Free education and freedom for Free Medical education in Sri Lanka
Prof S P Lamabadusuriya. IMPA Journal, Volume 14, No 1. December 2020
Note from Speedy: This important article by Sanath published by the Independent Medical Practitioners Association Journal Sri Lanka was sent to me by Sanath with the following request.
"Herewith I have attached an article titled "Free Education and Freedom for Private Medical Education in Sri Lanka", which was published in the IMPA Journal and a PowerPoint presentation I delivered at the OPA sometime back. It is a controversial topic in Sri Lanka at present, with the SL Government trying to pass a bill in parliament about expanding the KDU so as to accommodate fee-levying students for medicine, which has generated street protests. Please post both versions on our blog spot on my behalf".
I managed to trace the article on the Web and get a proper download. This
is the first part. The second is a
PowerPoint presentation which will follow. The article will be of great
interest to us and I am grateful to Sanath for sending it to me. Incidentally, I noted that our own SAP
Gnanissara is on the Editorial Board of the IMPA.
This is an excellent presentation. I remember thee name CWW Kannangara(not a relation of our Pram?)He was the father of he free education. As far as I can recollect, he represented Matugama electorate in the State Council. After independence, he was despatched as a High Commissioner to Indonesia or there about. He came back just before the 1956 General Election and Mr SWRD invited him to join MEP and contest the safe seat of Agalawatte. He declined the offer and decided to contest under UNP ticket and won the seat. under was left with eight seats, at the end. His son became an OBS&GYN Specialist and I was told he was the only Sinhalese Registrar to have worked with Prof A Sinnathamby.
ReplyDeleteI am surprised to learn that Sri-Lanka has a shortage of doctors in spite of Medical Schools in every corner of the island. Surely, there is no brain-drained that took place several years ago. I am sure Medical Schools possess high powered Medical technology such as CAT scans, and MRI scans. Good old days history and examination contributed to 90% or more in terms of diagnosis of ailments presented to doctors.
Excuse me for some spelling errors. My laptop too has started to cause headaches.
ReplyDeleteThis is an excellent presentation. I remember thee name CWW Kannangara(not a relation of our Pram?)He was the father of he free education. As far as I can recollect, he represented Matugama electorate in the State Council. After independence, he was despatched as a High Commissioner to Indonesia or there about. He came back just before the 1956 General Election and Mr SWRD invited him to join MEP and contest the safe seat of Agalawatte. He declined the offer and decided to contest under UNP ticket and won the seat. under was left with eight seats, at the end. His son became an OBS&GYN Specialist and I was told he was the only Sinhalese Registrar to have worked with Prof A Sinnathamby.
ReplyDeleteI am surprised to learn that Sri-Lanka has a shortage of doctors in spite of Medical Schools in every corner of the island. Surely, there is no brain-drained that took place several years ago. I am sure Medical Schools possess high powered Medical technology such as CAT scans, and MRI scans. Good old days history and examination contributed to 90% or more in terms of diagnosis of ailments presented to doctors.
Great analysis and sensible suggestions by Sanath. I shall publish my comments in 2 instalments.
ReplyDelete1. Sri Lanka medical education systems are not producing sufficient doctors to meet need as defined by WHO criteria. How applicable are these? Should the presence of Ayurveda and other alternative medical practitioners be taken into account?
2. The number of Medical Faculties has increased substantially and there is a wider spread covering most Regions.
3. Not clear whether employment is offered for all those who qualify. If the answer is yes, is it just for internship enabling registration only?
4. How many who meet the entry criteria fail to get a place as numbers are limited?
5. How many qualify and then leave (a) the Health Service and (b) The country?
6. More doctors are needed but what is the shortfall on a population basis by District? Is it very disparate, with major cities having relative excess compared to rural areas?
7. What are the numbers of private general medical practitioners compared to government doctors District by District?
8. Why does the Govt allow students to enrol abroad at a huge cost in foreign exchange? Will this stop if private medical schools are available. If so, will it happen if the entry criteria are loose and ability to pay is the main criterion?
9. What is the natural history of these graduates? How many return and how many stay abroad?
10. Can doctors who qualify abroad get Govt employment and are they disadvantaged when applying for jobs as preference is given to local graduates?
11. Are systems in place to ensure that foreign graduates meet the basic standards required by the SLMC to be registered in Sri Lanka?
12. Has the compulsory service period associated with a financial bond which was in operation when we qualified been removed?
