Cartels exist in various industries and take many forms. Unlike monopolies and oligarchies, cartels are more sophisticated in how they secure advantages.
The desire to form a cartel is strong because of its ability to control prices and carve the market by restricting output. Successful cartels do this without attracting any negative attention. Cartels hurt ordinary people, which is why antitrust laws prevent their formation and collusion is punished in other countries.
Cartels usually conjure images of machine gun-toting, cigar-smoking narco bosses. However, in reality, few conform to the stereotype.
An April 2017 meeting of educators in Colombo discussed how many practitioners the profession required. The speakers and the audience generally concluded that oversupply would somehow cripple the system. One speaker argued that quantity must be based on facts and principles, and not on biases. He and others were convinced that the industry was in danger of soon breaching the upper limit of supply.
Unlike noisy and bombastic drug dealer cartels, these respected academics and doctors were frail, mild-mannered schoolteacher types, like the character of Breaking Bad’s Walter White.
Another participant pointed out that physician-to-population ratios are a simplistic measure. He suggested that analysis of existing healthcare resources, its specialization and distribution, and the likely future prevalence of diseases, including non-communicable ones, must be considered.
To be fair, discussants at the Colombo gathering don’t control the number of medical college admissions, but as members of The College of Medical Educationists of Sri Lanka (COME), they were all influential. The topic of the afternoon’s discussion was ‘How many doctors does Sri Lanka need?’
To conclude that somehow there should be an upper limit is unusual. For instance, the IT industry, the accounting profession or management schools aren’t arguing for limits on graduates or MBAs. In fact, the profusion of talent has aided these businesses to build globally competitive firms out of Sri Lanka. The more talent there is, the greater the push on productivity and quality due to job competition intensifying, as the qualified also have opportunities to work overseas.
Somehow, doctors have demanded the medical services industry be treated differently. Society has so far indulged their demands by granting privileges like free-of-cost education including expensive overseas courses, the right to moonlight, priority access to schools for their offspring, government jobs and duty-slashed vehicles.
State university-educated doctors are one of Sri Lanka’s best-organised cartels. The sector is cartelized at several levels: from educators, who based on fuzzy logic conclude that the industry is at risk of being oversupplied, to the doctors’ regulator, which is non-transparent about qualifying criteria applied to public medical schools to train doctors in the same way it disqualifies a privately owned college, and the doctors’ union, which through brute force blocks students of the same private university from accessing government hospitals to gain clinical experience.
[pullquote]For every medical student entering a public university, at least two other Sri Lankans enter medical degree programmes at universities overseas[/pullquote]
Sri Lanka has mostly overcome its mistrust of firms that make a profit from educating students. Over the last two decades, for-profit companies affiliated to universities providing undergraduate and postgraduate education have grown to become a critical part of the country’s education system.
Contrary to a misleading idea that private education is a new thing, it has a history of over 100 years. London degrees were awarded in Sri Lanka from 125 years ago. Until schools were taken over in 1962, many were operated as non-state schools.
Recently established private education institutes have been small, dependent on a foreign university affiliation and offer part-time study options.
That was until the South Asia Institute of Technology and Medicine (SAITM) offered MBBS degrees, the basic qualification of a doctor, partnering a local regulator-recognised Russian university, Nizhny Novgorod State Medical Academy.
Eight of the 15 public universities in Sri Lanka have medical colleges training 1,000 doctors annually. Following a year-long internship, which the doctors’ union is preventing SAITM students from commencing, they qualify as doctors.
For every medical student entering a public university, at least two other Sri Lankans enter medical degree programmes at universities overseas. Annually, over 70,000 Sri Lankan students go overseas for undergraduate or postgraduate studies.
Documentary evidence proving a cartel’s existence isn’t easy to come by because colluding parties won’t sign agreements sealing such a deal. Like narco czars, they will negotiate in back alleys and conspire to snuff out competitors.
Sri Lanka’s murderous drug cartels spill blood on the streets eliminating their opponents. Doctor cartels are subtle, but far more devastating.
The first evidence of a cartel is the attempt to severely limit supply. Any patient who has spent two hours in a waiting room for a 10-minute consultation with a physician will attest that Sri Lanka faces a shortage of doctors.
By 2015, there was one doctor for every 1,100 people, a level close to the bare minimum one per 1,000 recommended by the Word Health Organisation, but much lower than in countries with good healthcare systems.
In 2013, the UK had a doctor for every 357 people, in Spain 208, Germany 257 and France 312. Sri Lanka could quadruple the number of doctors before it reaches ratios of Europe’s best healthcare systems.
None of the educators at the COME workshop suggesting that Sri Lanka potentially faces an oversupply of doctors had anything more than fuzzy logic to back their claims.
Following a modest MBBS enrolment in the first few years, by its sixth year, SAITM registered 160 students for its medical degree. If the rate of student growth continues, it has the potential to become the largest medical school in the country, and in a few years, possibly be training up to a third of medical graduates educated in Sri Lanka.
