, we already have postgraduate education through colleges like MCGP and Prof Kumara Mendis has community-based family medicine programs for foreigners. The College of GPs held DFM (Diploma in Family Medicine) exams in India. Similarly, why can’t Colleges attract foreign graduates for fulltime courses? We need to think broader, and mega in looking at the marketability of the products and foreign income.

Corruption is rampant in Developing countries like Sri Lanka and India. However, it is also not strange in Developed countries like USA, UK or Russia. Similarly, corruption in medical education is not confined to developing countries but also in countries like China, Russia and USA. 

We have privatised primary and secondary education: it has reduced the burden on government but “corruption” exists in many ways, due to emphasis on ROI & poor monitoring and accountability processes. We continue to lose foreign exchange. The foreign qualifications make it mandatory for them to pursue foreign higher education with resulting loss of foreign exchange and brain drain. Have we solved the problem? We cannot allow independent Private sector organizations to start private universities without monitoring of standards by government and therefore for the time being it has to be done later with proper planning and strategy to avoid corruption and sub-standard education. It is also critical to have proper standards in state Universities that are mushrooming for political reasons.

We have privatised health care: it has reduced the burden on the government but alleged “corruption” exists due to emphasis on ROI & the government’s role in monitoring and accountability processes have faltered. Private sector is happy, doctors are happy. But not necessarily patients! 

We need to learn from negative experience of NCMC and SAITM. Be aware of possible areas of corruption. Study world experience. Re-look z scores. Minimum standards must be increased if there are local students. Proper values have to be met with high academic standards, Monitoring and accountability processes by external sources such as UGC is essential provided there is no red tape.

*Address by Chief Guest, Convocation of MCGP, College of General Practitioners, 9^th February 2020