Paying for medical professionals

(this is the second part on medical education in Sri Lanka — first is here)

Free education, which Sri Lanka has had for decades, comes at a cost. There is an obvious rupees and cents cost, which I’ll get into a bit later. But the real cost is opportunity. For as long as record keeping has existed, the number entering universities in Sri Lanka for tertiary education has fallen well short of those actually qualified to do so.

In 2014, a total of 143,739 qualified for admittance to higher education institutions but only 24,180 were actually offered entry. That’s just around 16%. This isn’t an exception by any means — in 2011, 22,016 students entered universities even though 142,516 qualified. The rate of growth is also minuscule, for instance from 2010 to 2011 — a mere 469 additional students were given places in state universities. Universities are already bursting at the seams trying to cope with vast numbers of students; but for every single student who gets in — there are still around 6 left out in the cold. For 2015 and 2016, the percentages of those entering was 17.14% and 18.68% respectively; a small improvement year on year.

Let’s drill down a bit further. The university qualification rate for A/L Biology (essentially, the pre-med stream) students in 2016 was around 50% of those who sat the A/L exam (actual: 53.26%). This rate has remained consistent over the past few years.

Candidates (blue)/Qualified to enter university (red) for A/L Bio Science students, 2013–2016 (Ministry of Education, Annual Report 2016, pp 67)

From my previous post, we have an approximation of the number of medical students per year — on average, 1,000. Assuming boldly that everyone who qualifies for university wants to be a doctor (a bit of a stretch, I know) a mere 6% of those qualified are able to study medicine in a state university. As it is, only around 35% of the 3,500 or so admitted to university after doing A/L Biology actually studied medicine.

Is there pent up demand for more medical students? Given that establishment and operation of degree awarding medical colleges has many stakeholders in opposition, it’s hard to say. But looking at a few other streams may provide an indication:

Graduate output in state universities for selected streams of study, University Grants Commission report 2014

In 2014, the graduate output of state universities nearly doubled by simply allowing external degrees to be awarded.

In the meantime, admissions to study medicine remained flat.

University education in Sri Lanka (via the Department of Census and Statistics Pocket Book, 2016 ch 13)

Plainly, the current system excludes too many from attaining a degree of their choice due to lack of resources.

I’ve referenced this post questioning if Sri Lanka really needs private medical universities before. There are many examples of flawed advocacy within that piece (and I’m being charitable with that description and his motivations) but none more so than the following [in Sinhala]:

Written by an unnamed author on the “Professionals for Free Education” domain, allegedly sourced from a powerpoint presentation made to Colombo and Peradeniya medical faculties.

Let’s dissect his line of argument. The most important thing here is that comparing any of the UK, US or India to Sri Lanka’s system of medical education is not a like for like endeavour. Unlike Oxford, or Harvard — Sri Lankan medical schools are absolutely not open to anyone who may wish to apply. Even fee paying students, that rare phenomenon in Sri Lankan medical colleges, come from a small pool of candidates with other qualifying criteria. A fairer comparison will substitute the number of applicants metric in any of foreign universities for the entirety of the candidate pool in Sri Lanka.

Contrary to his contention, UK universities report a fairly high admittance rate overall (dependent on the university ranking and course). Via IB reporting on UCAS statistics for 2013, institutional acceptance rates range from 39% for Kings College London to 80% for the University of Exeter.

The examples used cherry pick the top ranked medical university in the UK, one of the most prestigious Ivy League universities in the US and a single medical university in India to show poor admittance rates. Look, he says. Sri Lanka isn’t bad. It’s shitty everywhere. While those examples may in fact be true (I didn’t bother fact checking); the candidate pool has many other universities to choose from.

Let’s try study at Cambridge University (any college) for medicine in the last five years as a counterpoint and you will find that the applicant/acceptance ratio is very similar to the current medical college system in Sri Lanka. Similar statistics are available for MBChB at the University of Edinburgh. But those are still top tier universities in the UK.

Medicine at Cambridge University (applicants, offers, acceptance) over the last five years

Other universities at lower ranks offer much wider opportunity for candidates. For instance the Hull-York Medical College (a little obscure, I know) also publish their entry criteria; which looks a little different from the bleak picture painted earlier.