13. What are the main reasons why the GMOA and other organisations oppose the establishment of private medical schools? If entry criteria are fair, if scholarships are awarded to needy students, if there is a quote reserved on a merit basis, what is the objection?
My second instalment (as there is restriction of number of words for comments allowed by Blogger).
ReplyDeleteFinally, what Sanath is suggesting seems very reasonable and fair, i.e.,
Safeguards in establishing PME
a) The admission criteria should be determined by the UGC and the minimum mark for admission should be higher than the minimum mark for admission to a state medical school for that year.
b) Scholarships should be offered to less privileged students.
c) The training and teaching facilities within the faculties, teaching hospitals and the community, should be closely monitored by the SLMC.
d) Preferably new private schools should be established in provinces and districts away from the big cities so as to minimize the internal brain drain. It would also lead to economic development of these rural areas.
e) All evaluations should be conducted together with the participation of academic staff from other state universities as visiting examiners so as to ensure transparency.
What are the reasons why this is being opposed? How is it that the GMOA is now wielding so much power. As a past Vice President myself, I cannot imagine a time when it was so influential.
My own feelings are
1. Any student who is good enough to be a medical student should have that opportunity regardless of financial , religious or ethnic factors and it should be free.
2. If there are financial constraints, a second smaller tier should be available for those who have the ability to be financed but only if they meet educational criteria.
3. If a student cannot get a place in a state university, I cannot see any harm in allowing private medical schools to do so provided they have strict academic criteria for entry and they all pass a common final examination for clinical competence. The big question after that is how selection is made to fill State posts. They are not necessarily children of rich parents. They are essentially those who were not in top list for state universities but were academically good enough. The academic top will have rich and poor parents just as the next academic tier in private universities will. Of course, some deserving students in this category may have poor parents and it is absolutely essential that they should not be held back and that state support is given to them. In this way, no deserving student will lose out.
4. For those who could not get into State or Private Medical Schools and who have parents who can fund education abroad, a decision has to be made under what circumstances they will be allowed to practise in SL and what sort of State posts they can apply for. They should not have any advantage over those educated in SL.
I shall be most interested to see other view points
Mahendra, thank you very much for posting my article on our blog spot. The caption would have sounded better if it was "Free Education and Freedom for Private Medical Education in Sri Lanka".
ReplyDeleteI will attempt to answer some of your questions.
3. All medical graduates are offered internship and employment thereafter.
4. The answers are in Tables 7&8
5. The numbers that leave the country are not known; there is no compulsory period of service.
The numbers who do not return to the country after going abroad for medical studies are also not known.
6. There is a maldistribution of doctors within the country. The Western Province has an excess of doctors. The OPDs of the National Hospital, LRH etc. are overstaffed. At any given time, although there should be about 15 MOs for a morning session at the the OPD ,only about 8 or 10 are working; the rest are busy running their private clinics. Most of the non -specialist MOs are part-time GPs. The GMOA is represented in the transfer boards and therefore the status quo remains.
8. The cost of private medical education in Sri Lanka would be very much less than overseas (eg. The KDU has private students who are charged less)
10 and 11.All foreign qualified graduates have to sit for the ERPM examination (formerly called the Act 16) and they are placed at the bottom of the list.(I have been an examiner, since the mid 1970s and the standards vary a lot.)
12.There is no compulsory period of service at present(It was removed by JRJ when he was the President, as he thought that it was against their human rights!)
13. I cannot understand the stand taken by the GMOA. In all other fields of education, such as Law Architecture, IT etc, private education is allowed.
I am ready to participate in a televised public debate against it's opponents (i.e GMOA),if it could be arranged.
Sumathi, when I deliver the lecture and I display CWWK's photograph, I request everybody to stand up and observe two minutes silence, mentioning that none of us would be in the room if not for this visionary!
Lama, In my opinion Medical Education in SriLanka should aim at treating the indigenous health issues and not what is found in America and the West. JRJ was absolutely right in getting rid of the Compulsory National Health service by the Doctors. I am sure rule never applied to other Professions. There were several gross violation of Human rights during SLFP regime and people had chance of going to Geneva with their grievances. Foreign trips were limited only a handful.
ReplyDeleteYou are a genius and should have been in the expert panel in tackling the Control of Covid in Lanka.
