Private medical education - relevant considerations

Professor Sanath P Lamabadusuriya - Emeritus Professor of Paediatrics, University of Colombo

A topic that has created much public interest through the media, is private medical education in Sri Lanka. This controversial topic first emerged in the 1980’s with the creation of the North Colombo Medical School in Ragama by the Sri Lanka College of General Practitioners. About 30 years later it has re-emerged with the establishment of the South Asian Institute of Technology and Medicine in Malabe.

The Colombo Medical School was established in 1870 and is the second oldest medical school in Asia and Australasia. However even a century later, we have not been able to establish and sustain a fully functioning Private Medical School (PMS) as yet. In 1962, the University of Peradeniya admitted the first batch of students to its newly established medical faculty. Although the reason for establishing a second medical school was to increase the man-power in the Ministry of Health (MoH), it is ironical that this same batch was not offered employment by the MoH soon after they completed their internship.

Family practitioners

Instead an allowance of a few hundred rupees was offered to each of them to attach themselves to well established family practitioners, to be trained in general practice. With the growing uncertainty of state employment, from about 1968, some of these doctors started appearing for the ECFMG examination conducted by the American Embassy in Colombo (about 75 percent of doctors who appeared for this examination in Colombo were Indians, because this examination was not conducted in India, so as to prevent brain drain!) Few months later all Peradeniya graduates were offered employment by the MoH; but by then some doctors had been offered employment in the US and the brain drain had started. By the 1970s, the brain drain had increased to such an extent that a compulsory period of service for five years was imposed by the MoH. This episode highlights the need for consistency in state policy regarding employment of doctors and cadre projections for the future.

Every year over 20,000 students qualify to enter the science stream in universities by obtaining the requisite grades of three passes in Biology, Physics/Mathematics and Chemistry at one sitting at the A/L examination; of these, there are vacancies only for about 1,200 students to enter the eight State Medical Schools (SMSs). Few years ago, few students were admitted to a newly established medical faculty in the Sir John Kotelawela Defence University to serve in the Armed Forces after graduation. The current criteria for admission to SMSs is based on a quota system: 40 percent on merit, 55 percent on a district basis and 5 percent reserved for educationally under privileged districts (there are 16 such districts).

Social equity

The total aggregate marks at the A/L examination was the yardstick which was replaced by the Z score in 2001. The quota system was introduced to ensure social equity. However it resulted in students only with exceptional results being able to enter a medical faculty of their choice. During the last decade or so students entering the SMSs have obtained at least two credits and a pass (except for two students from Mullaitivu and Killinochchi). When the quota system was initially introduced, it was envisaged that the merit quota would increase with the improvement in standards of schools islandwide. Sadly, it has not happened as yet. As a result there are many students with good results such as two A’s and one B at the A/L examination who are deprived of entry to SMSs. In addition there are thousands of students in International Schools sitting for the London A/L examination, some of whom may wish to graduate in medicine.

Students who fail to enter the SMSs and whose parents are able to pay the fees for medical education in a foreign medical school, have the option of receiving a medical degree from abroad. Not all such parents are affluent; some have to mortgage their property to pay the fees. At present hundreds of local students travel abroad for medical studies annually. Over the years billions of rupees have been drained out of the country for this exercise. Their parents have been deprived of having their children with them for five years or so. Some of them may not return to Sri Lanka after obtaining a foreign degree aggravating brain drain. The quality of medical education in foreign medical schools varies widely as reflected in the results of the ACT 16 / ERPM examinations conducted by the Sri Lanka Medical Council (SLMC).

East European countries

Some of these students fail at this examination repeatedly; their abysmal performance reflects on the quality of their foreign training. Some foreign medical schools in East European countries, do not allow their foreign students to register and practise medicine in their own country, where they have been trained. Therefore it is evident that these institutions are conducting a commercial exercise with scant respect to educational standards. Sri Lankan students who are admitted to such third grade medical schools are mostly misled by their local agents. Their parents have been ignorant of the educational standards of such institutions. Some of these poor quality medical schools have been recognized by the SLMC, based on information supplied by the individual foreign PMSs with some feed-back from the WHO. Time is appropriate for the SLMC to de-recognise some of these medical schools based on the ACT 16/ ERPM results.

