By Dr Kamal Wickremasinghe Courtesy The Island
The performance record of the current government of Sri Lanka re-establishes a number of principles about politicians promising systemic change. The first of these is the public choice theory of economics that explains political behaviour of all economic actors — politicians, voters and bureaucrats — on the basis of greed. Based on this premise, public choice rules out the potential for major changes in policy outcomes through a change of the identities of the people who hold public office. In this sense, the current government bears living testimony to the public choice theory.
Secondly, in its apparent inaction on several burning national social and economic affairs, the government almost provides a caricature of the type of dysfunctional government portrayed in the much awarded BBC TV sitcom ‘Yes, Minister’ sans the verbal jousts between the main characters that immortalised the show.
The report of the five-member Presidential Committee, appointed to resolve the issues related to the South Asia Institute of Technology and Medicine (SAITM), tends to suggest that the workings at the president’s office are not far removed from the parody of cynical political games portrayed in ‘Yes Minister’: it appears that the SAITM Committee has served the president with exactly the advice he wanted to hear. It can be inferred that in appointing the Committee, the president has acted on advice of the type the irrepressible Ministry Secretary Sir Humphrey Appleby of ‘Yes, Minister’ offered to the Hon Jim Hacker: ‘Minister, two basic rules of government; never look into anything you don’t have to. And never set up an enquiry unless you know in advance what its findings will be’.
On the positive side, the brevity of the Committee’s report, of just 11-pages, absolves it of any charges of wasting paper. Unfortunately, that seems to be the only good thing about the report. The report contains only two substantive recommendations for the future: that SAITM be converted into a not-for-profit public-private-partnership (P3) that would collaborate with established educational institutions, and an accreditation and quality assurance body with powers to enforce minimum standards for medical education and training be established.
The two substantive recommendations of the Committee again point to the lack of a robust policy framework — free of ideological baggage — within the government to consider the SAITM issue afresh. The Committee report makes no secret of the fact that it has operated within the framework of the government’s (its UNP component’s at least) total commitment to the out-of-date, neocon trap of privatising higher education including medical education. Embedded within this policy position is the aim of vested interests to make medical education open to anyone who has the ability and willingness to pay for it.
The perplexing solution of a ‘not-for-profit’ P3 offered in the report appears to be nothing more than the means to this end. It does not offer any solutions for the fundamental issues arising from SAITM, within a broad policy framework that takes into consideration the features that makes medical education different from all other forms of education. The government clearly needs to wake up to the universal presumption — in societies relatively free of corruption — that medical education is an inviolable public good that is ethically incompatible with the profit motive.
Firstly, it must be pointed out that the idea of a not-for-profit P3 is a contradiction in terms. Its beyond belief that the self-acclaimed economist who headed the Committee expects that private sector operators would be interested in operating ‘not-for-profit’ medical schools: A P3 venture typically involves a private entity financing a project in return for a promised stream of payments directly from government or indirectly from users. Harsha de Silva would find it easier to locate ‘hens with teeth’ than to find a private sector operator motivated by altruistic intentions of the sort needed!
The recommendation to expedite the establishment of an Independent Quality Assurance and Accreditation Authority (IQAAA) — by 30 November 2017— albeit in consultation with the SLMC — is also a dangerous proposition because the primary objective behind the crafting of the new ‘Authority’ appears to be to relegate the Sri Lanka Medical Council (SLMC) from its current care-taker role to a mere advisory role.
The report recommends that evaluation of medical degree programmes for accreditation be conducted ‘jointly’ by the IQAAA ‘and the SLMC’ using the legally empowered minimum standards and in accordance with the provisions of the IQAAA Act. The language of the report that the SLMA ‘shall’ work in collaboration with IQAAA gives the game away, however. It is clearly an imposition upon the SLMC that has stood to defend the current system that has maintained appropriate standards of medical education so far.
The supposed corrective measures as contained in the two substantive recommendations of the Committee will do nothing more than reinforcing the government’s commitment to privatising medical education in Sri Lanka and pushing the SLMC out of the way in order to achieve this target. The sinister targets and the paths chosen to achieve them are based on vested interests and ignorance of the damage such policies are bound to inflict on quality of medical care and patient safety in the country.
Firstly on the government’s apparent determination to privatise medical education, restated in the report by its chief ideologue of neoliberal (neocon) economic agenda. It needs to be recognised at least by the reasonable sections of the mega-cabinet that the purpose of the medical education process is to produce physicians capable of safely providing high-quality medical care to patients. As such, the design and conduct of the educational programmes provided by medical schools and graduate medical education programmes must ensure that new doctors are adequately prepared to face the challenges they will encounter on entry into practice. Current systems, globally, rely on meeting these requirements by imparting a satisfactory level of foundational knowledge through undergraduate training, and in-depth graduate training through residency in a hospital, under supervision.
