Background

The Sri Lankan public education system consists of five years of primary school, a scholarship examination, five years of junior secondary school, the General Certificate of Education (GCE) Ordinary level examination, two years of senior secondary school, and the GCE Advanced Level Examination (GCE-A/L) (1), the university entrance examination. In 2009, 1,611 students who studied in the biology stream entered medical colleges in Sri Lanka. Students are selected for medical schools on scores based on merit and a district quota system (2). There are eight faculties of medicine functioning under the University Grants Commission (UGC) and one under the Ministry of Defence. The first private medical school was the North Colombo Medical College established in 1980. However, due to heavy opposition from the Marxist party People’s Liberation Front, medical professionals, university students and other professionals, the college was nationalised and renamed the Kelaniya Medical Faculty. After graduation, all medical graduates are offered employment at the Ministry of Health. The majority accept it and continue to work in the government sector even after their internship year. All the medical graduates passing out are in a single list based on a common multiple choice and clinical examination. Graduates who top the list can opt for internship in a hospital of their choice before those placed below them. The lists of all graduating medical students are also standardised after common MCQ. Undergraduate students who qualified abroad must pass a licensing examination and are placed at the bottom of this list.

Sri Lanka has exemplary health indicators and is often referred to as a model for other developing countries (3). Sri Lankan medical professionals are considered to be skilled clinicians. These achievements are due to the high quality of training and standards maintained by Sri Lankan medical faculties. All medical schools and medical training are closely monitored by the Sri Lanka Medical Council (SLMC), an independent body benchmarking medical education.

The case for private universities

In addition to the many public schools providing free education, there are also private or international schools in Sri Lanka which follow various education systems ranging from the private Edexcel curriculum to the non-profit International Baccalaureate. There are limited opportunities for university education for students from public and private schools in Sri Lanka, due to the competitive nature of the GCE Advanced Level examination for public school students and the social prejudice against students from private schools. Many students therefore turn to private institutions in Sri Lanka or go abroad to obtain a degree. Prospective medical students continue to face many obstacles when trying to obtain a medical degree.

Established in 2009, the South Asian Institute of Technology and Medicine (SAITM) is the only private institution in Sri Lanka that offers both the MBBS and the MD degrees (4). Initially SAITM collaborated with the Nizhny Novgorod State Medical Academy, Russian Federation, to offer a joint degree for which final year students would be sent to the Nizhny Novgorod State Medical Academy in Russia (4). On August 30, 2011, the UGC officially granted degree-awarding status to SAITM, thus enabling students who are not selected to the public universities to obtain a local medical degree. This was fiercely opposed by the Government Medical Officer’s Association (GMOA), the trade union representing a majority of doctors in the state service. The GMOA argues that the SAITM is not recognised by SLMC, the regulatory body for medical education, and does not have the required legal documentation to function as an institute, and accuses it of being “a business rather than a college which produces future doctors” (5).

The GMOA’s claims seem legitimate. The association has genuine concerns about the quality of medical education in Sri Lanka. Another worrying issue concerns the lack of a hospital for final year students to undergo their clinical training. Third, they will have to practise in private hospitals as the government does not allow them to practise in government hospitals. These fears should be allayed with the opening of a teaching hospital which was to have been completed in September 2012 (4) but is not yet functioning.

Opposition from the SLMC means that even though students can get a degree from a private medical institute, they will not be able to practise medicine in Sri Lanka. The ban on practice in public hospitals contributes to the ever growing “brain drain”, as students who leave Sri Lanka to study medicine abroad rarely come back. The fear that private institutions, with better infrastructure and more innovative teaching methods will become more popular than government universities is also omnipresent and has forced the GMOA to go on nationwide strikes opposing private medical institutions.

I personally believe that private medical institutions are essential in Sri Lanka, for three reasons. First, they would reduce the “brain drain” which currently results in substantial intellectual loss to Sri Lanka (6). Private medical institutions would allow students to study and work in their home country without having to pay hefty tuition fees to universities abroad. Second, they provide opportunities for a medical career to a majority of students who are unable to go to government universities due to insufficient test scores; these scores may not always be indicative of a student’s actual intellectual ability or capability. Private medical institutions also allow students who have studied at private schools to pursue a medical career locally. Finally, private medical schools provide a much needed resource in this country – doctors. There can never be enough doctors in a developing country such as Sri Lanka, and doctors are always a vital asset to any country.

Nipuna Siribaddana

The case against private medical education

Private education has become an essential part of the global education system. As medical education is the stream in highest demand, the good and bad of private medical education needs careful analysis.

In developing countries, the increase in the number of private medical schools is due to economic development and an expanding upper class (7), and these private schools are profit-oriented. This is different from private medical education in developed countries which is driven by a workforce shortage; these private institutions are heavily state funded and are non-profit (8).

The primary, undeclared objective of for-profit institutions is income generation. Thus, profit making is the driving force of all decisions in these institutions, which violates the fundamentals of medical education, whose primary objective is to produce a competent health workforce. SAITM is no exception and is a for-profit institution. One example of the priority given to revenue generation in SAITM is its twice-yearly uptake of students (9)though the entrance exam is held only once a year. All (public) Sri Lankan universities have a once a year admission policy based on the annual entrance exam (GCE A/L). There is no rational reason except revenue generation, for having twice yearly admissions to take in students based on a single exam.

