Should the government open state hospitals to SAITM medical students?


by Ramya Kumar, MBBS (Peradeniya)

Earlier in September, the Sri Lanka Medical Council (SLMC) evaluated facilities for clinical training at the South Asian Institute for Technology and Medicine (SAITM) and declared them unsatisfactory. Based on the SLMC’s evaluation, SAITM does not provide adequate exposure to the range of health problems encountered in Sri Lanka. Moreover, exposure to emergencies in all basic clinical fields is lacking, as is training in public health and forensic medicine. Evidently, patient admissions to the Dr. Neville Fernando Teaching Hospital, SAITM’s clinical training facility, would need to see at least a fivefold increase to meet SLMC’s standards.

Last week, the Ministry of Health undertook to address the inadequacies in SAITM’s clinical training programme in response to a fundamental rights petition filed by the SAITM medical students in the Supreme Court. The Ministry pledged to open the Avissawella Base Hospital and the Kaduwela MOH to train these students. My sympathies are with SAITM students whose parents have spent millions of rupees on their education, but the government is under no obligation to subsidize the clinical training programme of any private for-profit medical educational institution.

The very establishment of SAITM was fraught with controversy. The institution commenced operations as the South Asian Institute of Technology and Management in 2008. Later, SAITM expanded its offerings to include medicine, a field that perhaps has the highest demand in Sri Lanka with clear possibilities as a lucrative source of income. All those associated with its establishment would have known very well that setting up a private medical school would be difficult given the North Colombo Medical College (NCMC) debacle that had taken place just a couple of decades earlier.

Nevertheless, in 2013, the University Grants Commission (UGC) shortsightedly granted degree awarding status to SAITM amidst protest from the Inter-University Students’ Federation (IUSF) and the Government Medical Officers’ Association (GMOA).This happened at a time when the UGC had a dubious reputation for having in its ranks stooges of the previous regime. The SAITM authorities likely assumed it would have the support of the then regime to make up for its shortcomings by using public resources, including the extensive public health system. SAITM began as a business and remains a business, a business that was built on questionable standards of ethics.

The SAITM authorities who admitted students before receiving SLMC accreditation must take responsibility for the present situation. In this context, references to SAITM’s philanthropic mission seem disingenuous, at best. In a recent interview, Dr. Neville Fernando stated that he "[feels] happy to come [to SAITM] and see hundreds of children being given a future" and that "it is those who hate the sight of children doing well who criticize this faculty" (Island, September 26, 2015). Dr. Fernando does not seem to understand that SAITM’s critics are determined to protect a system of "free education" that has provided a future for hundreds of thousands of students since the 1940s.

Free (medical) education and the district quota system provide social mobility to students from remote and rural areas. Admission to state medical schools is based on marks obtained at the A/Ls, which most candidates sit in the Sinhala/Tamil medium. Contributing to the ongoing debate on medical standards, Dr. Mahinda De Silva recently recommended in the Island that Sri Lanka use "better" medical admission criteria such as those employed in the West, for example, the Medical College Admission Test (MCAT), a writing sample, and a personal interview. Students who do well on personal interviews are generally from privileged social backgrounds, evidenced in the elitism of medicine in the West. This is not the case in Sri Lanka primarily because student admission is based on performance at the A/Ls and not on social capital. Opening the flood gates to private medical education will be a first step toward making medicine an elite profession as in many other countries.

The SAITM controversy also brings the Kotalawela Defence University’s (KDU) undergraduate medical programme into question. KDU’s admission criteria for officer cadets include 3 A/L passes; we do not know how KDU selects applicants from this large pool of potential students. According to Dr. Upasiri de Silva, in the Island (December 21, 2015), KDU generates revenue by charging fees from some students who receive training at the Sri Jayawardenapura Hospital, a government facility. It is also extremely disheartening that any medical programme should remain under the Ministry of Defense, and this may be an opportune moment to rectify this issue.

The medical profession may be divided on protecting free education given the number of renowned medical specialists on the payroll of SAITM (and KDU). Unsurprisingly, SAITM has attracted several (retired) consultants to its fold. According to Dr. Neville Fernando, clinicians at his hospital are paid a monthly salary of Rs. 500,000. Like NCMC, SAITM provides opportunities for easier access to medical education for kith and kin. Reportedly, about a third of SAITM medical students are the offspring of medical professionals. The IUSF recently alleged that SAITM has political backing for this very reason.

Others in favour of SAITM, and the project of privatizing medical education, suggest that there is an urgent need for more doctors to cater to the ageing populace. Increasing numbers will be ineffective without accompanying improvements in public health infrastructure to support geriatric patients, such as community-based facilities for long-term illness. Moreover, there is no guarantee that graduates from SAITM or any other medical school would choose to remain in Sri Lanka. It would be more prudent then for the authorities to address the deficit of doctors by implementing measures to retain medical graduates rather than producing more doctors by supporting private medical education.

Fans of SAITM also point to the double standards adopted by the SLMC, which has evidently granted approval to medical degrees from dubious foreign medical schools. Perhaps the SLMC should set higher standards for accreditation, but these students are required to pass the Act 16 exam in order to receive an internship placement. Regulating foreign medical schools is not within the scope of the SLMC’s mandate, which is to "[protect] health care seekers [in Sri Lanka] by ensuring the maintenance of academic and professional standards, discipline and ethical practice by health professionals who are registered with it". While it is hoped that the SLMC intervenes on other concerns under its mandate, it should continue its good work in regulating medical educational institutions in the country.

The problem that SAITM faces in providing medical students the required standard of clinical training reflects the gargantuan role played by our free health system in the provision of healthcare. It is not surprising that the Dr. Neville Fernando Teaching Hospital is unable to attract the required "mix" of patients when over 90 per cent of in-patient admissions are covered by the public health sector. A private hospital cannot provide the necessary clinical exposure simply because private healthcare is unaffordable to the vast majority of Sri Lankans. As a self-proclaimed leader in medical education, with "state-of-the-art facilities and infrastructure", SAITM should either take measures to attract the right "mix" of patients to its teaching facility or shut down.

In the end, private medical education/healthcare is a lucrative business. Let’s not pretend that it is about giving the younger generation opportunities. If altruistic motives drive such efforts, they should be focused on improving public medical educational institutions and increasing recruitment based on A/L performance, not the ability to pay exorbitant fees. While the SAITM students’ concerns are legitimate and must be addressed, the solution is not for the government to subsidize private medical schools. The government should be wary of setting such a precedent, and, instead, nationalize SAITM and bring it under the UGC as a non-fee levying institution.


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