Is there a role for private sector medical education in Sri Lanka?

By Prof. Carlo Fonseka

In 2005 as a part of the 25th anniversary celebrations of the Post Graduate Institute of Medicine of Sri Lanka (PGIM), its then Director Prof. Lalitha Mendis staged a debate on the above question. A team of four senior doctors proposed that there is such a role. They were opposed by a team of four medical students (three girls and a boy) from the Faculty of Medicine, University of Colombo. What follows is an edited version of the contribution made by Prof. Carlo Fonseka, as leader of the proposing team.

The four of us who are proposing that there is a role for the private sector in medical education in Sri Lanka are all well past out debating days. We have no wish to win this debate by hook or by crock. On the contrary, we have come here today to exchange views on a controversial subject with our young friends in the opposing team.

The essence of the matter under debate as we see it is this: Should the absolute State monopoly on western medical education in this country continue or not? We think that the absolute State monopoly should end; the opposition thinks that it should not. It is perhaps not without significance that with all her persuasive charm, Professor Lalitha Mendis has not been able to persuade even one mature, qualified, well-informed doctor to argue the case for continuing absolute State monopoly of western medical education. So the case has to come from the mouths of three lovely babes and one suckling!

Absolute monopoly

Of the four of us on this side, three have profited enormously from the absolute State monopoly of western medical education in our country. If the vast majority of people in the audience feel that the old order, that is to say, the absolute State monopoly of western medical education should continue, so be it. Democracy is the right of people to behave even foolishly without the use of violence. In the present stage of our lives we have nothing to lose from such State monopoly. You may then ask why we have changed our minds on the matter at this stage of our lives. I must confess that among the four of us I was the last to change. In any case, why have we changed our minds on the matter sooner or later? The answer is that we have changed our minds because the relevant facts on the matter have changed tremendously in the recent decades. When facts change we have been trained to change our minds.

That is the scientific attitude. Among the things that have changed is the method of selecting students to do medicine. I will elaborate on this matter later.

Knee-jerk response

We are looking forward to hearing what our young friends in the opposition have to say in support of continuing the absolute State monopoly on western medical education. It seems to us that theirs is a kind of knee-jerk response to the question. Should the absolute State monopoly on western medical education end? "No" they answer automatically and reflexly. Why not? Because it has always been a State monopoly and it should continue to be so, would be their position. If that indeed is the knee-jerk response of Prof. Lalitha's handpicked students, I say that they got their great brains by a mistake. I hope they have learnt enough physiology to know that their spinal cords would have been amply sufficient for their knee-jerk reaction.

Between the four of us, our team will place before you for your critical consideration something like ten separate but overlapping arguments in favour of our proposition that the absolute State monopoly on western medical education should end; and that private medical schools duly regulated by a competent designated authority should be allowed to operate. Of the ten arguments we have mustered I will deal briefly with just two.

Public and private goods

The first argument is based on the role of the private sector in a mixed economy such as ours. To help the opposition, which consists of innocents who are babes in the wood in all matters other than undergraduate medical studies, to understand my argument, I fear I will have to belabour the obvious. In a mixed economy there is a State sector and private sector.

The private sector relies on the market mechanism or price mechanism to decide what to produce, how to produce and for whom to produce. The State sector intervenes to promote social welfare especially where the market mechanism fails. To understand the matter rationally it is necessary to have some idea about what economists call "public goods" and "private goods". Examples of public goods are the national defence system and the weather forecasting service. Private goods are things like food, clothing, shelter, healthcare, education and so on. The main deference between public goods and private goods is that public goods never enter the market; they cannot be bought and sold. For example, nobody can buy a part of the national defence system for their private use. Education and health service are obviously private goods; they can be bought and sold. The private sector will not provide public goods such as a national defence system or lighthouses. Therefore, the public sector must necessarily provide public goods; but the public sector can also provide private goods such as healthcare and education.

Unrepentant socialist

As an unrepentant socialist, I believe that in our country in the areas of education and healthcare the public sector must intervene in a decisive way to provide educational and healthcare in the interests of the poor, the old, the sick and the disadvantaged. But there is no objection in principle to the private sector providing the private goods of education and healthcare and this is what is actually happening in our mixed economy. Our young friends in the opposition seem take the view that in the field of education, specifically in the field of western medical education, the State should have absolute monopoly in the provision of a private goods. It is a totally arbitrary and self-serving position to take which will cut no ice with this highly educated audience who are judging us. To put our young opponents to text of intellectual consistency we request them to answer the following questions during their submissions.

1. Did they ever go to private tutors when they were preparing for their medical entrance (GCE A/L) examination? If private education is good to acquire knowledge about the scientific basis of medicine (physics, chemistry and biology) why is private education bad to gain medical knowledge itself?

2. Do they believe that there should be no private hospitals in the country at all and that the State should have absolute monopoly on the delivery of healthcare? If not, why not? Are they saying that although good medicine cannot be properly taught in the private sector, good medicine can be practised in the private sector?

3. Do they believe that it is perfectly ethical and moral for their teachers in the State faculties who oppose private medical education to do private practice in private hospitals? Can't they see that their teachers who oppose private medical education, but enthusiastically rush to the private sector for private practice are shamelessly trying to have the best of both worlds?

Frustrated high achievers

The second argument I am going to present is based on information available to me as a member of the University Grants Commission (UGC). Everybody knows that the State uses a rigid formula for selecting the 900-odd medical students each year for the six State medical faculties. Of the students who gain entrance to medical faculties, there is one student whose grades or Z-scorers are the lowest of all. In preparation for this debate, I asked the officials of the UGC to find out the number of students in the biological stream aspiring to do medicine each year, who had Z-scores or grades higher than the Z -score or grades of the lowest - achiever admitted to a State medical faculty in the relevant year.

Here are the relevant figures.

Year Number of Students

2000 1784

2001 2143

2002 2892

2003 2411

2004 1959

Up to about the early 1970s the selection of students to medical faculties was a comprehensive process. There were two theory papers: a practical exam and a viva conducted by a high-powered committee which among other things considered the reports of principals about each student called for the viva. For several decades in the recent past selection has been done solely on the basis of the results of a written test consisting largely of the so-called objective type questions preparation for this examination is a drill involving rote learning of answers to questions set at previous examinations. There is a set of expert tutors in the country who are available by and large to almost all students preparing for this fiercely competitive examination. These skilled tutors have virtually become the equalizers of educational opportunity and in the process they have also become very prosperous. No government has dared for decades to alter the formula and method of selection. As the figures I have just presented show, during the five year period from 2000 - 2004 an average of about 2000 students have had grades higher than the grades of the lowest achieving student selected to a State medical faculty. Such students feel that they have been most unfairly treated. I have met hundreds of them with their parents at the UGC. They feel cheated and are frustrated and bitter.

The question is what we should do to help these well-qualified students to achieve their legitimate dreams. The State is doing its best but that has not been good enough to satisfy anything like the real demand. Because ours is a mixed economy and a democracy, people should have the freedom to spend their wealth in legitimate ways of their choice. If the State cannot satisfy the insatiable demand of the people for medical education, despite its best efforts, I believe that the State should allow the private sector to play a role in supplying the unsatisfied demand. This does not mean at all that the State should privatise medical education wholesale. It only means that the absolute monopoly by the State of western medical education in the country should end. In conclusion I ask in all seriousness, what is so special and sacrosanct about western medical education that only the State can provide it?