ReplyDeleteSumathi, thank you very much for the very generous compliment, which I don’t deserve at all
ReplyDeleteThere are more competent health professionals tackling the pandemic right now
Dear Sanath
ReplyDeleteWhat you have produced is a treatise on free education and its impact and also a multitude of other factors that influenced medical education. This indeed should be archived for posterity. Mention of Free education does for me raise some regrets for leaving the country although I worked in Sri Lanka for 7 years after qualifying. In the same breath I admire greatly those who remained in Sri Lanka despite the ethnic strife political upheavals and economic downturns to serve our country that simply could not afford the brain drain.
Nihal, it is important to document that the very first batch from Peradeniya was not offered employment after the internship. They were given a few hundred rupees and requested to attach themselves to a GP so as to be trained in GP work.That was the catalyst for the brain drain
ReplyDeleteSanath
DeleteAll who left the country did so due to valid personal reasons. If not then, by now we have developed a clearer conscience about leaving SL. I cant think of a better reason to leave than when not offered a job.
This is a digression from the important issues that you raised about medical education. The future is in our hands to change for the better.
Sanath, It was not just the first batch of Peradeniya graduates who did not get employment. When I finished my internship in Ratnapura in August 1968, I had to "play housewife" for about 4 months before I got my first government appointment as a Medical Officer in Karawanella.
Delete(This is an excellent article and my longer comment will follow at the end.)
Country did not have enough money to employ the doctors, during that period. It's was mainly due lack of planning and short-sighted policies adopted by the ruling parties. I remember, during Dudley Senanayake's period, following the Hartal, free rations were distributed to all the citizens, irrespective of their earnings. He resigned and UNP had the worst defeat under leadership of Sir John Kotelawala. During the Korean war the rubber prices shot sky high and the revenue we got was not used to develop the country.
ReplyDeleteDear Friends, I very much appreciate your comments; as the brain drain is an emotive topic, shall we leave it aside and comment on the need for private medical education in Sri Lanka ?
ReplyDeleteSanath, my thoughts on private medical education- very personal.
ReplyDeleteAt the outset I must declare that I am very much Left of centre in my thinking and I am not a great fan of free markets, motivation by profit and consumerism.
Education and health are two crucial areas where every human being should have fair access irrespective of wealth, ethnicity etc. They should not be an area eyed by people whose chief objective is to make money. However, I don’t believe that these sectors should be totally run by the State. There are many individual who are driven by altruistic motives to enter the arena. If these sectors are controlled in a sensible manner (very difficult but not impossible), very fruitful state-private partnerships could develop. The licensing procedure should be very strict and transaparent.
The primary motive for Private medical education should be to help meet the needs of Sri Lanka, to supplement the State sector which is lacking in resources to provide the required number. The State on the other hand, should have a clear plan to utilise doctors for the betterment of the country. A situation as arose in the late 1960s where doctors were left high and dry after they qualified, should never arise. I am reminded of a benefactor giving money to a poor person without checking what he is going to do with the money first.
Secondly, access should be controlled so that deserving students are not left out as they lack financial resources. Merit should be a crucial enlisting factor, but resource inequality should also be considered and I am in favour of regional quotas which are subject to regular revision
Thirdly, the most suitable students should be chosen, not the wealthiest.
Fourthly, the quality of the education should be high and monitored by the State.
Fifthly, the graduates who qualify must satisfy all the criteria for professional practice applicable to any doctor who wishes to practice in SL.
Lama, Speedy has expressed and impartial, constructive opinion about starting Private Medical Schools in SriLanka. I was a left minded person all through out but abhorred "Bloody Revolutions". Entrants to Private Medical School should be purely on merit and not left for the rich and the famous. It is also important that those graduate should not have step-motherly treatment when it comes to employment. GMOA should not open their big mouths in the process of selection.
ReplyDeleteAnd its quite sad to see KDU students being discriminated by some Consultants & even on public forums. As seen recently on Inter University Paediatrics Quiz conducted by Sri lanka college of Paediatricians, KDU was eliminated after just a toss ?.
ReplyDeleteKDU Graduates will be serving the country, treating Sri lankans doing a service to the community and they want to be good doctors too, so why some people want to stop it from happening I cant understand. Give them a chance to prove themselves.
I should be getting used to this by now but I cannot help but comment on the lack of comments on this important topic. I suppose our minds are preoccupied with other things of greater relevance to us in our stage of life!
ReplyDeleteIt is a pity that a lot of our friends with minimum worries seem to me that they are not interested in welfare of potential Medical students.
