Healthcare regulator Sri Lanka Medical Council (SLMC) sets regulations and standards for the profession’s education and practice. They also discipline healthcare practitioners, including nurses and pharmacists. Doctors cannot practice here without being licensed by the council.
The eight state-funded medical schools in Sri Lanka only train a limited number of those passing their Advanced Level examination in science subjects. Private medical schools can bridge the shortfall. In 2009, the South Asian Institute of Technology and Medicine (SAITM) commenced offering a MBBS degree, the basic qualification required to become a doctor. In 2016, nearly 70 students – SAITM’s first students – will complete their academic studies. However, the SLMC is unsatisfied about the clinical exposure that medical students obtain during their academic life by an attachment to a teaching hospital. As a result, the SLMC is refusing to license the SAITM-qualified med students as doctors.
Since December 2015, SAITM’s med students have received training in forensic, psychiatric, public health and community medicine at the Avissawella Base Hospital and Kaduwela MOH as part of the clinical training med students undergo. Students pay Rs50,000 for each of the six subjects they are trained for at these hospitals. However, the SLMC is not recognising this training. SAITM’s medical faculty has even requested the SLMC to oversee the clinical examinations to no avail.
Demand for private medical education is growing. Rising life expectancy and higher incidence of non-communicable diseases are the first reasons for rising demand.
The portion of over 60 year olds in the population will rise to 17% in five years from 10% in 2016. By 2051, they will make up 29% or so of the total population.
Non-communicable diseases (NCD) are also on the rise, owing to the ageing population, and dietary and lifestyle changes resulting from rapid urbanisation. NCDs accounted for 71% of deaths in 2012. The Ministry of Health says 25% of the adult population suffers from hypertension. By 2050, it forecasts that half the population will be diabetic.
Second, government hospitals are crowded and often lack facilities, so patients are increasingly turning to private healthcare services. Well-managed private hospitals are thriving. Private investment for expanding and improving healthcare services face a bottleneck in the form of a shortage of medical professionals, especially doctors. Sri Lanka’s state universities – which educate most of the doctors in Sri Lanka – are unable to meet rising demand created by private hospitals. “The shortage of skilled medical professionals is a key issue, crucial to attracting patients to the private sector,” Fitch Ratings Lanka, a credit rating agency, said in a 2015 report about private healthcare in Sri Lanka. This is a problem for patients too.
Three decades ago, Sri Lanka had one doctor for every 6,000 people. The ratio has improved to a doctor for every 1,100 people by 2015. However, it is still lower than the world average of 670 people per doctor, according to Fitch Ratings Lanka.
Third, the profession attracts those who want to serve others and be financially well-off at the same time. According to a World Health Organisation (WHO) report, there was a shortage of seven million doctors worldwide in 2013, which will double by 2035. With demand for doctors growing it will continue to be a lucrative profession.
[pullquote]In the UK, the University of Buckingham offers private medical degrees, but its teaching hospital is a separate entity, a government hospital. There is no reason why this model cannot work here[/pullquote]
Effective enforcement of healthcare standards is critical to protect patients.
The SLMC’s regulatory role includes reviewing medical schools. Eight state and a single private med school’s review documents aren’t made public.
In the UK, the US and other countries, doctors are evaluated periodically to determine that their skills and knowledge are up-to-date and they are fit to practice. In the UK, doctors are subject to a revalidation process every five years. Similar programmes are administered in the US. Revalidation builds the confidence of patients, employers and investors. The SLMC does not have a revalidation process for medical professionals practicing here.
Public pressure has forced reforms on medical regulators elsewhere. In the UK, a series of changes were forced on the medical council in the early 2000s. Now, half the members in the UK medical council are laymen or professionals who are not doctors. There is a separate tribunal to handle complaints, because it was argued that doctors couldn’t be trusted to deal fairly with their own. The UK’s medical council is answerable to parliament.
Sri Lanka’s medical council is not transparent. Its last published annual report available online is from 2010. The annual report also lists complaints against doctors and council action. Since then, the council is in the dark.
Sri Lanka needs more private medical schools, and they will need teaching hospitals that are expensive to set up. It will be difficult to attract the critical number of patients with a sufficient case mix for clinical training. This is because many people still opt to visit state hospitals where healthcare is free. At private hospitals, people won’t stand for having to pay only to have a trainee doctor prick and poke at them.
