Medical misadventures

Sunday Times Editorial

The issue of a private Medical College refuses to go away. It seems the flavour of at least the week gone by after undergraduates marched the streets facing police water-cannon. The Sri Lanka Medical Council (SLMC) is due to go to a superior court, the medical trade union (GMOA- Government Medical Officers’ Association) is howling in protest and political parties are joining hands to offer stubborn resistance to Government moves to allow fee-paying students at private institutions to become doctors. The public watches in dismay.

The latest upsurge of protests came after a Court of Appeal verdict rejecting the SLMC objections to a private medical institution (SAITM) offering medical degrees. The long ongoing campaign to block these Government moves, begun with the previous administration and being continued with the incumbents in office, continues. The SAITM issue is plagued with allegations of bribery and corruption, intimidation, irregularities, ‘incest’ and vested interests involving ministers, doctors, health officials and business interests best left to the President and the Supreme Court now to unravel. But it also involves an issue that goes beyond SAITM – that of private medical universities.

Theme Cartoon added TW is from Sunday Observer

Universal Adult Franchise in 1931 was credited with providing Sri Lanka with a health care system that gave rise to statistics that were the envy of many economically developing, especially in the region and even developed countries. Surveys have shown that giving women the vote in 1931 ensured the people’s representatives paid attention particularly to maternity and neonatal care and paediatric facilities. This required quality medical education and trained nurses and midwives. And what is more, throughout these decades, this relatively high standard of health care has been achieved despite a shoe-string budget from successive Governments.

Cartoon from Ceylon Today

Alas, scores of doctors trained at State Medical Colleges at the expense of the meagre resources of the taxpayers have left the Health Department to serve in hospitals in foreign countries, distinguishing themselves no doubt, but depriving the country of their own services. Many who went for further education and training, as they should have, never returned. Yes, they paid a pittance in the form of a bond, but what of the place they occupied at the limited Medical College. Who can replace that? 

Cartoon from Ceylon Today

Every year 1,200 medical graduates join the state health service. 2015 figures on the renewal of registrations by the SLMC indicate 27,000 renewals. If for argument’s sake more than 2,000 have left the country over the years, and more than 1,000 are not practising, there are still more than 20,000 in service. But there is a serious maldistribution of doctors in the remote areas where doctors and patients lack adequate facilities and services, not to mention shortages in some specialties.

In the 1980s, the J.R. Jayewardene Government took the first steps in rectifying this anomaly of a shortage of doctors by starting a private Medical College. He managed to steamroll political opposition to it.

Today’s crisis also has a political element. It is not limited to downright envy that children of affluent parents can become doctors while others cannot — unless they enter the State Medical College. It is also not limited to the fact a greater influx of doctors will mean more riding the gravy train of private practice. This is a move from a socialist-welfare State struggling to make ends meet, providing free health care without the money to foot the bill for it, and hoping an open economy will take care of the bills and burdens of the State to deliver the goods to the people.

The entire medical education exercise is inexorably linked to the University entrance examination and the current ‘Z’ score system. For many years, when University entrance was on merit, there were accusations that some examiners were partial towards a particular community giving high marks for papers answered in a particular language stream resulting in a greater intake to the Medical Faculty in particular than was in proportion to its population. Others dismissed this with scorn saying they were simply cleverer than the others. Then came standardisation and the quota system to give rural students either in Kilinochchi or Kamburupitiya a better chance of entering universities, but that backfired into a trumped up racial discrimination issue and was said to be the springboard to attract youth to a violent insurgency in the north.

While there can never be a foolproof system in a country where false addresses and documents are produced for entry from primary schools onwards, the ‘Z’ score may have also caused reverse-discrimination by depriving bright students mainly from the cities entering medical school and universities because of quotas given to rural students. Conversely, rural children were deprived of places because city students took temporary residence in the provinces for examination purposes.

Those thousands thus deprived must be given an opportunity of access to higher studies even at a later stage. The Open University opened new vistas for children thirsting for knowledge and a degree, but were kept out of universities due to a corrupted entrance system.

The country is in need of more doctors, though no one really knows what the shortage is. The numbers going abroad for medical studies because they don’t have access to a medical faculty in Sri Lanka is an astounding 500-800 on average a year. It costs them Rs. 2-5 million a year depending on if they go to India, Bangladesh, Nepal or to the United Kingdom. This money has to be met with foreign exchange to the tune of Rs. 15 billion or more. Only half of these outgoing students return to Sri Lanka. These cold statistics cannot be simply ignored. For the GMOA, paradoxically, doctors who pass out of some of the foreign medical schools are not an issue should they sit for the local qualifying examination conducted by the Sri Lanka Medical Council (SLMC).

That is what is at the crux of this debate. Whatever medical education is obtained, the SLMC ought to remain the ‘Gatekeepers’ to the profession, the licensing body for medical practitioners in Sri Lanka. It must sue – and be sued, and take the responsibility for untrained, unqualified doctors unleashed on unsuspecting patients, especially the poor. “Business schools” giving medical degrees that do not meet the required standards will inevitably collapse if their graduates don’t get registration to practise as doctors. In some countries, in the neighborhood as well, politics has crept into the regulation of some private medical colleges tarnishing the otherwise good reputation of the quality medical colleges. That is the last thing that must happen here.

Higher education in economically advanced countries comes at a financial cost to the undergrad. Many students keep paying their student loans for many years after graduation and while in employment. In Japan, fees are charged according to the parents’ financial status. Scholarships are given in abundance for poor students in universities where fees are charged from those who can afford to, and are willing to, pay. That’s how prestigious private universities, including medical colleges abroad have the funds to provide quality education without waiting for government handouts that are not there.

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