Features
Medical education at crossroads
By Saman Gunatilake
MBBS, MD, FRCP, FCCP, Hon FRACP
Emeritus Professor of Medicine, University of Sri Jayewardenepura
Consultant Neurologist
One of the most quoted phrases of Karl Marx, the German philosopher and political theorist, popularly known as the ‘Father of Communism’, is “History repeats itself, first as a tragedy, second as a farce”. This quote has made its way to common usage through the years, especially the initial part of ‘History repeats itself’. Marx’s words seem to be a good fit for many occasions and the current attempts to restart private medical schools is one such situation. Whether Sri Lanka today is ready to venture into private medical education is a highly debatable issue at present and for a start it would be worthwhile to look back at the past.
History of Private medical schools
North Colombo Medical College (NCMC) was the first privately funded medical school in Sri Lanka. It started in 1980. Since its inception the NCMC came under criticism and opposition of many socialist elements in the island, and especially the state university student bodies. Their slogan was stop privatising medical education. These protests reached a peak in 1989 and university and medical faculty education was disrupted badly with student strikes and protests being a regular scenery. Soon after, the NCMC was nationalised with the government sending the army to occupy the buildings at Ragama stating security reasons. Its board was replaced by a Competent Authority, Prof. Carlo Fonseka. He continued as the first Dean when the NCMC was transferred to the University of Kelaniya as its Faculty of Medicine in 1991.
History repeated in 2008 and, as Marx said, this ended up in tragedy. The South Asian Institute of Technology and Medicine was established in 2008 by Dr. Neville Fernando with the aim to provide tertiary qualifications in medicine, engineering, and information technology, management and finance, and information communication technology and media. The institute was initially affiliated with the Nizhny Novgorod State Medical Academy (Russia), the Asian Institute of Technology (Thailand) and Buckinghamshire New University (England), awarding degrees through those respective institutes. In 2011 SAITM applied for recognition from the University Grants Commission (UGC) as a degree awarding institution, with the ability to award its own degrees. The UGC, in 2013, granted SAITM a degree awarding status despite protests from the Inter-University Students’ Federation (IUSF) and the Government Medical Officers’ Association (GMOA). These protests continued for months and student education came to a standstill, students not attending lectures and exams. MBBS courses dragged on and exams were delayed by over a year and as a result even the running of hospitals were affected. GMOA strikes disrupted patient care in hospitals countrywide. Even the parents of state medical school students formed a body to fight the issue after seeing the plight of their sons and daughters. Following a fast unto death campaign performed by the parents of State Medical Students, on 8th Nov 2017, the Government of Sri Lanka, decided to abolish SAITM, suspend the new enrollments immediately. Students who were doing the medicine course in SAITM and their parents too were in a very dire situation. Their course too dragged on and most had to spend up to 10 years before they qualified by joining overseas universities and the Kotelawala defense university medical faculty. The staff who were teaching in the SAITM were left to their own means. So, wasn’t this a tragedy in the real sense? If this is repeated it will be a farce in Marx’s words. Farce is defined by some as foolish show, mockery, a ridiculous sham. It seems the government probably misinformed by and together with a few retired academics are planning to repeat history. To understand why I say so, we need to have an in-depth knowledge of what the medical course entails.
Current status of medical education
MBBS courses in our medical faculties are very similar and run on similar curricula approved and monitored by the University Grants Commission and the Sri Lanka Medical Council. MBBS course is quite different from most other courses as it deals with ill living human beings. Major difference which non-medics are ignorant is that of the clinical training. More than 50% of the course involves training in hospitals in the last three years out of the total five years. Government has taken a decision to increase the numbers taken for medical courses and also to start two fee levying privately run medical schools. No one would be against this as a principle. Country needs more doctors and no question about it, also in the last 12 months many young and specialized doctors have left the country making some hospital sections even to close down.
First let’s consider the training in state medical schools and why new admissions cannot be increased freely. Clinical training in the last 3 years involve working in hospitals in all days of the week, some Sundays and some nights. From the days I was a medical student and till recently a batch of students would have about 150 students. They are divided into groups of about 12-15 in each group and are allocated to each ward to work under the supervision of a hospital consultant. If the group had 150 there would be about 12 groups. Training would be for a period of 2 months in major specialties like Medicine, Surgery, Paediatrics and Obstetrics and for 2 weeks in others like Cardiology, Neurology, ENT, Neurosurgery, Orthopaedics etc. A group is limited to 12 to 15 because that is about the maximum a hospital ward could accommodate and also suitable for bedside teaching. A ward in a state hospital generally have about 40 to 60 beds and so a student will be given to be in charge of 3 to 5 patients at a given time to study and discuss with senior doctors in the ward till those patients are discharged and then a new patient will be allocated. This is a very dynamic process that changes daily. If the student numbers are increased this system will fail as the hospital has only a limited number of wards, patients and teachers. Prior to increasing student numbers hospital facilities have to be increased to suit the increase. This involves long term plans like increasing available number of hospital wards, beds and trained teachers. If the numbers were increased without paying attention to availability of adequate infrastructure standards will go down. Our MBBS graduates have a good standing internationally and the degree is recognized by the UK and Australian medical councils.