The quality of outputs always has a positive correlation to the quality of inputs. In profit making private medical schools, the primary qualification for admission is not academic merit but the ability to pay high tuition fees. To be eligible for admission to the SAITM, three “S” passes (lowest pass grade) in the GCE A/L exam is sufficient (10). For state medical schools, even three “A” passes (highest grade) are sometimes inadequate. Despite the existence of a district quota system, there is an obvious gap between students entering public medical schools and those in SAITM. This will certainly compromise the quality of doctors graduating from SAITM. One may argue that some of the best ranked medical schools in the world are private medical schools. However, these are non-profit schools and some require a grade point average of more than 3.8 and medical college admission test results of more than 40 for admission (11), which is even more competitive than admission for state-run medical schools in Sri Lanka. Not a single student admitted to SAITM is eligible for admission to state universities.

The quality of training provided by private medical schools has been analysed by several investigators and has been shown to be inadequate by global standards especially in the for-profit sector (12). Most appointments of qualified staff members in private institutions are for part time employment or merely for the purpose of accreditation, not for actual academic teaching (13). The few qualified staff members listed on the SAITM website are staff members of other faculties on sabbatical or from foreign universities, or retired professors (9). A majority of the permanent medical staff members are foreign graduates who have failed the licensing exam to practise medicine in Sri Lanka. They are not allowed to practise medicine according to the state law and are not eligible to teach clinical subjects in public medical institutions. At present, there is only one qualified clinical teacher listed in on the SAITM website. He is a staff member of a state university and not a permanent staff member of SAITM (9).

The availability of clinical materials for training is the most challenging part of clinical training. In Sri Lanka, 96% of inpatient care is provided by government hospitals. The private sector basically provides ambulatory care services or consultation services. There are three characteristics of private medical facilities that threaten quality clinical training: early discharge to reduce costs; terminally ill patients who cannot be subjected to examination, and disproportionate admissions of elderly patients who are unable to provide good histories due to senile dementia (13). This means that students in a private institution attached to a private hospital will get inadequate exposure to actual cases. Further, people who pay for their treatment in the proposed private hospital for SAITM are more likely to refuse examination and history taking by medical students. This lack of clinical exposure will certainly affect the quality of training in SAITM.

One major ethical concern in SAITM is the lack of social diversity among medical students. These students come from a higher socio-economic class which can afford 6.5 million Sri Lankan rupees for their education. Apart from the students, patients will be from the same privileged class who can afford a private hospital. This lack of social diversity has been shown to produce a socially insensitive health workforce (14). These students could become socially incompetent doctors who are not sensitive to the key issues in Sri Lankan society. In addition, training in isolation from the country’s health system will make these graduates incompetent for practice in a Sri Lankan setting, at least in the short run. These factors are likely to compromise the future of patient care in the whole country.

Lack of opportunity for students to pursue medical education due to the highly competitive nature of state university admissions is another argument put forward by proponents of SAITM. It is generally accepted that medical education is among the most competitive educational fields all round the world. All the best ranked medical faculties have extremely high standards for the admission of candidates. The probability of Sri Lanka students obtaining a medical degree is much higher than in the other countries in the region. In India (population 1.22 billion), Pakistan (population 170 million), and Bangladesh (population 150 million), the annual intake into medical schools is around 40,000, 4,000 and 3,000 respectively, compared to 1,600 in Sri Lanka for a population of 20 million.

Another factor is the lack of doctors in Sri Lanka. The present doctor: population ratio in Sri Lanka is around 1:1,000, which is well above the WHO recommended standards of 1:2,000. On average, state universities produce 1,600 doctors each year. However, there is a gross misdistribution of doctors: rural areas suffer from insufficient numbers while urban centres are overcrowded with doctors. The evidence from other countries is that graduates from private medical faculties are more likely to stay in urban centres, aggravating the rural/urban divide (15). This is a major concern especially when these graduates are likely to be more influential in changing transfer lists. This could create further problems in the present health system.

The argument that private medical schools could prevent brain drain is another fallacy. The worlds’ largest private medical training is in India and their analysis shows that the boom in private medical schools has resulted in a brain drain of high quality doctors from state universities (16). In Sri Lanka the problem of brain drain is most acute among physicians with postgraduate qualifications, and this is not related to the competitive nature of university admissions.

Some people believe that private medical education will help reduce the cost of private medical care. This is unrealistic considering the enormous amount of money paid by these graduates for their education. They will not be able to recover this amount by practising in the government sector, where the initial monthly salary is around Rs 40,000. Inevitably, private practice will follow, charging higher fees to get returns on their investment. All evidence thus suggests that private medical schools increase the burden of medical costs in a country.

As concluded by Joy et al in their systematic analysis of private medical schools (17), private, for-profit medical education will enable a few, partially qualified rich people to pursue a medical degree, widening the gap between rich and poor. It will seriously threaten the quality of future healthcare and also indirectly contribute to increasing the cost of healthcare in Sri Lanka.

Suneth Agampodi

Conflicts of interest and funding support: The authors declare that they have no conflict of interests when writing this article and have received no funding support for writing this article.