Private Medical Schools: An Educationist’s Perspective
February 28, 2012, 7:30 pm , The Island.
Raja C. Bandaranayake
[The text of the Inaugural Lecture of the Forum for Sri Lankan Medical Educationists, delivered on 9 January 2012, at the Postgraduate Institute of Medicine]
Continued from yesterday
Introduction
The opening of a private medical school in Sri Lanka has created a great deal of interest, and a certain amount of anxiety, in the medical profession. Such a reaction is, perhaps, coloured by the earlier experience with such a venture several years ago. It is important to realise that there are several types of private medical schools in the world, and often useful discussion of this topic is hampered by misunderstanding and emotion. The writer of this article has no intention of entering into the current debate. However, because he has the education of the physician in Sri Lanka very much at heart, and has been associated with such education for over half a century, an attempt is made here to take an unbiased look at the issues from an educational, rather than an emotional or political, perspective. A definition of private medical education is attempted initially, followed by a summary of some significant events in history from which lessons can be drawn, and an overview of the pros and cons of this form of medical education. Finally, some suggestions are made in order to facilitate private medical schools to make a useful contribution to the training of the physician and, consequently, to the delivery of quality healthcare in the country.
4. Medical Tourism: A new term, "medical tourism", has been coined to identify the increasing tendency for patients to seek cheaper options overseas, in the face of increasing costs of healthcare in certain more developed countries. India has been the leading country to cater to medical tourism, one force which may have led to the mushrooming of private medical schools in this country to meet this lucrative demand. Singapore is another destination of choice for medical tourists, because of the high standards of medical care in that country. Nevertheless, as far as I am aware, there are no private medical schools in Singapore, though there are several in neighbouring Malaysia.
5. Targeted clientele: In many countries medical schools are being established to cater to the needs of specific communities, such as minority, ethnic or disadvantaged groups. Some of these are public while others are private. In Australia, for example, James Cook Medical School in Townsville, Queensland targeted students from rural Australia and the neighbouring Pacific Islands which lacked a system of undergraduate medical education of their own, other than the Fiji School of Medicine. In India some private medical schools were opened to cater to the needs of different caste and ethnic groups. Some countries reserve seats for lower socio-economic and minority students, the US schools being a notable example of this practice for a long time. Political expediency may be one factor which drives governments to resort to this practice. The Bond University Medical School in the Gold Coast in Australia, a recently established private medical school, has been free of government subsidy and influence but is actively seeking support for scholarships to indigenous and East Timorese students.
6. Income-driven forces: Undoubtedly, a potent force that drives the opening of private medical schools is the potential for income generated from such schools. Many are the examples of large businesses which have seen a lucrative source in the privatization of medical education. Unfortunately many have under-estimated the cost of instituting and maintaining a medical school of high quality. As a result they either run at a loss or lower their standards, even though intentions might have been good initially. Sometimes, they expand into other health-related ventures to compensate for the loss in revenue occasioned by a quality medical school. Charging tuition fees is a two-edged sword: higher fees can be afforded by a minority of the population, while lower fees cut down on profits. Something has to give, and often it is the quality of the product.
In the search for the much wanted academic dollar, many developed countries whose funding for higher education has been drastically cut, have resorted to an aggressive search for income from other countries through such means as attracting international students for medical education, and opening of private medical schools in partnership. Prestigious schools have created departments of International Medical Education partly, at least, for this purpose. Others have opened branches in other countries at considerable expense to the latter, and lent their prestigious name to encourage students to attend, even before minimal requirements, such as adequate staff, have been addressed. As a result the standards of the curriculum in the earlier years of operation are in jeopardy. Some established private medical schools have set up branches in neighbouring countries without adequate facilities initially. Such practices do not contribute to the quality of training in the host country.
The Pros and Cons of Privatization of Medical Education
Advantages
In the face of difficulties faced by governments to meet the ever-expanding demands of increasing populations, privatization of medical education has the potential to contribute to increasing the access of healthcare to all sections of society, if it is implemented with the benefits of the community in mind. It has been found that the geographical distribution of medical schools does not mirror the regional population. For example, the Caribbean, with a total population of less than 40 million, had 54 operating medical schools in 2007, while of the 57 African nations, 16 did not have a single medical school. These workers also found a strong relationship between the number of medical schools and physician density. Naturally, if the medical workforce increases, the doctor to patient ratio would do likewise, assuming the population remains constant. Any medical school, whether public or private, has the potential to improve the health of the community in which it is located. However, there are hidden dangers.