ReplyDeleteOK, Speedy and Sumathi, I took the hint! It was just that I was busy with other things! I agree this is a very important topic.
DeleteSanath, you have laid out the facts very clearly in this excellent article. My take on the situation, just from reading your article is as follows:
ReplyDelete(I cannot comment on the fact that consultants are discriminating against KDU graduates etc, because I am not living in SL.)
1) Sri Lanka has a shortage of doctors and something has to be done about it.
2) While the quota system gives the outstation students (who may be less affluent) an opportunity to get into state medical colleges, it unfairly discriminates against some of the urban students from Colombo, Kandy, Galle etc.(who may be more affluent) who may have entered on merit alone.
3) These students who don't get into the state medical colleges may choose to study medicine abroad or apply to one of the private medical schools.
3) If they travel abroad to study, they may end up staying in those countries where they studied, contributing to the brain drain.
4) If they return, they have to sit for the qualifying exam to practice in SL. (I gather from the article that there are doctors who coach these candidates for the exam and earn big bucks?)
Sanath, I have some questions and suggestions.
1) Are there certifying bodies (commissions?)that examine the private medical schools as well as the state medical schools to see if they are operating up to national standards? They should have the same requirements.
2) Do the private medical provide scholarships to deserving students?
3) Perhaps Sri Lanka should set up a system where there is a financial incentive for doctors who work in underserved areas. I don't know what, but if there are grants given to young doctors to set up a practice in rural areas, patients won't have travel far to see a doctor. Another idea is to provide incentives for specialists to travel out of the cities to see patients who are less affluent in rural areas. (Forgive me if such things already exist!)
In the US there are some programs where young doctors who serve in "underserved areas" have some of their student loans forgiven. I knew some people who did this in the past, and I am not certain if these programs still exist.
Srianee, thanks for your well considered comment. I too felt that the most appropriate people to comment are those who are still based in Sri lanka and have local knowledge. As I indicated and you have also done, we can only suggest guide lines and principles.
ReplyDeleteSrianne, you have raised very important issues that can change the current system of Medical Education.It may take many years to achieve American and Western system.I certainly don't blame you for not commenting.
ReplyDeleteThanks Mahen and Sumathi. As you mentioned, it would be unfair of me to express opinions when I don't have all the facts and am not practicing in Sri Lanka. So, I will only ask questions. If I remember correctly, one of the conflicts between the private medical schools and the state medical schools arose because the medical students were competing with each other for clinical rotations in the Colombo Hospitals. As we all remember our clinical rotations with some of the consultants at the General Hospital, LRH and DMH, taught as so much. All medical training programs need to be affiliated with good medical centers where the medical students get exposure to all types of patients.
ReplyDeleteHere's my question: Why don't the people who establish these private medical schools set them up near good outstation hospitals, where the students could get some excellent clinical training? Why do they all have to be in Colombo? Many of us did our internships in good outstation hospitals with excellent consultants, in places like Ratnapura, Galle, Kurunegala, Anuradhapura. Medical students would benefit greatly if they did their rotations in those places.
Perhaps they already do! Sanath, could you respond please. Thanks.
Srianee, I very much appreciate your detailed analysis of the situation regarding PMC in Sri Lanka and possible solutions.
ReplyDeleteOne of the key roles of the SLMMC is to monitor the standards of medical education. When I was in the Council of the SLMC,I was a member of a small team that visited Rajarata and Kelaniya medical schools, so as to evaluate their standards etc.
When foreign medical schools apply to the SLMC for recognition so as to admit Sri Lankan students, they have to submit a detailed portfolio. This is followed by a visit by two SLMC councillors I have visited several medical schools in India, Armenia etc, to evaluate standards.
When SAITM was functioning, several scholarships were offered to needy students. Rajarata and the Eastern Medical Faculties offer an additional allowance to attract academic staff. Yes, there were problems when SAITM students were sent to GHC,LRH etc. for their clinical training.
Ideally Private Medical Schools should be set up in the outstation towns such as Moneragala, Mulativu etc. That would help to minimise the internal brain drain as well as develop these remote towns. Karapitiya is a good example. When I first visited Karapitiya in 1979, it was a "Kada Mandiya". Now it is a bustling town.