Applicant/offer numbers for the Hull York Medical College, UK

With all this information at our disposal, let’s try an apples to apples comparison. By a reasonable but arbitrary measure, let’s select the Colombo medical faculty as being the premier medical teaching establishment in Sri Lanka at this time. Places at this university college are in high demand. Let’s be generous and allocate 250 seats in any given year to this university. In Sri Lanka, therefore only 1 in 5 (or 20%) of all medical students get a seat at this university. Expand this to those entering university in the Biology stream and we’re now down to 6% or about 1 in 19. Expand this to all those in Sri Lanka who qualified to enter university after doing A/L Biology in any given year and we’re now at 1.13% (or about 1 in 100). What this means is that the Colombo medical faculty has a comparable admittance rate to the Mayo Research Clinic in Minnesota with a fraction of the international reputation, prestige or research output.

Is my math flawed? Yes, under the artificial scarcity imposed by the present system; there will never be competitive applications to enter the Colombo medical faculty from the entire population that qualified for university.

Other countries with private, fee levying institutions offer a diverse pool of candidates the opportunity to study medicine. Sri Lanka, in comparison, only provides a smaller, closed pool of medical colleges of which the entry chance is smaller than the chances of any applicant entering the Johns Hopkins Medical College.

Sri Lanka spends a great deal of money on education.

Expenditure on education, Dept of Census and Statistics 2016

and yet by most global measures still spends too little.

Expenditure on education in Sri Lanka; as a percentage of the GDP, as a percentage of government expenditure; and expenditure on tertiary education as a percentage of total education expenditure (all figures from World Bank data, via UNESCO Institute for Statistics)

So how much does each student in the tertiary education system cost the state?

Cost per student in the Sri Lankan university system, University Grants Commission report 2014

Averages are misleading, since there aren’t many places on the planet where arts degree costs are as high as science/engineering degrees. According to this article, fee paying medical students at Sri Lankan universities pay US $12,000 per year (1.85 million LKR at October, 2017 exchange rates – 9.2 million LKR for five years).

Of the entire student body in state universities, around 6% are medical students. Everything else being the same (it isn’t, we aren’t even considering the necessary increases in capital expenditure); a proportionate increase to expand output by 500 more doctors annually would require an expansion of the state annual tertiary education budget by (a very very approximate) LKR 500 million, and that’s assuming other streams of study and the university system as a whole gets no additional investment.

500 more doctors per year, as a reminder, will annually increase our physician density by approximately 4.5 per 100,000 as opposed to 3.0 per 100,000 at present. This means that instead of taking an entire century to catch up to Bulgaria’s physician density in 2017, we can now do it at the lightning quick pace of 75 years. This increase in expenditure would also catapult our slightly below global average spend on tertiary education into the heady echelons of top 20% among all nations.

Let’s tie all the facts from this post and the previous part together.

  • Sri Lanka urgently needs more medical professionals (which must necessarily include an expansion in the numbers of medical officers) to deal with current and looming healthcare crises
  • Sri Lanka already has a low density of medical officers per unit of population. The very slow rate of expansion from the current monopoly of state sponsored medical educational institutes doesn’t help. Student admission numbers in 2015 and 2016 showed no growth whatsoever.
  • The current state medical education system (in common with the tertiary education in Sri Lanka) excludes many; and provides few with the opportunity to pursue medical education. The rate of candidates being selected to the Colombo medical faculty, for instance, is shamefully comparable to the acceptance rate for far more prestigious medical colleges in the US.
  • Educating a doctor currently costs the state anywhere up to LKR 10 million per head; a number that they would be hard pressed to expand to the point which physician density reaches global norms.

Do private medical colleges (where private institutions and individuals bear the cost of infrastructure, education) sound unreasonable in this climate?

The point of these two posts was not to tediously re-litigate SAITM fit for inclusion in the ranks of medical colleges. I may have an opinion on that issue, but this is besides the point. The truth, hopefully apparent from the data shown across this series, is that Sri Lanka is in dire need of more medical professionals. Short of an unlikely infusion of funds into the medical college system at a near unprecedented scale; it appears the only feasible way to grow the numbers entering the medical profession is by opening the doors to private; and public/private partnership programs.

There are risks associated with opening the door to such partnerships. A dilution of quality, and entirely legitimate fears that this may be the start of a descent down a slippery slope where state sponsored (medical) education continues to be defunded at the expense of private programs. Unfortunately, it’s hard to stay sympathetic to those concerns when there are medical professionals actively seeking to sabotage private endeavour; when there are plenty of examples of how the populace of Sri Lanka has had their quality of life uplifted by better access to healthcare.

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