Do we Need Private Medical Colleges?


by Sandamalee de Fonseka


Our education system is a web of contradictions. We enjoy free education since 1938. Even uniform material is provided free. Our exams however lean more to eliminate than to qualify. Parents thus spend considerably on private tuition, almost from grade one onwards. Still, less than 30,000 enter tertiary education annually, while over 100,000 eligible are denied. Though rich with natural resources and sharp-thinkers, our main foreign exchange comes from exporting menial labor to the Middle East - a region with often cruel conditions. It is this hard earned ForEx that pays the tuition fees of those seeking foreign medical degrees. Some foreign graduates however return inadequately trained on theory or practice. In 2012, Professor Carlo Fonseka, speaking on the need for PMCs in 'Check Mate', on Rupavahini, states, "I've been in the field of medical education and Sri Lanka has a very good record," explains Professor Fonseka. "I may be in the minority when I say that we don't have enough doctors. If you doubt me, let's go right now to any of these private hospitals now, where doctors are working at late hours just trying to clear crowds. "Ideally, the State should produce the required numbers, because it has all the required resources. However, if for some reason, if the State is unable or unwilling or for policy reasons - they want to end the monopoly on the medical education by the State - then I should go along. "I'll give four reasons why there's a case for PMC in this country at this stage of development,First: there are not enough doctors. Only 55 doctors or so for about 100,000 people. Compare with UK - 220, America - 230, Australia - 250, India 60 or more. Pakistan - 71 odd. Only Bhutan and Nepal are below us. So, we need more doctors;Second: our system of selecting medical students by the State, this reverse discrimination on district quota leaves out many well qualified students;Third: there's a demand for medical education - 200 or more leave Sri Lanka every year in search of medical education and are a drain on our ForEx;Fourth: if we set up medical colleges here, our ForEx will be saved and we can draw students from outside. It'll raise our national income."Mahajana Eksath Peramuna politburo member, Yadamini Gunawardena is of the view that the problem is due more to the State's lack of commitment than capacity constraints.

"We need to first evaluate our options," he explains, "which are to increase capacity in our State universities, invite the private sector to establish PMCs and/or seek foreign medical degrees.

"Cabinet papers have been presented in the past for increasing the capacity, but only one succeeded and resulted in establishing a new medical faculty at Rajarata. We can still increase capacity in other faculties as revealed by a survey done in 2004 by the Ministry of Higher Education together with the University Grants Commission. It was found then, 250 more students can be accommodated without an additional stress on government funds. That was about 12 years ago. Now, with additional faculties, this figure is 350. So, before considering second and third options (PMCs and foreign degrees) we must utilize this available capacity.

"The current need can be helped without much of an increase, say 50 per faculty, then more students can be accommodated without any serious additional cost to the State.

"The two important ratios any country works with are number of beds per 1000 population (patients) [Sri Lanka 3.0, Singapore 3.7, U.S. 3.05, UK 2.95, India 0.5, Pakistan 0.7] and patient per doctor [Sri Lanka 1800, Cuba 170, Russia 230, U.S. 390, Pakistan 1400, India 1700]. Sri Lanka's higher Human Development Index than elsewhere in the region is thanks to many contributing factors, especially free health and free education, not to mention our indigenous and ayurvedha.

"Sri Lanka has eliminated malaria and polio. Child mortality is below one percent and life expectancy has increased in the last decade. So, this sector's other aspects that also contribute to HDI is also served. It's thanks to our medical profession, their standards and because the best people study and teach at our faculties."

When considering PMCs Gunawardena emphasizes that the standards specified by the Sri Lanka Medical Council must be met, which the two PMCs we had so far unfortunately failed. 

"Those teaching at a PMC must be a licensed and active in the field. If lecturers whose license have lapsed are employed, it will deteriorate the quality of teaching."Then, clinical practices must be facilitated. The hospital provided must have an emergency facility servicing adequate number of emergency cases. Otherwise, how can the students learn the different aspects of emergency? Like that, there has to be so many technical aspects that needs to be set up." states that engineering, "is a precise science. Attention to detail and the highest safety standards must be adhered to at all times...there is massive potential for failure in the more ordinary."When the best of engineering brains had still resulted in disasters such as Chernobyl, Bhopal, Titanic, Apollo 13 and so many others, engineering cannot be lightly taken. In many respects, engineering and medicine are similar. Both are precise sciences, but medicine also requires a certain intuition and a definite ability to hone in another's cause for distress. 

