By Samandika Saparamadu –

The private university concept was mooted in the late 1970’s with economic liberalisation policies. It also takes us to the painful traumatic memories of the late 80’s when hundreds of young men were brutally killed. This was during the reign of terror from 1986 to 1990 with the protest against the Private Medical College (PMC), Ragama. This saga of commercialising medical education continued with eight attempts to form Private Medical Colleges (PMC’s) over the last three decades. The lust for mega profits by some unscrupulous local businessmen in exploiting medical education has led to recent controversies and malpractices, which surfaced through reports and news headlines pertaining to the SAITM (South Asian Institute of Technology and Management) racket.

PMCs in Sri Lanka is no longer an issue of economics or health but sociological and political, much more deep rooted indeed. It is an important social determinant of the health of Sri Lankans over the next few decades. I will try to make it succinct to not waste reader’s time.

Status quo

Recently, I was taken aback by online comments, reviews and articles written against public universities and in favour of the PMC. I was curious on why there was so much animosity towards free healthcare system, free education and doctors in Sri Lanka. After some research, I discovered that this is a common problem in every ‘highly sought after’ field with limited opportunities, specially when it’s given on a merit basis! However, the online comments were completely undermining the experiences of my batch-mates during their housemanships (Internships) in Sri Lanka (SL), not too long ago. Fortunately or unfortunately, online comments and posts in general in Sri Lanka do not represent the normal curve. As per “Internet live stats” percentage of population with Internet in Sri Lanka is only 19.9% and internet literacy rate is even less than 20%, as per Department of Census and Statistics. Therefore, it is vital to point out that the online majority hardly represents the opinion of the country’s majority. Nevertheless, there are many socio-economic factors that make people hate doctors in Sri Lanka, and out of which the “Colonial factor” is an important one. It is certainly a topic for another day.

So, it is also crucial to acknowledge that online hate comments are not only about ‘Anti PMC’ sentiments (“No PMC” campaign), which could impose a falsified idea on people as if the campaign is against all private education institutions and students.

Now hang on there! We need to get to the basics first. Do you have an idea about child mortality rate in Sri Lanka, vaccine coverage, maternal mortality rate, doctor patient ratio, have you ever been to a peripheral hospital, have you ever been to outskirts of northern, north-eastern, central, north central, southern, western and eastern provinces (not on road trips!) and spoken to villagers in their native lands? If you don’t have a general picture regarding basic health and it’s shortfalls in Sri Lanka, I would strongly suggest that you do basic research immediately.

Quality and standards

I repeatedly came across this quote “Maintain the quality and let them carry on with SAITM (PMC in Sri Lanka)”. Here the million dollar question would be “how to maintain quality and standards?” Many people don’t bother about quality and in fact they don’t understand the determinants of quality that healthcare people are concerned about. Take this simple example. Do you remember the protesting state medical students a few years ago (They have been on the road pretty often over the last few years), asking for proper lecture theatres, professorial units and clinical facilities for Rajarata Medical faculty? Did you ever wonder what triggered that?

Was it because they were told by the government that their degree program is not validated by UGC (University Grant Commission) because of poor facilities? Did commoners take note of it and started picking on students of Rajarata University saying that they are not qualified enough to treat them? No! Those were requests arising from medical students, students’ unions (politically inclined and non-political) and trade unions of doctors.

In contrast, in the midst of the countless allegations made by SLMC (Sri Lanka Medical Council), GMOA (Government Medical Officers’ Association), students’ movements and the five member independent committee which was appointed by former Minister of Health Maithripala Sirisena of the Rajapaksa administration, against the quality of training at SAITM, no one cared except a few parents of students of SAITM (about 10-15, and out of which most of them were doctors!) who sought legal advice on this matter, mainly to get their money back due to poor clinical training. And now, the SAITM students are out of the blue, on the roads asking for clinical facilities. Then again, did you wonder why? Have they now realised that the training is not good enough? No!

It is just because the SLMC decreed that the clinical training provided by PMC is not sufficient to be qualified for SLMC recognition. This is where the problem is and now we can get to the crux of the issue. When you buy a medical degree, you don’t ask for quality and what the student needs (or may be the parents of the student) is just an affordable degree, period! (provided you are not an exceptional high achiever). Let us also not forget that many get there or end up in private medical schools for many reasons (as per stats from Indian Private Medical Schools), when it is a commodity. Remember, it’s all about South-Asia, the largest cohort of self promotors who are abnormally obsessed about fake and superficial social status.

