Colombo Telegraph

SAITM As Model For Expanding Medical Education?

By Sumathy Sivamohan, Harini Amarasuriya, A. Karunatileke, Athula Samarakoon, Upul Wickramasinghe, Waradas Thiyagarajah, Chinthaka Rajapakse, Shamila Ratnasuriya, S.Thanujan, M.Mauran, Amali Wedegedera, Niyanthini Kadirgamar and Sylvester Jayakody –

A Response to the Subcommittee on Higher Education of the Parliamentary Sectoral Oversight Committee

On the 1st of August, concerned Academics and Activists gathered at the Honourable Speaker, Karu Jayasuriya’s office in the parliament and handed over a response to the report on SAITM made by a sub-committee of the Oversight Committee on Education and Human Resources.  Copies of the report to be given all the members of the Oversight Committee, Prime Minister, Leader of the Opposition, Government Whip, Opposition Whip and the Minister of Higher Education and Highways were also handed over to the Hon. Speaker. 

SAITM: An ill-conceived response to the question of health and education in Sri Lanka

The government appears ill prepared to address the unravelling situation around SAITM. Its current actions are mired in violence, bombastic rhetoric and unrealistic projections of great economic advances to be made in the business of education and health. The policy paper of the Subcommittee on Higher Education of the Parliamentary Sectoral Oversight Committee,  Expansion of Medical Education in Sri Lanka With the Participation of the Private Sector:  Adopting the South Asian Institute of Technology and Medicine (SAITM) as a Model published on 23 November, 2016 is a justification and conceptualisation of  SAITM as an educational institution, offering it as a panacea for the supposed ills dogging the heels of the two sectors. It is an illustration of the nature of the government’s approach to some very serious issues, undertaken in an ad hoc, unprofessional and unethical manner. The ill-conceived nature of the report unequivocally demonstrates the fact that SAITM is itself a poorly planned programme that barely addresses the problems that exist in the areas of health and education and creates new ones that will be insurmountable in years to come.

Both health and education have been the cornerstone of the democratic structure of the Sri Lankan state.  A policy shift on either of these sectors demands careful thought, public engagement, and the highest degree of integrity on the part of all the policy makers. Yet on both counts, the policy paper demonstrates abjectly poor thinking and a clear lack of vision for the country.

SAITM: Is it numbers?

Regarding Health, the paper says that SAITM will address the lacunae in the system presented by the inadequate number of doctors in the country. In other words, SAITM will be able to add to the number of doctors in the country. Such a claim, if stated with any sincerity, demonstrates that the policy makers have absolutely no understanding of the existing system of health care delivery. The problems besetting the health sector are not a mere matter of numbers. They are an integral part of the structure of health care provision, namely distribution and specialization. As medical professionals, researchers and those who actually care about the state of affairs in Sri Lanka will tell you:

a) The inadequate number of medical professionals lies in the areas of distribution of doctors across the country. In 2015, Colombo District had 182.3 doctors per 100,000 population (employed by the Ministry of Health) compared with 37 doctors per 100,000 population in Nuwara Eliya District (Vallipuranathan 2017). That same year, Colombo District recorded the highest number of medical officers (5344), while the lowest number was recorded in Mullaitivu District (Health Information Unit, Ministry of Health 2015).

b) Doctors on completing their internship are posted to peripheral areas, but can leave those stations before they are eligible for transfer if they pass a screening exam for a course of specialization. There is no mechanism in place to retain non-specialist doctors in such areas, resulting in a large number of cadre positions remaining vacant.

c) To make matters worse, the Ministry of Health promotes specialization over strengthening primary care. But this drive for specialization has not been combined with greater provision of facilities in the regions. Specialists, owing to frustration with the meagre and inadequate facilities and other factors like lack of ‘good’ schools for their children, tend to turn toward urban centres, in many of which there is a glut of health care professionals, including doctors.

d) As health care professionals go, a severe dearth of caregivers exists in the nursing and midwifery sector, compounded by issues of distribution. Nursing and midwifery are an integral part of the provision of health care and this thriving sector needs to be nurtured. In 2015, there were 7436 nurses in the Colombo District compared with 44 in Mullaitivu. That same year there were 853 midwives in the Kurunegala District versus 51 in Mullaitivu. There is also a dearth of ancillary healthcare providers, including radiographers, lab technicians, pharmacists, physiotherapists, etc., particularly in the peripheries (Health Information Unit, Ministry of Health 2015). The over emphasis on having a large number of doctors belies the situation on the ground.

e) Figures from the World Health Organization (WHO) are often bandied about by the pro-SAITM lobby to argue for more doctors. WHO does not recommend a gold standard for its member states in terms of physicians per population, the 2006 World Health Report estimated that a health system needed at least 2.5 doctors, nurses and midwives per 1000 population (or 250 per 100, 000) to function. According to the 2014 Annual Health Bulletin published by the Ministry of Health, in 2014, 85 medical officers and 185 nurses (totalling 270) per 100,000 population were employed by the Ministry of Health (Health Information Unit, Ministry of Health 2015).

f) The same WHO Report highlights migration of doctors and resulting global and within country inequalities as a major issue. Sri Lanka too must address redistribution and implement measures to retain doctors in the public health sector.

