Private medical education

November 7, 2011, 6:32 pm

By Professor Sanath
P. Lamabadusuriya MBE

Emeritus Professor of Paediatrics
University of Colombo

A topic that has created much public interest through the media is private medical education in Sri Lanka. This controversial topic first emerged in the 1980s with the creation of the North Colombo Medical School in Ragama by the Sri Lanka College of General Practitioners. About 30 years later it has re-emerged with the establishment of the South Asian Institute of Technology and Medicine in Malabe.

The Colombo Medical School was established in 1870 and is the second oldest medical school in Asia and Australasia. However even a century later, we have not been able to establish and sustain a fully functioning Private Medical School (PMS) as yet. In 1962, the University of Peradeniya admitted the first batch of students to its newly established medical faculty. Although the reason for establishing a second medical school was to increase the manpower in the Ministry of Health (MoH), it is ironical that this same batch was not offered employment by the MoH soon after they completed their internship. Instead an allowance of a few hundred rupees was offered to each of them to attach themselves to well established family practitioners, to be trained in general practice. With the growing uncertainty of state employment, from about 1968, some of these doctors started sitting for the ECFMG examination conducted by the American Embassy in Colombo (about 75% of doctors who sat this examination in Colombo were Indians, because this examination was not conducted in India, so as to prevent brain drain!) Few months later all Peradeniya graduates were offered employment by the MoH; but by then some doctors had been offered employment in the US and the brain drain had started. By the 1970s the brain drain had increased to such an extent that a compulsory period of service for five years was imposed by the MoH. This episode highlights the need for consistency in state policy regarding employment of doctors and cadre projections for the future.

Every year over 20,000 students qualify to enter the science stream in universities by obtaining the requisite grades of three passes in Biology, Physics/Mathematics and Chemistry at one sitting at the GCE (A/L) examination; of these, there are vacancies only for about 1,200 students to enter the eight State Medical Schools (SMSs). Several years ago, a few students were admitted to a newly established medical faculty at the Sir John Kotelawela Defence University to serve in the Armed Forces after graduation. The current criteria for admission to SMSs are based on a quota system—40% on merit, 55% on a district basis and 5% reserved for educationally under privileged districts. (There are 16 such districts). The total aggregate marks at the A/L examination was the yardstick which was replaced by the Z score in 2001.The quota system was introduced to ensure social equity. However it resulted in students only with exceptional results being able to enter a medical faculty of their choice. During the last decade or so students entering the SMSs have obtained at least two credits and a pass (except for 2 students from Mullaittivu and Killinochchi)) When the quota system was initially introduced, it was envisaged that the merit quota would increase with the improvement in standards of schools island wide. Sadly, it has not happened as yet. As a result there are many students with good results such as two As and one B at the GCE (A/L) examination but they are deprived of entry to SMSs. In addition there are thousands of students in international schools sitting for the London A/L examination some of whom may wish to graduate in medicine.

Students who fail to enter the SMSs and whose parents are able to pay the fees for medical education in a foreign medical school, have the option of receiving a medical degree from abroad. Not all such parents are affluent; some have to mortgage their property to pay the fees. At present hundreds of local students travel abroad for medical studies annually. Over the years billions of rupees have been drained out of the country for this exercise. Their parents have been deprived of having their children with them for five years or so. Some of them may not return to Sri Lanka after obtaining a foreign degree aggravating brain drain.The quality of medical education in foreign medical schools varies widely as reflected in the results of the ACT 16 / ERPM examinations conducted by the Sri Lanka Medical Council (SLMC). Some of these students fail at this examination repeatedly; their abysmal performance reflects on the quality of their foreign training. Some foreign medical schools in East European countries do not allow their foreign students to register and practise medicine in their own country, where they have been trained! Therefore, it is evident that these institutions are conducting a commercial exercise with scant respect for educational standards. Sri Lankan students who are admitted to such third grade medical schools are mostly misled by their local agents. Their parents have been ignorant of the educational standards of such institutions. Some of these poor quality medical schools have been recognised by the SLMC, based on information supplied by the individual foreign PMSs with some feedback from the WHO. Time is appropriate for the SLMC to de-recognise some of these medical schools based on the ACT 16/ ERPM results.

