Doctor, can I have your numbers please?
Upton Sinclair once said it’s difficult to get a man to understand something when his salary depends on not understanding it. I started this post as a detailed rebuttal to an unusual idea that Sri Lanka really didn’t need any more doctors (post is in Sinhala). Somewhere along the way, this became a tedious, overly long treatise on why I think private tertiary education is essential to Sri Lanka’s standing in healthcare indicators that matter. Although the author of the post I linked to tries hard to make the case that private medical education is not really necessary, I believe the very opposite is true; of medical colleges in particular. How this pertains to SAITM is, to be clear at the outset, not the point of this post but can be inferred.
For those impatient to get to the punchline, there’s a tl;dr right at the end.
Let’s start with some necessary background — depending on context, Sri Lanka punches above their weight on some core indicators that concern the medical profession. You could call Sri Lanka a success story (also see: Sri Lanka ranks top in health indicators). Unfortunately, this is indeed context dependent; because the numbers rely on careful framing to look good. Comparing Sri Lanka to India and Pakistan; countries with by and large worse infrastructure, Sri Lanka looks a success story. This narrative is derailed somewhat if we also include Maldives, which handily matches Sri Lanka in some healthcare related statistics (and has improved faster from a much worse baseline position).
But you could argue (and I have no doubt overzealous medical students will, since they have plenty of spare time these days) — Maldives has a mere 1/40th of the population of Sri Lanka. Yes, accurate — as SL in turn has 1/60th of the population of India. So why would we be comparing ourselves to Indian standards (as the linked article in the opening paragraph does, repeatedly) in an attempt to show all is well? A more pertinent framing would question if Sri Lankan health indicators are of a globally acceptable standard. Take maternal mortality, where Sri Lanka (approximately 30 deaths) outstrips most of its regional neighbours but is nearly three times higher than even poorer Eastern European countries.
(via stats from World Bank Data)
Arguing to maintain status quo in healthcare is fundamentally for me a question of aspiration. When people do this (as the linked article performs significant contortions in trying to make the point), what they really argue for is standing still; with seeming complacence for how the population demographics and healthcare needs are changing over time.
The task of improving healthcare outcomes for a populace is a complex topic. While not being a policy maker in any shape or form, let me draw a few correlations (while reminding readers that correlation does not imply causation).
Since 1990, the number of medical officers in Sri Lanka per 100,000 has increased by 540% to 84.8 (Annual Health Bulletin, 2014). In fact, the number doubled in the decade from 2004 to 2014. Other key healthcare professionals (for instance, nurses by 320%) have increased as well, although by fewer than the number of medical officers. However, the healthcare budget as a percentage of GDP has not seen similar growth.
This era has coincided with significant gains made in some (but only some. more on this later) healthcare indicators that matter — by 2013, neonatal mortality and infant mortality had shrunk to less than half the 1995 figure (see the graphs above). Why do I go on about maternal mortality in particular? Because that is among several tracer indicators (PDF) used to measure progress towards sustainable development goals for health.
Now, you could argue that there is no single (or simple) answer to why Sri Lanka’s healthcare indicators improved. Was it increased numbers of medical officers? Increased investment? Both? I can’t say and to be fair, neither can anyone else. But the correlation between better coverage of medical officers/physicians per unit of population and better healthcare is undeniable. From the same countries used in the previous example (where available)
Is it a coincidence that SL maternal mortality is around 3x the countries I’ve selected; while physician density is less than 0.3? Yes, probably but it is worth noting nonetheless.
Unfortunately, while Sri Lanka has made huge progress in some primary healthcare indicators, they are not doing anywhere near as well in another category — non-communicable diseases (or NCDs, in the parlance).
Let’s take a big one — cancer. Look at the massive increase in incidences over the last three decades for breast and lip/oral cavity cancers in particular.
The Annual Health Bulletin reports 71% of annual deaths in Sri Lanka now occur due to non-communicable diseases; of which cardio vascular disease accounts for nearly 30% (diabetes claims 9.4%). If that weren’t enough of an indication as to the changing nature of healthcare in SL, consider that around 14% of the population is over 60 years old at present; and this is expected to double by 2041.
How many doctors does Sri Lanka produce at present? The article linked in the first paragraph says around 1,325 without offering a citation. Accepting that figure prima facie, the University Grants Commission said 1,144 medical students graduated from state universities in 2014. Going back a few years, there were 797 in 2010, 1,061 in 2011 and 820 in 2012 (the 2012 figure includes dental students, for reasons I don’t quite understand). An average of around 1,000 per year seems consistent with figures from the Ministry of Health; which says that around 8–9% of medical officers in Sri Lanka were internees in 2014.
So in effect, Sri Lanka is adding about 1,000 doctors to the ranks of medical officers each year under the present system. This translates to an increase of about 3 per 100,000 population annually.
Globally, Sri Lanka is near the foot of the table as far as physician density is concerned. This, from WHO statistics (in 2010, SL had a density of 0.72 per 1,000, verifiable from the table above)
It’s possible to have worse healthcare outcomes with a higher physician density than Sri Lanka. Sudan had a density of 3.058 in 2014, Libya had a density of 2.092. What hasn’t been possible though, is to have a lower density and do significantly better than Sri Lanka, at least for the stats that I’ve uncovered. As an aside — let that sink in for a bit. Sudan has 2.5 times more physicians per capita than Sri Lanka. Bet they’ll keep that one out of the briefing notes for the anti-SAITM rallies.
This is already a lengthy post so let me tl;dr this one right up for you.
Thesis: Sri Lanka is doing just fine with public (state sponsored) medical education.
But in truth — Sri Lanka only has state sponsored medical education at present — and at present levels is only capable of growing its density of medical officers at 3 per 100,000 on an annual basis. This means we will take approximately 47 years to catch up to Poland’s density in 2017; a century to catch up to Bulgaria.
Does it matter? Yes, if you accept that more medical officers can help (if not be wholly responsible) for improvement in key healthcare indicators for the 2030 SDGs. We are, for instance, an entire order of magnitude worse than 2016 Greece in maternal mortality statistics.
If you don’t consider improving those figures to be important, consider that the entire SL population is ageing rapidly and is estimated to double its share of senior citizens in just 23 years. In the meantime, mortality due to non-communicable diseases is climbing fast; much faster than the rate at which we currently produce doctors to treat those diseases.
Still feel like we don’t need more doctors? You might be alone in that.
Some proponents of free education in Sri Lanka will tell you that there is a simple solution to this. Increasing the funding to healthcare education will increase the number of medical professionals produced by the existing system. This way, the system can expand to meet rising demand.
In the next part (yes horrifically, there is a next part), we’ll take a look at what it costs the state to educate a medical officer today.