The focus on doctor-numbers is terribly misplaced. Even so, on what ground does the government assume that graduates of SAITM who have been educated with private funds and belong to a class of relative affluence will be willing to serve in peripheral areas in the country, where one finds the largest need for more doctors? It needs to be understood, far and wide, that SAITM will NOT solve the problems of health care provision.

Higher Education: the new site of struggle

It is concerning  higher education that the government’s policy paper reveals the ugly side of its ambition. The shift to privatisation rears its head once again in the section that looks to formulate policy for the future. In its opening paragraphs, the report quite rightly laments the fact that 82% of students who qualify to enter the state university system are unable to secure places owing to the system’s inability to accommodate them all (p. 7). This is of course a very grave concern and should be tackled with the seriousness and integrity it demands; instead the government and its allies like the Parliamentary Committee have come up with a very poorly conceived solution that is SAITM.

SAITM is very clearly a ruse, an ill-conceived ruse maybe, to bring in privatization in education not ONLY in the form of a private university, but through the seemingly innocuous, but deadly mode of PPP: Private Public Partnership.  From pages 8 to 13 the document outlines the nature of private education embodied by SAITM, its basis, mode of sustenance and implementation. The section deals with admission criteria, delivery of a ‘standardized education’ and the establishment of a monitoring body as well as the management of teaching hospitals, which will be in the hands of the government. Item 2 which deals with the SAITM – STATE interface is captioned, “Proposal to enhance the clinical exposure of SAITM medical students through Public-Private partnership” (8). In the details that follow, Private Public Partnership (PPP) is given as a facility that is designed to ease SAITM’s path to procuring and delivering a ‘standardized education’ to its students and gaining a reputation on par with state universities. Under this scheme, public universities and public hospitals will be endowed with the task of bestowing academic respectability on SAITM. 

Of course such an ideological and material position compels us to ask many questions: Why is the government so concerned about an institution that will produce a 100-odd students each year, while so many of our state funded medical faculties are in need of expansion and upgrading? Those who are in support of SAITM themselves have drawn attention to the possibility that some of the medical faculties in the state system lack staff and facilities. Isn’t it then so much more the reason for the government to be putting forward proposals to upgrade state funded university medical education? Why bend over backwards to accommodate SAITM? In whose interest is such a move anticipated? In a contradictory move, Minister of Health, Rajitha Senaratne recently proclaimed the inauguration of two new state medical faculties (Sunday Observer, 5 February, 2017). Is this a knee jerk reaction to the opposition to SAITM proposal  on the part of the government or is it another of its attempts to pull the wool over the eyes of the people to smoothen the transition to private medical education? What is necessary at this point is the greater strengthening of facilities and education in some of the peripheral universities.

The paper is replete with inaccuracies and faulty reasoning. To name just one: on page 5 the report states that international school students cannot enter state funded universities and therefore some accommodation has to be made for them. A cursory look at the way the school system works will tell you that this is a fundamentally flawed understanding of the way the A/Levels are run. Any student in Sri Lanka can take Sri Lankan A/Levels, and the fact that students of international schools in fact have entered the state university system proves the statement as blatantly false. However, the larger concern is not the mistake, but the attitude of those involved toward the very important subject of education. Also, the argument about the need to attract more international students can be countered by the fact that there already are quite a number of international students in the state medical faculties.

PPP: the spectre of privatization

Underneath its disingenuity is a more sinister agenda. The report is a thinly disguised proposal for the gradual privatisation of universities. Where such an agenda reveals itself is in the way the much touted and much celebrated term PPP is conceptualized in the report. The section on private medical establishment and PPP is fairly detailed in the document. PPP is understood as a partnership between public universities and private ones, particularly in the field of medicine. The universities of Peradeniya and Colombo are supposed to take the lead here. We are of the view that such thinking has real life and momentum for, in a recent announcement, the government gave voice to ideas of making the Universities of Peradeniya and Colombo transit to self-funding entities (The Island, 22nd July, 2017).

What exactly is PPP? One would assume that PPP is designed to serve the public by harnessing privately held material sources to support and nurture public institutions, so that the public benefits from such a partnership; extend a helping hand to the citizenry, emerging as a powerful bloc through the public institute, students for instance. Research is another area in which PPP has been envisioned as potentially beneficial to the public. While both the above features are controversial and have been questioned on many different grounds, including ethical ones, one might at least argue a case for it. Critiques of PPP are a plenty, and we cite one here by Faranak Miraftab, “Public Private Partnerships: The Trojan Horse of Neoliberal Development” in Journal of Planning Education and Research, 24: 89-101.