Sri Lanka, as a low income country with a chronically under-resourced health system typified by chronic shortages of medications, supplies, facilities, and management systems, faces other secondary drivers of the need to strengthen medical education. Experience in India and other less developed countries has shown that private medical schools isolate medical education from the aims of a broader health care’ system, treating medical education as part of a lucrative educational business.
The best way to realise the folly of the government’s approach on the SAITM issue is to look around for relevant experience worldwide. The purpose here is to demonstrate the faults in the government’s commitment to privatising medical education and its devious attempt to ‘beat the SLMC to shape’ in order to achieve this ideology driven by vested interests, with the help of experience in the hotbed of Western medicine, the US and the ‘worst case’ scenario of privatised medical training, India.
An examination of the evolution of the medical education system in the US shows a history of effectively insulating against private sector involvement in this most market-oriented country of the world. Examination of the key features that prompted this particular approach point to vital requirements of effective medical education SAITM currently lacks.
The American ‘medical school’ began as a supplement to the apprenticeship system under a reputable senior practitioner that prevailed during the 17th and 18th centuries. The privilege of being accepted by the ‘preceptor’ had to be repaid by carrying out menial tasks including running errands, washing the bottles and mixing the drugs. The opportunity to gain some clinical experience was afforded only towards the end of the long apprenticeship. The quality of the training varied depending on the capacity and conscientiousness of the master, and keener students went overseas to learn at hospitals of Paris, London or Edinburgh.
The first recorded formal medical education in America began as a course of lectures on anatomy and midwifery —started in 1762 by William Shippen Jr. (1736-1808). Shippen, who had returned with a medical degree from the University of Edinburgh Medical School— after an initial apprenticeship with his father—started a series of lectures on anatomy expressly ‘for the advantage of the young gentlemen now engaged in the study of physic, whose circumstances and connections will not allow going to anatomical schools in Europe for improvement of their knowledge’. He made the lectures open ‘also for the entertainment of any gentlemen who may have the curiosity to understand the anatomy of the Human Frame.’
Shippen, together with John Morgan (1735-1789) —known as the ‘founder of Public Medical Instruction in America’— went on to establish colonial America’s first medical school, attached to the College of Philadelphia (now the University of Pennsylvania). John Morgan’s commencement speech ‘A discourse upon the institution of medical schools in America’, delivered at the commencement ceremony of the College of Philadelphia, on 30 May 1765, is still considered highly relevant in terms of setting yardsticks for medical education.
It is significant that the first American medical school was conceived as part of an institution of learning, and connected with a large public hospital. Since that beginning, colleges of medicine have always been ‘branches growing out of living university trunks’. This organic connection guarantees certain standards and ideals medical education could ill afford to forego; The Medical College of Philadelphia offered Bachelor of Medicine and Doctor of Medicine degrees, both involving prescribed coursework followed by an apprenticeship for a year to “some reputable practitioner in Physic” at the Pennsylvania Hospital and a public examination.
The requirement of access to a public hospital is not simply a matter of aesthetics; clinical training component of medical education is vital to the ‘rounding off’ of the young doctor’s preparation; it allows an opportunity to review and systematise knowledge that would only be of theories, through practical experience. That is where theories would be tested under the light of facts relating to the disease and parts affected, with the aid of clinical professors; Such ‘bedside training’ is compulsory for the medical students since books alone can never give adequate knowledge about diseases and the best methods of treating it before the students are sufficiently qualified to prescribe for the sick.
In Sri Lanka, we find the government engaged in a poisonous quarrel with the profession on objections to SAITM granting medical degrees without an affiliation with a reputed university or access to a public hospital, vital for academic credibility and to further clinical training respectively. Any unplanned moves towards allowing more ‘independent’ medical schools of its type would harm medical education and medical practice in unforseen ways.
Even in India where poorly regulated private medical schools have been mushrooming over the last several decades, university affiliated medical education became the norm, since the 1850s with the opening of the first three Indian Universities in Chennai, Calcutta and Mumbai, after the British established the Madras Medical School (1835) and the Portuguese the Goa Medical College (1840).
America also provides the best example of a country taking effective measures to protect its medical education system from being exploited by ‘education merchants’: By the turn of the 20th century, medical education in America had been taken over by profit motivated enterprises, producing a surplus of poorly trained physicians. A majority of the medical schools with low admission standards, poor laboratory facilities, and minimal exposure to clinical material was causing the problem. The situation compelled a group known as the Hopkins Circle (predominantly members of the religious group Philadelphia Quakers) to commission a comprehensive review of the medical education system, resulting in the ‘Flexner Report’ of 1910.