The implications of SAITM’s success in the supply of doctors in five years from now could alter the health sector by improving access to care. On the other hand, failing to alter the supply beyond the output of public medical schools will leave the healthcare sector struggling.
Private medical colleges are transforming health services in Southeast Asia. For instance, Malaysia, which had just five public medical schools in 1998, now has 21 private colleges awarding MBBS and MD degrees. The number of public colleges has also risen to 11. Malaysia’s current one doctor for 600 people ratio is forecast to improve to 1:400 by 2020, around the levels of countries in Europe with the best healthcare. Malaysia – with a 30 million population compared to Sri Lanka’s 21 million – has 47,000 doctors.
[pullquote]Sri Lanka suffers from a simple mismatch: Demand for healthcare is rising faster than the supply of healthcare workers[/pullquote]
It’s estimated that Sri Lanka has around 20,000 doctors; for a doctor-to-population ratio of 600 (similar to Malaysia), it would need 15,000 more. At the current rate of public medical school output, this would take 15 years to bridge, should none in service now retire or migrate, and the population not increase. In the past, around 15% of doctors qualifying here have migrated.
If, as forecast, Sri Lanka reaches middle-income status in five years (GDP per capita of $7,000) and the doctor-to-population ratio of 1:400 is a suitable expectation, it will need over 52,000 physicians. Without inward migration and ramping up medical school output, this won’t be possible.
The main doctors’ union, Government Medical Officers’ Association (GMOA) and physicians like those gathered at the recent conference are keen to highlight that supply will increase in the future as Sri Lankan medical students overseas return. Their argument implies that a limit must be applied on the number of doctors and medical school student admissions.
Doctors’ power rests largely on their professional prestige. In Sri Lanka, doctors’ lobbies have won special treatment not available to other citizens, like duty-slashed cars, priority admission in schools for their kids and wide-ranging influence.
They are also opposing improvements to healthcare in general, including a four-year degree programme for nurses. In many countries, doctors’ responsibilities are being shifted to better-qualified and experienced medical staff like nurses, physicians’ assistants and technicians to supplement the gap, successfully reducing healthcare costs and improving access. Not all medical conditions need to be solved by a doctor. However, Sri Lankan physicians are opposing similar improvements here.
Healthcare professionals provide a service, as do lawyers, bankers and software engineers. It would be unusual for job guarantees in any field of work, including healthcare.
Plato said that a true physician is not a mere moneymaker. A medical degree is a badge of respectability anywhere in the world. Jobs are for making a living, but doctors save lives too. These views about doctors make healthcare reforms torturous. Patients nervous about the quality of care, regulators concerned about who should do what and where, and hubris of doctors’ lobbies are bound together in opposition to change.
Surely, healthcare can’t be improved by merely increasing the quantity of doctors alone. However, their numbers and other healthcare workers like nurses, lab technicians and pharmacists have the most immediate bearing on delivering high-quality care across the country.
It is a myth that healthcare here is world-class, and by implication that its users must then be satisfied. Sri Lanka’s healthcare is only better than standards in least developed countries. But it scores well on basic healthcare outcomes like life expectancy and child mortality.
However, middle-income country challenges include quality of healthcare in cities and provinces, rising non-communicable disease, and preventive healthcare.
Sri Lanka is a fine example of healthcare dysfunction. It suffers from a simple mismatch: Demand for healthcare is rising faster than the supply of healthcare workers.It invest
s disproportionately on training doctors compared to training other key healthcare workers. Despite the resource limitation and the ability of private sector investment to bridge gaps in education, the regulator and the doctors’ union have prevented this.
Few industries have as corroding an effect on people as healthcare when supply and competition is limited.
Medicine hasn’t fundamentally changed in millennia. Doctors examine patients, diagnose their ailments, prescribe medicine and advise on lifestyle changes to make them better again. In the last century, doctors’ associations for licensing and setting rules emerged, and medical schools have separated the trained ones from the quacks.
The Sri Lanka Medical Council (SLMC) regulates the sector here and registers doctors before they can practice. Doctors qualified at Sri Lanka’s public medical schools dominate SLMC decision-making.
SLMC’s refusal to recognise the degree awarded by SAITM – despite government policy supporting setting up private medical colleges here – now hinges on the lack of a teaching hospital with enough patients for clinical practice. The doctors’ union has opposed and obstructed over 800 SAITM students from gaining access to government hospitals for clinical practice despite a court order to the contrary.
SAITM isn’t faultless, however, its issues aren’t insurmountable.
Creditably, the government has courageously stood against the doctors and regulator cartel, refusing to shut down or nationalise SAITM. Despite reasonable solutions over patient safety, while upholding the freedom for education, the doctors’ union’s obstruction is seen as an attempt to preserve the cartel’s advantages.
Cartels fear that allowing SAITM to prevail will encourage other private medical colleges to set up campuses in Sri Lanka, eroding their ability to control supply and pricing.
Ironically, due to their indispensible nature, when the need arises, the narco industry shares a trait with health services. In a cornered market, narco bosses have ready customers: the addicts. Just like dope addicts can’t do without their fix, the sick have no option but to seek medical treatment.