The present admission scheme to State Medical Schools is 1)Merit -45% 2)District Quota-50% and 3) Educationally under privileged districts-5%. This was introduced by Lalith Athulathmudali in the early 1990s. His vision was to gradually increase the merit quota at the expense of the other two, as facilities improve in the rural areas. This never happened because of opposition by the rural MPs. As there are expressways, IT facilities island- wide and as tuition masters travel all over the island, the quota system is very unfair. Furthermore in Colombo, Royal College cannot be lumped with Lumbini Vidyalaya, although both schools are in Colombo.
It is much better to grade the schools according to the facilities available, rather than by it's location.
Sanath, thank you for answering my questions. I agree that the quota system is rather unfair. But, there are always two or more sides to the argument and I am sure it is a "hot button"issue, especially when the politicians get involved.
DeleteIn the US we have "Affirmative Action" which is a policy that enables disadvantaged students to enter college. To be honest, I don't know exactly how it works, but those against Affirmative Action claim that admission to colleges and universities should be based on merit alone, which obviously would give the students from privileged backgrounds an edge.
I am sure you are doing your best to make this process in Sri Lanka more equitable. Are you part of some sort of an advisory panel? But, would those who have power and control over the situation listen to your recommendations?! Politicians often think only as far as the next election. Sadly, this is universal.
It was also interesting to read about Karapitiya transforming from a "Kada Mandiya" to a bustling town. That needs to happen in other places too.
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ReplyDeleteSrianee, thank you for your comments. So far, I have not been invited to serve on any panel.
ReplyDeleteI consider myself to be an excellent example of a beneficiary of free education. I entered RPS in January 1948, RC in January 1954 and left RC in December 1960. My father paid the princely sum of Rs 2.00 per term for facilities fees! I proceeded to London on a Colombo Plan Fellowship and acquired the MRCP(UK) and DCH (Lond.) within 6 months. As I had time left, I acquired the PhD (Lond) in two years and three months, which was funded by the British Government. By the way, I happen to be the first clinician in Sri Lanka to acquire a research degree. I have eleven qualifications after my name and I have not spent a cent to acquire any of those!
Our elder son Shamin and daughter Dilusha also graduated from the Colombo Medical Faculty. When the Dean launched a fund to landscape the quadrangle of our faculty as part of the 150th anniversary celebrations in 2020,I readily donated one million rupees in lieu of three members of our family been educated there, free of charge.
I am personally aware of the cost of medical education abroad, as our second son Harshan is an Oxbridge graduate and I had to spend through my nose to fund him!
Lama, you could be the biggest benefactor from the medical fraternity. Your expenditure in education your son, Harshan at Oxbridge is worthwhile. He will earn that money in no time as a NHS Consultant. I had not enough money to educate my two children in private schools and had no chance of entering Oxbridge. However both entered Birmingham University and graduated in Biochemistry(daughter)and Medicine(son).I will certainly donate a handsome amount to Medical schools, in Colombo(Alma mater)Sabaragamuwa(my place of birth)and Rajarata(where I worked nearly 2 1/2 years),provided I win a windfall, in the lottery. That is a promise that I will keep up to.
ReplyDeleteSanath
ReplyDeleteI read your article only now as i was very busy.
Excellent article!
I agree with you that Sri Lanka should have private medical education as we have a shortage of Doctors and all state medical colleges can accommodate only a limited number of students.
This will prevent foreign exchange going out of the country for medical education abroad.
Both my children studied medicine abroad. If there was private medical education in Sri Lanka they may have studied here.
Why is the GMOA against Private medical education? Is it because proper standards are not maintained selecting the students?
I feel Sri Lanka should have private medical education but admission should be strictly on proper standards and requirements. Chira
All of us wish to see proper procedures are followed in selecting students in to private Medical schools,nepotism, favouritism wll creep in and the standards will go down. We do not want to see second class graduates coming out from those institutions.
ReplyDeleteSrianee,Chira,Sumathi et al, Thank you for your very genuine concerns.
ReplyDeleteI have covered all this in my article; the minimum admission mark to a PMC, should be more than the lowest Z score for a State Medical School.The UGC should monitor all admissions.
The SLMC should monitor the facilities available, the staff and the training.
The PMCs should be established in remote areas so as to minimise the brain drain and create a brain gain from among the Sri Lankan Expatriates,
About 10% of scholarships should be offered to deserving students.
Examiners from State Medical Faculties should actively participate in all the examinations. Last year I participated in the Final MBBS examination at the KDU. I examined both the SAITM as well as KDU cadets and foreign students. The standards were satisfactory in all groups of students.