Our country is still very short of doctors. At present as there is no compulsory period of service for doctors, they could leave the country any time for greener pastures abroad. Many state hospitals in the Northern and Eastern Provinces are grossly understaffed. More specialists are required in many areas. According to the SLMC, there are only about 16,000 medical officers working in the country at present. Accordingly, we have about 80 doctors per 100,000 people whereas the doctor population ratio is very much higher in other countries; Cuba has about 590 doctors per 100,000 people. There are several options to fill this wide gap. Due to inadequate financial resources, more SMSs cannot be established by the government at present. We cannot possibly allow students to continue to travel abroad for private medical education for reasons stated earlier. The SMSs could admit some students on a fee-levying basis, who have missed out on the merit quota by a few marks. The quantum of fees to be levied should be estimated based on the expenditure incurred for providing free medical education on a per capita basis. These additional financial resources could be mobilised to provide better facilities for the non fee-levying students. A more viable option is to set up PMSs locally. Sri Lanka is one of the few countries in the region without PMSs. India, Bangladesh, Nepal, Malaysia etc. have well established PMSs together with SMSs. In some of these countries, twinning programmes are in place where part of the training is overseas in a well recognised university. Such a degree would receive more credibility if the twinning is to a recognised foreign university. A well established PMS with high standards of education and competitively priced will attract students from abroad.

In a scenario where the country is still short of doctors and thousands of students are deprived of entry to SMSs in spite of being eligible to do so, there is an urgent need to produce more doctors. Therefore, the ground situation is fertile to allow PMSs to be set up locally. The admission criteria should be the same as for SMSs, but without a quota system. However, for such a venture it is mandatory that adequate resources be made available in the private sector. Such resources include sufficient finances, manpower, lecture theatres, auditoriums, examination halls, tutorial rooms, audio-visual units, libraries, laboratories, museums, IT facilities, clinical skills laboratories, recreational and residential facilities. Finally, it is essential to have a private hospital with at least 250 beds for clinical training as it is not possible to have a PMS without its own teaching hospital. Currently, students are introduced to the hospital environment as early as the first year in SMSs. In most PMSs in India, the private teaching hospitals provide health care free of charge for some patients so as to attract adequate clinical teaching material for the students. Such a system should be established locally. PMSs should invite examiners from SMSs for the evaluations so as to ensure proper standards. Such ventures should be socially responsible as well. To do so, scholarships should be offered to needy students who have the requisite entry criteria but who have been deprived of admission for financial reasons. It is imperative that the SLMC monitor the standards very closely so as to prevent mushrooming of sub-standard PMSs. It is logistically far easier for the SLMC to monitor local rather than foreign PMSs.

The annual cadre expansion is about 800 to 1000 in the MoH. As about 1,165 medical students are admitted annually, there is a fear of reaching saturation point early in the state sector. However, it is well known that thousands of quacks are practising in Sri Lanka especially in rural areas. They continue to do so because of a need for medical care. With the numbers of registered doctors increasing, they would eventually replace the quacks in the future, ensuring better health care for the country at large.

There is a school of thought that in the future doctors may be deprived of employment in the state sector as the numbers keep on increasing. My personal opinion is that the state is obliged to provide internship for all medical graduates but not continuous state employment for all. Thereafter employment by the MoH should be cadre based and should be reviewed regularly with other stakeholders such as the universities, PGIM, professional colleges and GMOA. With more specialists available, quality of care would definitely improve and public satisfaction would grow.

To summarise, there is an urgent need for establishment of PMSs in Sri Lanka with the regulatory and socially accountable issues in place. Entry criteria should strictly adhere to the UGC standards and be transparent. Our country would then have sufficient well trained doctors, be able to save billions of rupees that are draining out of the country and attract foreign exchange as well.

 

Research for what?

November 7, 2011, 6:36 pm

By Dr. C.S. Weeraratna (csweera@sltnet.lk)

The World Science Day falls on 10th November. This article examines to what extent Science and Technology has been effectively used in Sri Lanka to alleviate poverty and socio-economic development of the country.

A large number of scientific organizations operate in Sri Lanka. There are 26 institutions that carry out research in hard sciences, in addition to the 14 universities, whose staff is also expected to conduct research. Among the organizations which promote research are the National Science Foundation (NSF), the Council for Agricultural Research Policy (CARP) and National Research Council (NRC). According to a report of a committee of three scientists, appointed a few years ago by a former Chairman of NSF, this foundation had funded 1725 research projects during 1970-2000. The cost of these 1275 projects is not known. During 1995-2000, NSF has funded 217 research projects involving a sum of Rs. 102 millions. The details of the research projects carried out by NSF since 2000 are not available. Council for Agricultural Research Policy (CARP), since its inception in 1988, has funded about 500 projects related to agriculture, fisheries and animal husbandry, involving around Rs. 550 million. A five member committee of senior scientists appointed in 2006 by the former Minister of Agriculture to review CARP was of the opinion that the benefits of the research output did not commensurate with the investment. There is hardly any information available on the involvement of NRC in promoting research. Hence, one may wonder whether these three institutions have contributed significantly towards economic/technological development of the country.