Many countries depend on expatriate doctors. Unfortunately the migration of physicians is such that the flow is, generally, from the more to the less needy countries. Countries in the Arabian Gulf Region depend heavily on expatriate doctors. While the governments of these countries have been actively opening new medical schools, the products of these schools are unable to meet the demand. As a result, these countries have become a haven for doctors from developing countries, particularly the Indian sub-continent, to earn the much valued dollar. Over the past decade a number of private medical schools have been operating in these countries, and more continue to be opened. The demand for expatriate doctors is likely to diminish when the products of these medical schools are available. The problem, however, is that, in pursuance of the income on which these schools largely depend, places are made available to overseas students as well. In some of these schools foreign students outnumber local students. It is likely that such students would not remain in the country for long after graduation, returning either to their home countries or looking for opportunities to further their postgraduate education, which is poorly developed in many of the countries in the Region.
Another advantage of private medical schools is that they create a competitive environment with public schools and with each other. If the standards attained by the private school are high, and they develop a good reputation for medical education, other schools would aspire to reach those standards. For example, in one state school I visited in North America I often heard expressions of hope that they would become the "Harvard of the North", meaning that they would like to emulate the curriculum developments that had taken place in Harvard Medical School, which was considered a prestigious school in the US. As alternatives become available for students, faculty and the community, the monopoly exerted by state schools will be diminished.
If the private school has a strong financial backing, it is likely to have up-to-date facilities and resources. These can reach the students without much red-tape and delay, as is often evident in state schools. The private school has the opportunity to be freed of the burden of the bureaucratic machinery of the government, and can use this freedom either to the advantage of the students or of the investors. I know of some schools which opt for the former in spite of a potential loss of revenue. Thus whether this freedom is seen as an advantage or a disadvantage depends very much on the motives of the founders of the private school.
Disadvantages
Fundamentally, many private medical schools are set up as business ventures with the chief purpose of making money. Rarely does the noble cause of alleviating the suffering of the masses enter into the equation, though such laudable intentions have often been proclaimed by such institutions. If this "business mentality" pervades the setting up and the running of the institution, then many disadvantages would accrue from the privatization of medical education. Balancing profit with quality in healthcare is a tightrope act which many entrepreneurs are incapable of or do not care to face.
It will be obvious from what I have just said that the main disadvantage of private medical schools is the poor quality of training provided to the students if monetary gain takes precedence over alleviating affliction through education. I have seen many instances of this in different countries.
There are many reasons for the poor quality of training provided in some private medical schools:
* The poor quality and numbers of academic staff
* A rapid turnover of academic staff
*Diminished staff incentives due to the short-term nature of contracts and uncertainties about tenure, even though they may be lured to private schools by the offer of comparably higher salaries
* Dependence on visiting staff from other institutions or countries, compromising
o continuity of training
o relevance of training
o integration of training
o motivation of in-house staff
* Inadequate hospital or other facilities for clinical training due to the following:
o Many private schools start admitting students without making prior provision for their clinical training in the hope that, by the time students reach the clinical years, some arrangement would be made with neighbouring hospitals.
o Even when such arrangements are made hospital staff pay scant attention to clinical training because of their practice commitments
o Often such arrangements with hospitals independent of the medical school are quite expensive, and erode the profits of the school.
o An academic atmosphere may be lacking in the hospital, even though some hospital staff may relish the opportunity to be involved in teaching.
The relationship between the private medical school and the teaching hospital may take one of several different forms:
1. The private medical school has its own teaching hospital. This is the model used by most established schools.
2. The private medical school shares a teaching hospital with a public medical school. This model usually affects both schools adversely.
3.The private medical school pays a fee to a public hospital for using it as a teaching hospital. Usually the fee is very high fee, eroding the school’s income.
4. The private medical school uses one or more existing private hospitals for clinical teaching.
(To be continued tomorrow)
University students today said they were in the midst of discussions with fisheries, teachers and labour unions who had vowed to unite in their take trade union action in protest against the increasing cost of living and people’s suppression.