In the UK, teaching hospitals offer incentives to patients being treated by trainee doctors and participating in clinical trials. In Sri Lanka, free healthcare ensures that state teaching hospitals have a ready supply of patients of every kind. This was the main reason why SAITM’s training hospital couldn’t attract enough patients – because they couldn’t afford to give free healthcare.
The government manages several hospitals that provide modern healthcare services, friendly and efficient staff, caring nurses, and miracle-working doctors. But there are few of them concentrated in cities.
Several smaller government hospitals away from cities don’t have the full range of services, not enough staff including doctors and always too many patients. Private medical schools can invest in them as teaching hospitals. A large proposition of tuition fees goes into clinical training; these can be funnelled to the lower ranked hospitals. Everyone benefits. The Sri Lanka Medical Council could have proposed a similar solution to SAITM and made an effort to see that it worked.
In the UK, the University of Buckingham offers private medical degrees, but its teaching hospital is a separate entity, a government hospital. There is no reason why this model cannot work here.
In 2011, SAITM signed an agreement with the director of the Western Province Department of Health for their med students to undergo clinical training at government hospitals in the region. Nothing happened.
The state doctors’ union refused to train the med students and threatened strike action. “I did not want to risk the lives of patients,” SAITM’s founder Dr Neville Fernando says. He has invested Rs3 billion in his school. The state doctor’s union violated the rights of citizens of this country to access government hospitals and broke the very oath they took as doctors, the Hippocratic Oath, which says, “I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow”.
Medical education everywhere tends to be expensive for several reasons. Maintaining a teaching hospital is expensive. Teaching costs money—you need doctors specialising in various fields and an army of nurses and technicians to support them. Then there is the cost for medical supplies and equipment. In developed countries, teaching hospitals carry out advanced research, which costs a lot of money as well.
Dr Neville Fernando, a surgeon, founded SAITM with a Rs1 billion investment, offering degrees in IT, media, engineering, finance and medicine. A few years later, he invested Rs2 billion to build a 850-bed teaching hospital.
[pullquote]The Sri Lanka Medical Council’s stance on private medical education seems unhealthy in the absence of a transparent review process for state universities. According to the University Grants Commission, four of the eight med schools have none or fewer professors than SAITM[/pullquote]
The 2015 SLMC report on the faculty and the teaching hospital found three shortcomings, which it felt disqualified the private med students from being licensed to practice in Sri Lanka. First, the teaching hospital did not have enough trauma patients with an adequate mix of cases from emergency surgeries to delivering babies. Second, the teaching hospital limited access to forensic medicine, mainly training doctors to assist courts of law; and third, it had limited access to field work carried out by healthcare officers of the Ministry of Health.
Despite these limitations, the 2015 SLMC report commends SAITM for its innovative approach to overcome these three shortcomings. For instance, the use of audio visual aids and simulations impressed the inspection team, as did the initiative of sending the private med students to work with low-income families to expose them to preventive medical care training.
Since December 2015, SAITM med students have undergone training supervised by specialist doctors at two government hospitals and several private hospitals.
The Sri Lanka Medical Council’s stance on private medical education seems unhealthy in the absence of a transparent review process for state universities. According to the University Grants Commission, four of the eight med schools have no or fewer resident professors than SAITM. Some doctors on the council don’t like the idea of private education in the first place, so decisions making is clouded.
Writing about the country’s first private med school (North Colombo Medical College-NCMC), which was taken over by the government in 1989, SLMC President Carlo Fonseka in an article to a daily newspaper in January 2016 says Sri Lanka’s first private med school was “patently a pre-meditated assault carried out in broad daylight on academic propriety and social equity”. He also says “to aggravate the iniquitous unfairness, the NCMC was built on crown land”. It’s from this hang-up and entitlement that med schools should be free and serve only a few that are keeping the doctors’ regulator away from wiser counsel.
Blocking private medical education is to deny children access to education and deny patients’ rights for better healthcare. By working closely with SAITM and being supportive, the SLMC will be in a better position to ensure that standards are maintained.