In Sri Lanka, during the last two decades, perhaps a few thousands of research studies, involving billions of rupees worth of scarce resources, have been conducted. Findings of these research projects were presented at numerous conferences, seminars, symposia etc. It is important that we utilize these research findings for the benefit of the country, but there is no effective system to achieve this. Instead, the authorities are concerned in conducting more and more seminars, and workshops which appear to have no significant impact on effective use of Science and Technology. Most of the seminars and conferences were mostly "talkshops". For example, the Sri Lanka Sustainable Energy Authority, in September 2008, conducted an expensive training workshop on bio-fuels at a hotel in Kandalama, Dambulla. National Science Foundation held a seminar in Nov. 2009 to discuss and decide action to be taken to promote the use of bio-fuel. A number of papers were presented at this seminar on the use of straw to produce alcohol, use of Jatropha to make bio-diesel. There appears to be no output from these workshops.

Amir Muhammed, the chief guest at the 58th annual session of the Sri Lanka Association for the Advancement of Science, held in Dec. 2002, concluded his address as follows. "I would like to emphasize that judicious application of science and technology for economic development holds the key for a speedy improvement of the quality of life and reduction of poverty in our region. While a balanced development of basic, applied and adaptive research is essential for healthy development of any society, the countries of our region, suffering from major problems of poverty and low quality of life have to use S&T primarily for poverty eradication and solution of major problems, at least in the short term".

 Challenges:

The challenges which we face in Sri Lanka have increased considerably during the last five years. For example, the trade deficit which was Rs. million 253 billion in the year 2005 has doubled to Rs. billion 585 in 2010. The expenditure on food has increased considerably. In the year 2005, we spent nearly Rs. 120 billion to import food, and in 2010 it has increased to Rs.244 billion. Out of this Rs. 70 billion was on sugar and milk most of which can be produced locally using appropriate S&T. The cost of agricultural inputs such as fertilizers and pesticides run in to around Rs. 50 billions which can be reduced substantially by effective use of S&T.

The expenditure on petroleum imports has increased substantially from Rs. 68 billion in 2000 to Rs. 341 billion in 2010. The expenditure on imported fossil fuels is a major economic burden that will increase with time. The use of oil to generate electricity is increasing its cost. The total expenditure on petroleum imports is more than what we earn by exporting tea, rubber and coconut products. Hence, attention must be paid to exploit alternate energy sources in Sri Lanka, especially renewable forms in which S&T plays an important role. We have been talking about use of biomass, Gliricidia , bio-waste, bio-fuels, bio-diesel to generate energy but nothing much has happened. Two years ago there was an inert ministry committee appointed by the former Minister of Science & Technology to examine the alternatives to petroleum. A report highlighting the alternatives was submitted, but up to now action appear to have been taken on the proposals by the Ministry of Science and Technology. .

Chronic Renal Failure (CRF), a disease affecting kidneys, is widespread in some parts of the North Central Province, North Western and Uva provinces. Around 10,000 people, in the three provinces indicated above are currently undergoing treatment for this disease. Use of appropriate S&T is necessary to control this disease.

Thus, we have to face many challenges. To overcome these, the Ministry of Science and Technology should collaborate with the appropriate ministries to conduct relevant research and make use of their results effectively.

  Relevant Research

Scientists themselves have responsibilities to do research that is needed by the country. This is why the former Minister of Science & Technology, in his message to the 62nd Annual Sessions of the Sri Lanka Association for the Advancement of Science said the research effort should place more emphasis on development." Relevant research is critical for development and has a positive impact on the other development processes. For example, the increase in the average rice yields in Sri Lanka from 2,666 kg/ha in 1970 to around 4500 in 2010 can be mainly attributed to research leading to the development of new high yielding rice varieties, produced by the rice breeders of the Dept. of Agriculture.

Science and Technology need to be used to utilize locally available resources. The research efforts need to be directed more towards those aspects, which have a direct impact on the economy of the country, and to solve those problems, which affect the lives of the people. Conducting research alone will not lead to economic development. The research must be relevant to the issues the country is facing. The technologies developed by research need to be commercialized, for which appropriate investments have to made. The Board of Investments need to coordinate with the scientific organizations to attract investments on commercialization of proven technologies.

Sri Lanka is importing a large number of goods which has resulted in a wide trade gap. Producing these goods locally would not only save foreign exchange but also help to generate jobs and increase incomes, thereby increasing the standard of living of the people.

Introduction of S & T and Research & Development can bring-in cost savings and quality improvement enabling competitiveness. Some Economists are of the opinion that reducing the value of the rupee would promote our exports. Effective use of S&T would promote our exports as it would enable us to increase industrial productivity, leading to producing better quality goods and services at prices that can overcome the competition from abroad. Scientists, technologists and the decision makers need to promote the use of science and technology as an integral part of the effort to achieve rapid economic development, improved quality of life and to alleviate poverty.