Colombo, Peradeniya, Galle, Jaffna, Jayawardenepura, Rajarata and Eastern are well established medical faculties. Of them Rajarata and Eastern are still understaffed and don’t have professors in most departments. Recently Rajarata had to close down the paediatric unit due to lack of specialist consultants. Sabaragamuwa (Ratnapura), Wayamba (Kuliyapitiya), Uva (Badulla) and Moratuwa are new faculties started recently and have enrolled students. Sabaragamuwa students are ready to start their final year but the final year clinical attachments haven’t been sorted yet and the final year departments have no staff to teach and they have no hospital wards under them. They are struggling to find qualified staff and have no proper buildings to house their laboratories, and lecture halls. Departments have only one or two permanent members. Universities need to attract young and bright lecturers but the opposite is the truth, there is no suitable background for them to join these faculties and many are leaving the country for overseas jobs.
These new faculties are facing the issue of finding suitable hospitals for student training. Most hospitals that are suitable for training are already being used by established state faculties. Most days of the week students spend the mornings in the hospital and attend lectures and tutorials in the faculty and return to hospital for seeing patients. For this the hospital and faculty have to be close to each other. The new faculties are in a crisis situation finding hospitals for training of their students. These shortages will escalate student unrest. Hostel facilities are another important issue as students in a faculty are from all parts of the island. There have been requests from authorities to increase the intake of students to Colombo and Galle and from what I know to increase the intake to 300 from the current 150-200. This is an impossible task. Lectures can be done on line, but in medicine, surgery and other hospital specialties the most effective modes of training are using small group discussions and bedside teaching. Students need to spend time in operating theatres watching operations, but the number that can be allowed in to an operating theatre is limited due to risks of infection. Such ad hoc increse cannot be done without compromising on the training and overcrowding of hospital wards. Patient welfare is also an important area to consider.
When too many students are in a ward, patients will be disturbed by students trying to examine them and this would cause negative responses from patients and their relatives. With all these drawbacks and the apparent collision course the state medical faculties are heading, new private medical schools are to be established with government approval. Where would this lead us to?
New Private Medical faculties
In Sri Lanka, becoming a doctor is still the number one choice for most students. Therefore, there is a bigger demand than that can be catered for. So, the parents who can afford seek entry into overseas medical schools pay exorbitant fees. They are studying medicine in China, Russia, eastern Europe, UK, Malaysia, Australia and India, to name a few. Some argue that the country can save foreign exchange if these students can be educated locally. Many would wish for private medical education in Sri Lanka and that is a very reasonable one. But are we ready for that as a country, and is this the opportune time? From what I have said before it is apparent that starting state medical faculties in the recent past had been done without proper plans and foresight. Where are we going to find clinical teachers and hospitals to cater private medical schools? Clinical teachers have to be selected from high achievers. They should have adequate experience in teaching, proper postgraduate qualifications and outstanding academic records. Parents would not pay fees if the faculty is not up to international standards. Obtaining international recognition too would be a difficult task. This would be a problem that would be faced by even the new state medical faculties. If the terms are attractive state medical faculty teachers may join the private medical schools. That would make the situation in state faculties much worse. When there are no suitable hospitals for training of state medical students where would you train private students? This would result in student protests and student rivalry and even clashes. Result: history repeats, as a farce or tragedy again? There are some private hospitals mainly in Colombo suitable for student training but may not be adequate. Hospitals have to be in close vicinity to where other teachings are done, or else the hospital should provide facilities for lectures and other non-clinical work. The urgent need is to look after the already established medical faculties. Some may even run the risk of losing their local and foreign medical council recognition. From what I know at present the situation in some are terrible and need urgent attention. Starting a private medical school or two will not help to earn dollars to save our bankrupt economy. Time to venture into Private medical schools would be when we have recovered economically and our state faculties are doing well. The question is how long will that be?
by Dr Gotabhya Ranasinghe
Senior Consultant Cardiologist
National Hospital Sri Lanka
When we sought a meeting with Hon Dr. Ramesh Pathirana, Minister of Health, he graciously cleared his busy schedule to accommodate us. Renowned for his attentive listening and deep understanding, Minister Pathirana is dedicated to advancing the health sector. His openness and transparency exemplify the qualities of an exemplary politician and minister.
Dr. Palitha Mahipala, the current Health Secretary, demonstrates both commendable enthusiasm and unwavering support. This combination of attributes makes him a highly compatible colleague for the esteemed Minister of Health.
Our discussion centered on a project that has been in the works for the past 30 years, one that no other minister had managed to advance.
Minister Pathirana, however, recognized the project’s significance and its potential to revolutionize care for heart patients.
The project involves the construction of a state-of-the-art facility at the premises of the National Hospital Colombo. The project’s location within the premises of the National Hospital underscores its importance and relevance to the healthcare infrastructure of the nation.