People start talking about the quality when they seek medical care and that is the basic need of patients and consumer behaviour. At that point they will be more inclined to know whether the doctor is an Indian (at Lanka hospital), or a locally trained doctor or as most preferred, both local and foreign-trained!

Board exams in medicine

I had a couple of conversations with my friends on this topic where I threw the question, “Forget about PMCs, tell me whether you are happy to take your kid to Mr.Xxx?” (This person failed a few subjects at A/L examination but he studied at a foreign university to become a doctor) Everyone looked perplexed as they shook their heads saying “No!”. In my opinion, I would not hesitate to take my family members (parents or kids) to him as far as he gets through the ERPM (Examination for registration to practice Medicine in Sri Lanka) / Act 16, because I know that he has passed the Sri Lankan board exams, in which we trust.

However SLMC has now rectified this issues with the new application process for foreign medical colleges through the Medical Council.

Whereas SAITM openly advertises “No Act 16 is required!”, when it comes to board exams. This is not a joke. It’s a shame that SAITM owner Neville Fernando is afraid of allowing his students to sit a common exam, which in turn jeopardises the lives of Sri Lankans. It is not a surprise, given the fact that Neville Fernando and his house has failed to release entry qualifications of his students at SAITM, so far!

Let’s analyse more socially inclined countries like most of Europe, New Zealand, Australia, more social capitalist countries like Germany, socialist Cuba and capitalist USA. All these countries are good examples of solid and sound regulatory mechanisms for recruiting medical professionals and all of them have strict board exams to measure and evaluate the level of knowledge and hands on training of a candidate. It is to make sure that countrymen get access to safe medical care and their lives are in good hands.

Let’s look at Sri Lanka in comparison to a few countries around the world when it comes to salient issues. For an example, we copy our taxation from Singapore, try to duplicate ruling powers of Singapore and even trade and finance models! Yes, all while competing in the same market as Singapore. We (as in the State) hate India (for the time being we are in India’s good books) Bangladesh and China (our government was in a romantic relationship with China a few years ago but not anymore) when it comes to power decentralisation, public transportation, education, medical care, public policies, hygiene, environment pollution, exploitation, women’s rights and population growth. Our politicos like to be good acquaintances of the US and the U.K. (with a positive connotation to colonial mindset) if its about public relations and Japan, if it is donations and aid matters.

The hypocrisy is real! Our politicians, educationists and other people who support the PMC always tend to take examples from India, Bangladesh and China when it comes to private medical colleges. Well, even Singapore, the epitome of Asian capitalism doesn’t have a Private Medical College (Duke-NUS is a semi government graduate medical school largely funded by the government and attached to NUS).

Class structure and income redistribution

Do ponder why our people do not bother to ask “Why are there so many cheap MBAs in every corner of the city?” It’s because of the same reason. The problem is, our people opt for elitism without understanding that spending a couple of million rupees (maybe even more) on a degree or getting medical treatments from a private hospital doesn’t get them there. If I cut to the chase, the Sri Lankan middle class doesn’t like to be called a “middle class”. Ultimately it sums up to an income redistribution issue if you bother to work it out. After all, without changing the system and without changing attitudes of people, it’s absolutely not worth talking about “Quality and Standards”. Nobody on earth can maintain it, specially in a country like Sri Lanka that has ranked pretty badly in the global political corruption list, as high as 83-85 (out of 165 countries), over the years.

The next determinant is income inequity which is an ever growing issue since 1948. People increasingly tend to think that bridging this gap isn’t a tough task as far as they have a cling to a corrupt politician. And unfortunately it works and I have tons of examples (I am sure that everyone has a story to share) on how people with the mindset of getting rich overnight, get things done by being on good terms with politicians. Interestingly it has a direct link to the process of student enrolment to SAITM as well. One student from Negombo got in to SAITM through the previous Minister of Education (S B Dissanayke) who was a friend of the student’s father without even a simple pass (S pass) for Advance Level (A/L) physics. It really does not matter whether the student has completed requirements on repeat attempts or not, as far as he gets enrolled into a degree program without qualifications. This is a serious issue and trusted news sources say that there are quite a number of similar stories at SAITM. It probably explains why the owner is reluctant to release entry qualifications of his students.