 Need for a Private-Private partnership

Most of the research undertaken by Sri Lankan scientists end up as mere publications in scientific journals with very few research outputs yielding a commercial product or a process. As such, the contribution of R&D to the economy of the country is negligible. An accelerated programme to transfer the knowledge and technology generated in research laboratories to industrial enterprises capable of converting that knowledge to commercial products or processes should be initiated. These industrial enterprises are mainly in the private sector and the research capabilities lie with the state universities and research institutes. Hence, effective public private partnerships are essential for establishing strong, knowledge intensive, high tech industries in Sri Lanka. However the public R&D organizations in Sri lanka appear to be incapable of liaising effectively with the industry and researchers. Perhaps, Private –Private partnerships may be more effective.

Knowledge management: How microinsurance can best benefit low-income households

November 7, 2011, 8:13 pm

In 2010, the ILO’s Microinsurance Innovation Facility introduced a knowledge management framework, aligning its research and communication strategies and new approaches for improved capture, analysis and sharing of lessons learned from its activities. Craig Churchill, Head of the ILO’s Microinsurance Innovation Facility shares his thoughts about the benefits of the new approach.

Q:What made you go into knowledge management (KM)?

Craig Churchill: The mission of the Facility has always been about learning. As we have finished our five rounds of grants, we needed to maximize the potential of the information that our 55 grantees harvest when implementing their projects.

The goal of the KM framework is to learn how insurance can best benefit low-income households, and to use this knowledge to contribute to the development of appropriate insurance products for low income people, successful business models and effective education approaches. Concretely, we needed to have a blue print, coupled with appropriate systems and tools to capture and disseminate lessons from the field. The KM strategy is what will help us to go beyond the mere implementation of microinsurance projects that we fund and into the replication of successes and learning from failures by the greater microinsurance community.

Q:Concretely, how do you extract information and turn it into knowledge?

Craig Churchill: The Facility relies primarily on its innovation grants programme to churn out useful lessons. Each grantee implements a learning agenda that strives to answer concerns that are core to their organization. Knowledge capture is done by implementing a series of reporting and information extraction processes and tools. One of the key tools is the Learning Diary, a simple yet reflective tool used to capture lessons that a project generates while working toward its milestones.

The knowledge capture activities are supported by the KCapture component of the Facility’s Knowledge Management Portal where grantees can upload, consolidate and share information. This KCapture component, which is still in beta version and accessible only by our grantees for confidentiality reasons, enables the Facility to centralise the information in one location facilitating not only grantees reporting, but also allowing the Facility to organise, consolidate and analyse the emerging lessons and trends more effectively.

Q:What are you doing with the lessons you collect?

Craig Churchill: We have set up on our website (www.ilo.org/microinsurance) a Knowledge Center which is a comprehensive microinsurance information sharing platform that enables users not only to learn from what others are doing, but also share their own experiences, and connect with other practitioners. Moreover, the Facility uses a variety of tools to package knowledge. Grantee specific lessons are shared using the online Learning Journey documents which are chronological and narrative accounts of all lessons learned by a partner during project implementation, including challenges and successes. Lessons along thematic lines are shared in online Thematic Pages, and in publications such as the Microinsurance Papers and Briefing Notes.

Lesson alerts are also sent via email to microinsurance players in what is called the "Emerging Insights" series which provide bite-sized lessons on a variety of topics from microinsurance practitioners, such as the use of scratch cards or why targeting migrants, and not their families, makes more sense. All these tools are available in the Facility’s Knowledge Center. More engaging tools are likewise being used, including webinars (i.e. online presentations and seminars) on key microinsurance issues, videos on specific lessons available on YouTube, discussion forums for online exchanges, and other social media tools. Conferences and workshops, as well as capacity building activities are also important forums for disseminating the emerging experiences of grantees and partners.

Q:What do you want to achieve through gathering and disseminating lessons?

Craig Churchill: Generating the lessons is only half the battle. We also need to make sure that we actively promote the emerging experiences so that ‘do’s’ are replicated and ‘don’ts’ avoided. To influence microinsurance practitioners, however, it is not enough to publish a book or put information on a website. These passive knowledge dissemination methods must be complemented with efforts to proactively encourage the adoption of good practices. We are likely to have greater success in changing behaviours and practices through interactive dissemination tools. The Facility’s capacity-building activities are therefore a critical dissemination strategy for influencing the practices of microinsurance providers at large.

On the one hand, we need a larger cadre of experts who understand the lessons and are interested in a career path that enables them to propagate the findings of good and bad practices. They will act as the lessons champions. But we are also busy with setting up curriculum modules for insurance training centers, co-organizing trainings with Business schools (such as with the Gordon Institute of Business in South Africa) and using for workshop the Harvard Business case methodology to share with practitioners hands on knowledge that can help them reflect on the viability of their business and improve the value they offer to their clients. To assess the impact of the knowledge we produce is not an easy task. The point is not really to figure out how many people have used it but - more importantly - how they use it so that a greater number of low-income people benefit from quality risk mechanisms. (Courtesy ILO)