But shockingly, even the façade of benefits accruing to the public is not a cardinal concern in the policy paper. The text is transparent. Under section 5 captioned “Establishment of Private Medical Education,” the report lays out the fundamental principle on which private medical education is formulated: Private medical education with “government involvement” (p.14). One is compelled to ask, “why government involvement,” and “what does that involvement entail?” As it turns out, the involvement of the government here means the establishment of units of private medical education within and affiliated to state universities, beginning with Colombo and Peradeniya, with other state universities to follow suit.

“The benefits for the respective university will be the (sic) getting funds from this venture for the upgrading of the facilities of the state faculties of Medicine,” says the report in section 5.1 ( 14). To an undiscerning reader this might seem like a sound plan. State universities will have financial input from private entities. But this beguiles the fact that state universities come in with massive investment in knowledge production at multiple levels, the training of its staff from kindergarten to the PhD or its equivalent and further, heavy investments in infrastructure, development of sites of research – laboratories, libraries and archives, development of territory and a supporting community, and finally the political programme of social upliftment. 

Private medical establishments in collaboration with public universities will actually be parasitic upon the resources of public universities, for they will bring little into the collaboration financially, and their existence will erode into the investment and foundation of education built over decades. There will be a greater ‘brain drain’ of doctors and professionals from the state sector to the private sector than what exists today with out-of-country migration, taking with it all that was deemed valuable and worth investing in. PPP here would mean the state financing and sponsoring private medical education. In turn and ironically, state investment in public institutions will be considered unviable, undesirable and untenable and the call for “Let private enterprises do the job of investing in education,” will prevail.

One of the obvious instances of this parasitic existence lies in the realm of staff and the sharing of trained personnel across the two streams. Pay attention to the laughable and yet sinister attempt to lease out the staff of public medical faculties to private enterprises. One of the purported benefits of private universities is supposedly to:

Reduce the burden for the government for the salary increase of professors and lecturers in state universities who are at the moment disgusted about their salary, this is the very reason why it is difficult to recruit medical teachers to the universities as the government medical officers salary with other allowances – such as overtime etc – is double that of a senior lecturer in a state medical faculty. They would be able to be visiting lecturers to these private medical schools. (p.15)

While one is slightly nonplussed as to where the extra hours for teaching in the private medical universities are going to come from, the policy makers’ abject indifference to the education at public universities and education as a social good is apparent. Another word for this is “poaching,” with the government aiding and abetting in this illegitimate act. The teachers in the public university system will be teaching in private medical educational enterprises, severely undermining both the quality of education in the public sector and creating an unfair non level playing field, in which public education will be the loser. The students of public medical universities seem to be a dispensable commodity and accommodated within the system only on sufferance.

Conclusion

The government’s argument for SAITM can be summarised as follows:

a. There are not enough government doctors and we need to produce more doctors graduating each year.

b. The government is not in a position to expand the state medical system by improving on its numbers. Though the Minister of Health has made statements that seem to counter this position, in general such a position is still in currency within government policy.

c. Therefore, the government will expend an enormous amount of energy and material resources, including finances, toward the establishment of a private medical university. The government does not have money for itself, but it has money to give the private sector. How much more illogical can it get?

The convoluted argument outlined above gives the lie to any notion of disinterested altruism and service to the people of the country on the part of the government. It is in fact an insidious programme of private medical education that is SAITM. What one can infer from the report is that SAITM like many other recent moves in education and health, are a part of the neo liberal agenda pursued by successive governments. In this, it follows rather discredited practices in the global arena. Yet, globally, there have been waves of resistances to aggressive privatization of public entities, particularly in the area of education. It is foolhardy for our government to push on without much forethought on these emerging trends and resistances. We need a visionary policy on education and higher education, not ad hoc measures that will lead to the destruction of much that has been fundamental to the welfare of the people. The take-over of the Neville Fernando Teaching Hospital might indeed be a great leap from the frying pan into the fire as the government makes headway with its plans to establish PPPs in education! In responding to the policy report on Higher Education and SAITM by the Subcommittee on Higher Education of the Parliamentary Sectoral Oversight Committee, and in exposing the scam it is, we hope to begin an informed dialogue on SAITM, private universities in general, and the future of Free Education.

By:

Prof Sumathy Sivamohan, University of Peradeinya – University Teachers for Free Education

Dr Harini Amarasuriya, Open University of Sri Lanka –University Teachers for Free Education

A. Karunatileke, University of Kelaniya – University Academics for Social Equity

Dr Athula Samarakoon, Open University of Sri Lanka – University Academics for Social Equity

Upul Wickramasinghe – Education Renaissance Programme

Waradas Thiyagarajah, University of Colombo – Education Renaissance Programme

Chinthaka Rajapakse, Movement for Land and Agricultural Reform

Shamila Ratnasuriya, MONLAR

Amali Wedegedera, Alliance for Economic Democracy Alliance for Economic Democrac

Niyanthini Kadirgamar, Alliance for Economic Democracy Alliance for Economic Democracy

S. Thanujan, Mass Movement for Social Justice

M.Mauran, Mass Movement for Social Justice 

Sylvester Jayakody, General Secretary – Ceylon Industrial, Mercantile and General Workers Union

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