At this stage the other crucial question to ask is “Are we sure that 3 S passes is a good criterion to select a student for a medical degree?” Feel free to research and decide for yourself. One important thing to remember is that the medical profession is an age old field of tons of documented scientific work and it has evolved through millions of complicated processes to make sure that the patient/client is safe in the hands of a physician and NOT to make sure that everyone’s doctor dream comes true.

Political involvement

I know I have been talking about quality to a point of irritation. Doesn’t anyone question, “If the system is so fragile and vulnerable, how come we are confident that the state medical schools are well maintained and only qualified people are matriculated?”

The answer is quite interesting! There are many steps to make sure that correct candidates are always taken into medical schools in Sri Lanka. But using the Swiss cheese model of error analysis, there are rarely people who get in there without proper qualifications. Over the last 10 years I knew only one such incident and it was surprisingly (or rather not so surprising, given the history of his father!) a member of parliament “Chathura Senaratne”, who was the son of the health minister, Rajitha Senaratne. He was an Anandian and as per gossips from Ananda college, he hasn’t sat for his AL exam but got selected to either Ragama or Rajarata university. His Father pulled a few strings and finally got him to Colombo Medical College. He was 3 years elder to me and since he missed his batch a couple of times he ended up in my batch and particularly in my group because Senaratne and Saparamadu are two adjacent surnames in alphabetical order. So we were in the same clinical group for a few weeks during our second year and one fine day he told me and my friends “Machang, I have a spinal cord injury and need to go abroad for treatments. I am not sure of the day I can return…”. However he didn’t exactly know what was the issue of his spine/spinal cord and he vanished for years.

In 2012, my good old friend Buddhika rushed in to my room at Bloemfontein with a paper in hand and asked me to read the article. It was a Sinhala newspaper and the headline said “Cat-loving doctor couple”. Well, it was about Rajitha’s son Chathura Senaratne and his girlfriend who studied at SAITM (She is still attached to SAITM). By then, Chathura had gained his MBBS from somewhere and he was, for us, more like a quack. I hope this is a clear example of misleading political and media gimmicks that disrupts good working systems in the “Wonder of Asia”. Trusted news sources say that Rajitha’s daughter in-law is the reason why he is nauseatingly pro-PMC right now.

If we let this happen this time around, in a few years down the line it’ll be just like Indian private medical schools. Even the secretary general of Health Ministry will open one, because it’s always big money!

Well, if you are still not sure about ridiculous political backing to get this illegal proclamation legalised, I will share one personal experience with you. When I first wrote an article against SAITM back in 2011 as a member of the Medical Faculty Students’ Union (MFSU), it got published on a couple of websites to be thankful to DailyMirror and in turn it resulted in a special visit of a defence ministry agent to my Negombo residence showing how the government was pushing Neville’s almighty dollar and proving the existence of the then totalitarian rule.

Are we running out of doctors?

Other counter argument to quality is, “It really doesn’t matter even if there are both qualified and under-qualified people in the field, market will determine who are the best and the next…” So the counter question to ask is, “What is the reason to get poorly trained or “low-quality”(because it is officially labeled that the institution is not capable of producing good graduates with sufficient training) doctors in the healthcare system?” Why people deliberately want to change a system that performs well? Is it advised to change the winning team just before the finals of a cricket match?

Now the question to the question is, “Are we running out of doctors?” Answer is yes! We did not have enough doctors in Sri Lanka, and the estimated doctor patient ratio a couple of years ago was about 1:1811 as per a survey done by a group of researchers led by Dr Mendis. This ratio is far below the global average of 170 per 100,000 population but is encouragingly more than that of average of South Asia (40+), Bangladesh (23), India (51) and Nepal (05) but not on par with Pakistan (66) and Malaysia (67.3). It was expected that the doctor to population ratio in Sri Lanka to rise to about 90 per 100,000 population by 2015, in other words one doctor per 1100 persons. We are on the subject of numbers! Do we know how many doctors we need for Sri Lanka? There are many considerations other than doctors per 100,000 population to estimate this. Has the Ministry of Higher education consulted the Ministry of Health about the number of doctors to be produced each year before opening new government and private medical schools at great expense to the country? There is a lack of coordination, dialogue and policy between the Ministries of Higher Education and Health, the market and the consumption of manpower, respectively.