The Flexner report’s decrying of the prevalence of profit motivated medical education led to the implementation of more structured standards and regulations for medical education. A system based on the German model that was already in place at Johns Hopkins Hospital under the influence of the German trained bacteriologist William Welch (known as ‘the Dean of American Medicine’) was adopted. The quality of the student body was assured by limiting admission to students who had a university education prior to medical school. The first two years training was in the basic laboratory sciences before progressing to clinical training at a university hospital under medical professors dedicated to research and teaching. The enactment of state licensing laws to enforce Flexner recommendations sounded the death knell for the profit motivated proprietary medical schools in America, leading to its complete disappearance from the US for decades.
The Committee recommendations of converting SAITM to a P3 project will do nothing to address the complaints of the SLMC and the medical profession in general. It will still be a private institution without affiliation to a reputed university or a public hospital capable of offering enough clinical cases for training of medical students.
Then we come to the other substantive recommendation to establish an IQAAA. Probably, it is a good idea in respect of the so-called ‘international schools’ — found on almost every bazaar along the road from Colombo to Kandy — and for private ‘universities’ to be established in other fields of study. In fact, quality assurance and accreditation became buzzwords of the globalisation merchants eyeing the education sector in developing countries, over two decades ago. The University Grants Commission (UGC) under the previous education administration became an early enthusiastic convert to the processes associated with it, sweetened of course with lucrative World Bank contracts.
The term accreditation means different things to different people: in the US, it refers to a process of review and assessment of quality as a test for accrediting an institution. In the UK, accreditation refers to a Code of Practice by which an institution without its own degree awarding powers is given authority by a university to offer its degrees to students meeting the requirements. Lawyers would be smacking their lips about the prospects the ambiguity of meaning offers to private institutions promising ‘higher education’.
Currently, all medical schools in the United States and Canada must be accredited by the Liaison Committee on Medical Education (LCME). The LCME, established in 1972, is sponsored by the Association of American Medical Colleges and the American Medical Association. It publishes many guides and standards including the Directory of Accredited Medical Education Programs. The LCME in effect, is an expanded SLMC type body with exclusive participation of the medical profession. It currently accredits 134 US schools, including four (4) in Puerto Rico, and 17 in Canada.
The LCME works in collaboration with the Accreditation Council for Graduate Medical Education (ACGME), founded in 1981, responsible for accrediting the graduate medical training programs (internships, residencies, and fellowships) for physicians in the US. The board of directors of the ACGME is made of four members each representing the American Board of Medical Specialties, American Hospital Association, American Medical Association, Association of American Medical Colleges, and the Council of Medical Specialty Societies. The most significant feature of the LCME and the ACGME is that they, as bodies governing standards of medical education, are made of medical professional without interference from outside parties, profit motivated or otherwise. In his consideration of the report, the president needs to remove the prism of the UNP’s neocon economic model and take a fresh independent look at the options before him.
As highlighted in a previous item, India as a jurisdiction with ineffective control of privatisation of medical education provides blood-curdling examples of the ill effects of allowing the process; Although the law limits operating private medical schools to not-for-profit bodies, and requires to charge a ‘reasonable’ tuition fee from students, the main source of income in these schools has been reported to be student fees. While course admission into public medical schools is primarily based on academic merit, admission into private institutions is very much on the ability of the student to afford it, limiting medical education to the privileged. Significantly, the Medical Council of India (MCI) is also under attack from the Brookings Institution a key player in Indian domestic policy making these days.
Solutions to SAITM issue need to be sought within the broader framework of the objectives of medical education, recognising the basic truths that effective medical practice involves implementing ‘complex interventions’ requiring competence beyond mere reliance on completing a course of study and passing an exam. Producing competent medical practitioners must include emphasis on competencies beyond medical knowledge and basic clinical skills in order to ensure patient safety.
Overseas experience suggests that enterprises engaged in medical education for profit do not have the commitment to broader health care needs of the country’s population. It’s the domain of the government and it’s the government responsibility to ensure safe and efficacious medical care of the people. Privatisation of the onus of medical education (which essentially is privatisation of health care) is tantamount to the abrogation of the government’sresponsibility.
The cost argument lacks credibility in view of the countless billions of rupees sought and obtained almost on a monthly basis through supplementary estimates for the importation of luxury cars for politicians. The government financing medical education is unlikely to be as costly!
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