Thus, Gunawardena insists that unlike other fields, those in the medical profession cannot afford to fail in their professional capacity. 

"Engineers, journalists, lawyers, accountants may all fail in their professional capacity somewhat without causing permanent, serious blunders that can somehow be rectified. If a doctor fails, it could result in the loss of organ or even life, which is irreversible."Professor Fonseka explaining the new challenges faced by the medical field says, "Time was when communicable diseases like smallpox, polio, diphtheria, tetanus, whooping cough, measles and etcetera were the scourges of human kind. But with advanced medical science, these have been contained. Some like smallpox are eliminated."It's the non-communicable diseases (NCD) that are now confronting us. The World Health Organization had identified four types of NCD,First: the cardiovascular diseases that is heart attacks, strokes, high blood pressure;Second: diabetes;Third: cancers of all sorts andFourth: lung disease."He points out that NCD are the result of our present unhealthy living styles, including bad eating habits. Every year, tobacco and alcohol consumption results in deaths in the same proportions as the 2004 tsunami.Despite qualified doctors and facilities available to address NCD, many Sri Lankans opt medical care outside Sri Lanka. Does that indicate a lack of confidence in our doctors' capabilities?Speaking to this writer, one whose son was born with a heart condition and needs regular open-heart surgery to insert the required valves since four months explains, "we feel the Chennai doctors for cardiac pediatric care are more experienced. Because here, we don't have dedicated teams attached to hospitals, each specialist takes individual decisions. In Chennai, a dedicated team who's there round the clock looks after the patient. They discuss and take collective decisions. 

"Another reason to decided on Chennai this time also was because here the next valve available was 18mm, which means another open-heart surgery in about a year or so. But in India we could go for 24mm, meaning if all goes well, we can wait for about five years. Also in India, we can find the medicines we need easier than here. "Getting used to Chennai hospitals is very tough, especially after been in our private hospitals. We learned many things the hard way. Once my son developed a skin irritation because bedsheets had dried bird-droppings. After that, we got our own sheets and had them laundered privately. Also, you need to be on top of the drugs administered. "Nurses are very intimidating mainly because their tone sounds so guttural - but actually they are very maternal like our nurses. As you are one of so many they're treating, there's no personalized care and everything is regimental. There's no negotiating with the rules. Here, hospitals are very flexible when my son is in ICU, but there, we only could see him for 10 minutes at a time. That was hard."A risk associated with overseas treatment is that there's no accountability if a complication arises afterwards due to surgery. Still, many seek medical treatment overseas. Obviously, we need a closer look than just the ratio, number of patients per doctor, to comprehensively understand whether we have adequate numbers of doctors. Medicine is now a much more specialized field.

Professor Fonseka rejects the notion that a PMC in Sri Lanka cannot produce doctors of standard. 

"The experiment has already been done in 1981 with the North Colombo Medical College. It functioned for about 10 years and produced 850 doctors, who are doing very well in Sri Lanka and various parts of the world. About 100 doctors are no second to any other doctor we have produced in the country. So the private sector can produce doctors of good quality."

Professor Stanley Kalpage, a founding member of the NCMC, at the final Convocation, explains what went wrong. 

"Selecting 100 students from some 1150 applications created enemies. The politicians to whom they complained became critical. The Government Medical Officers Association took up cudgels against the College thinking that State medical faculty graduates would be pushed out of employment in government hospitals."

The debate for PMC should not be taken lightly, because as Gunawardena stresses, it is our health that is at stake. 

Numbers only summarizes the full picture. For instance, between Ordinary Levels and Advanced Levels, nearly one and a half million students are left behind. That does not mean, free education has failed. Our health standards is one testament. At the same time, free education is not a panacea either. 

For some reason, State capacity is not increasing as per requirement. In the meantime, our would-be doctors are seeking degrees from countries as backward as Nepal and Bangladesh. Surprisingly, despite their low HDI, some of their PMCs' standards are to the SLMC's satisfaction. Is this the best alternate we can provide our future doctors?

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