In short, ideally, the expected doctor-patient ratio has to be calculated and projected by the Ministry of Health (MoH) following a formal status analysis and the target has to be established as a KPI (Key performance index) in health manpower sector, and proper implementation plan has to be drawn together with the Ministry of Education to walk the talk as a ten year plan. But in contrast, the MoH has decreed that there is a doctor saturation in the country by 2016 and they are going to cut down the number of doctors absorbed in to the government sector. So, now the question remains a question! Why on earth does the government promote private medical education? Is it to force future doctors onto streets without internship opportunities and jobs? Create a work force into a field in which the government has cut down the demand? These policies and statements of the state clearly contradict each other like “living death” and promisingly exposes the corruption of prospects.

Medical education

Let’s talk more about Medical Education. It is a vast field that has even created tens of thousands of job opportunities around the globe. Not to boast about Medicine but it is a well known science in the world that has it’s own largest discipline for its educationists. This is because it has evolved from Egyptian civilisation to Hypocrites to modern technology driven medical practice over 4000 plus years, with piles of documented scientific literature. So, you and I cannot take things for granted when it comes to medical education because it rolls back to basics, which is safety of the patient first. Please read and be informed before thinking of commenting on another discipline or science which could be totally off your scope. If you have been a strong supporter of PMCs without knowing much about Medicine, I’m sure you will find “Blind men and the elephant” by John Godfrey Saxe interesting.

Having said that, don’t we need to urgently reform our health system? Yes indeed, we need big change! Our direct, referral-less channeling system, GP (General practitioner) system, inpatient and outpatient information systems, follow up mechanisms and many more have to be reoriented and a lot of changes need to be brought about in order to make our free healthcare system more accessible, safer, and more efficient. There are many interesting fields of study where people work tirelessly to make their professions efficient, safe and people friendly, including “behavioural insights”. So there are a lot of things for us to learn and implement, but if someone thinks that opening a private medical college and paving the way to open many more that are already in the pipeline will help you bring about a change, all I have to say is, my friend you gotta read first and get a good dose of reality!

It drains money out of the country!

Well, Facebook was tempting me to share a memory a few months ago which was a snapshot of an article that I wrote on this issue more than 4 years ago and it was absolutely a tremendous pleasure when I realised that what we researched, said and believed four years ago is still valid and facts and statistics are precise as of today.

I feel ridiculous when I recall how we used to counter argue, hilarious arguments like “it drains money out of the country”, “government should encourage such investments”, “creating opportunities”, “quality is not an issue as far as it is monitored”, “you got to maintain quality and not to shut it down” and etc. Also we wasted a lot of time on counter arguing “no opportunities for talented students”, “public sector is not accessible” and etc, because the answers are “Clearly hidden” in the campaign itself and the campaign is to find solutions to all these issues. These people who waste their valuable time on roads are protesting against obnoxious government policy driven pronouncements, to strengthen state education system, to reinforce medical education, to increase annual enrolments to universities with better physical facilities and to protect the residents including your near and dear ones. If it’s today, I would not bother to answer any of those questions and instead I’d simply say “Are you freakin kidding me, just go and do some self-study on the economics of the matter!”

Last but not least

The bottom line is; if people are inclined towards capitalism, more like a disguised middle class looking for trendy capitalism while living in a computer generated dream world aka Matrix, they should come up with smarter investment plans with clear win-win opportunities (there are tons of examples from around the world but I don’t want to waste time on this) if not let it be equally accessible while creating more opportunities for students (ideally our people should be deprived of benefits of free services to realise how important it is for any country, any society!) If someone is arguing for a midway approach (for an example a tripartite approach), which is great; make sure that the Government is financially strong enough, knows how to prioritise, corruption free and been endowed with a trustworthy court system. Trust me, we are no where close to realising this lucid dream.

Hope we can now get to the bedrock of this issue!

Now you may try answering one last question. Would we like to give “Sakvithi”, the famous finance fraud which came to light a few years ago, another chance to restart his business with proper structure and transparency while maintaining standards? If you can answer “yes”, you can probably say yes to giving Neville Fernando another chance to maintain quality and standards and to restart his business which was built on fraudulence, infringement, deceitful advertisements and underhand money in millions (Please read the report of the five member committee for more details).

At this eleventh hour it is our courteous entreaty that the good-governance government retracts this rotten legislation and publicise the illegally maintained Private Medical College, SAITM for the sake of highest standards of Sri Lankan medical services and swindled students of SAITM.

I rest my case!