Our country is still very short of doctors. At present as there is no compulsory period of service for doctors, they could leave the country any time for greener pastures abroad. Many state hospitals in the Northern and Eastern Provinces are grossly understaffed. More specialists are required in many areas. According to the SLMC, there are only about 16,000 medical officers working in the country at present.

Financial resources

Accordingly, we have about 80 doctors per 100,000 population whereas the doctor-population ratio is very much higher in other countries; Cuba has about 590 doctors per 100,000 population. There are several options to fill this wide gap. Due to inadequate financial resources, more SMSs cannot be established by the government at present. We cannot possibly allow students to continue to travel abroad for private medical education for reasons stated earlier. The SMSs could admit some students on a fee-levying basis, who have missed out on the merit quota by few marks. The quantum of fees to be levied should be estimated based on the expenditure incurred for providing free medical education on a per capita basis.

These additional financial resources could be mobilised to provide better facilities for the non fee-levying students. A more viable option is to set up PMSs locally. Sri Lanka is one of the few countries in the region without PMSs. India, Bangladesh, Nepal, Malaysia etc. have well established PMSs together with SMSs. In some of these countries, twinning programmes are in place where part of the training is overseas in a well recognised university. Such a degree would receive more credibility if the twinning is to a recognised foreign university. A well established PMS with high standards of education and competitively priced will attract students from abroad.

Private sector

In a scenario where the country is still short of doctors and thousands of students are deprived of entry to SMSs in spite of being eligible to do so, there is an urgent need to produce more doctors. Therefore the ground situation is fertile to allow PMSs to be set up locally.

The admission criteria should be the same as for SMSs, but without a quota system. However for such a venture it is mandatory that adequate resources be made available in the private sector. Such resources include sufficient finances, manpower, lecture theatres, auditoriums, examination halls, tutorial rooms, audio-visual units, libraries, laboratories, museums, IT facilities, clinical skills laboratories, recreational and residential facilities.

Finally, it is essential to have a private hospital with at least 250 beds for clinical training as it is not possible to have a PMS without its own teaching hospital. Currently students are introduced to the hospital environment as early as the first year in SMSs. In most PMSs in India, the private teaching hospitals provide health care free of charge for some patients so as to attract adequate clinical teaching material for the students. Such a system should be established locally. PMSs should invite examiners from SMSs for the evaluations so as to ensure proper standards. Such ventures should be socially responsible as well. To do so, scholarships should be offered to needy students who have the requisite entry criteria but who have been deprived of admission for financial reasons.

It is imperative that the SLMC should monitor the standards very closely so as to prevent mushrooming of sub-standard PMSs. It is logistically far easier for the SLMC to monitor local rather than foreign PMSs.

Foreign exchange

The annual cadre expansion is about 800 to 1000 in the MoH. As about 1165 medical students are admitted annually, there is a fear of reaching saturation point early in the state sector. However it is well known that thousands of quacks are practising in Sri Lanka especially in rural areas. They continue to do so because of a need for medical care. With the numbers of registered doctors increasing, they would eventually replace the quacks in the future, ensuring better health care for the country at large.

There is a school of thought that in the future, doctors may be deprived of employment in the state sector as the numbers keep on increasing. My personal opinion is that the state is obliged to provide internship for all medical graduates but not continuous state employment for all. Thereafter employment by the MoH should be cadre based and should be reviewed regularly with other stakeholders such as the universities, PGIM, professional colleges and GMOA. With more specialists available, quality of care would definitely improve and public satisfaction would grow.

To summarise, there is an urgent need for establishment of PMSs in Sri Lanka with the regulatory and socially accountable issues in place. Entry criteria should strictly adhere to UGC standards and be transparent. Our country would then have sufficient well trained doctors, be able to save billions of rupees that are draining out of the country and attract foreign exchange as well.