This facility will include a cardiology building and a tertiary care center, equipped with the latest technology to handle and treat all types of heart-related conditions and surgeries.
Securing funding was a major milestone for this initiative. Minister Pathirana successfully obtained approval for a $40 billion loan from the Asian Development Bank. With the funding in place, the foundation stone is scheduled to be laid in September this year, and construction will begin in January 2025.
This project guarantees a consistent and uninterrupted supply of stents and related medications for heart patients. As a result, patients will have timely access to essential medical supplies during their treatment and recovery. By securing these critical resources, the project aims to enhance patient outcomes, minimize treatment delays, and maintain the highest standards of cardiac care.
Upon its fruition, this monumental building will serve as a beacon of hope and healing, symbolizing the unwavering dedication to improving patient outcomes and fostering a healthier society.We anticipate a future marked by significant progress and positive outcomes in Sri Lanka’s cardiovascular treatment landscape within the foreseeable timeframe.
by Fr. Emmanuel Fernando, OMI
Jesuit Fr. Aloysius Pieris (affectionately called Fr. Aloy) celebrated his 90th birthday on April 9, 2024 and I, as the editor of our Oblate Journal, THE MISSIONARY OBLATE had gone to press by that time. Immediately I decided to publish an article, appreciating the untiring selfless services he continues to offer for inter-Faith dialogue, the renewal of the Catholic Church, his concern for the poor and the suffering Sri Lankan masses and to me, the present writer.
It was in 1988, when I was appointed Director of the Oblate Scholastics at Ampitiya by the then Oblate Provincial Fr. Anselm Silva, that I came to know Fr. Aloy more closely. Knowing well his expertise in matters spiritual, theological, Indological and pastoral, and with the collaborative spirit of my companion-formators, our Oblate Scholastics were sent to Tulana, the Research and Encounter Centre, Kelaniya, of which he is the Founder-Director, for ‘exposure-programmes’ on matters spiritual, biblical, theological and pastoral. Some of these dimensions according to my view and that of my companion-formators, were not available at the National Seminary, Ampitiya.
Ever since that time, our Oblate formators/ accompaniers at the Oblate Scholasticate, Ampitiya , have continued to send our Oblate Scholastics to Tulana Centre for deepening their insights and convictions regarding matters needed to serve the people in today’s context. Fr. Aloy also had tried very enthusiastically with the Oblate team headed by Frs. Oswald Firth and Clement Waidyasekara to begin a Theologate, directed by the Religious Congregations in Sri Lanka, for the contextual formation/ accompaniment of their members. It should very well be a desired goal of the Leaders / Provincials of the Religious Congregations.
Besides being a formator/accompanier at the Oblate Scholasticate, I was entrusted also with the task of editing and publishing our Oblate journal, ‘The Missionary Oblate’. To maintain the quality of the journal I continue to depend on Fr. Aloy for his thought-provoking and stimulating articles on Biblical Spirituality, Biblical Theology and Ecclesiology. I am very grateful to him for his generous assistance. Of late, his writings on renewal of the Church, initiated by Pope St. John XX111 and continued by Pope Francis through the Synodal path, published in our Oblate journal, enable our readers to focus their attention also on the needed renewal in the Catholic Church in Sri Lanka. Fr. Aloy appreciated very much the Synodal path adopted by the Jesuit Pope Francis for the renewal of the Church, rooted very much on prayerful discernment. In my Religious and presbyteral life, Fr.Aloy continues to be my spiritual animator / guide and ongoing formator / acccompanier.
Fr. Aloysius Pieris, BA Hons (Lond), LPh (SHC, India), STL (PFT, Naples), PhD (SLU/VC), ThD (Tilburg), D.Ltt (KU), has been one of the eminent Asian theologians well recognized internationally and one who has lectured and held visiting chairs in many universities both in the West and in the East. Many members of Religious Congregations from Asian countries have benefited from his lectures and guidance in the East Asian Pastoral Institute (EAPI) in Manila, Philippines. He had been a Theologian consulted by the Federation of Asian Bishops’ Conferences for many years. During his professorship at the Gregorian University in Rome, he was called to be a member of a special group of advisers on other religions consulted by Pope Paul VI.
Fr. Aloy is the author of more than 30 books and well over 500 Research Papers. Some of his books and articles have been translated and published in several countries. Among those books, one can find the following: 1) The Genesis of an Asian Theology of Liberation (An Autobiographical Excursus on the Art of Theologising in Asia, 2) An Asian Theology of Liberation, 3) Providential Timeliness of Vatican 11 (a long-overdue halt to a scandalous millennium, 4) Give Vatican 11 a chance, 5) Leadership in the Church, 6) Relishing our faith in working for justice (Themes for study and discussion), 7) A Message meant mainly, not exclusively for Jesuits (Background information necessary for helping Francis renew the Church), 8) Lent in Lanka (Reflections and Resolutions, 9) Love meets wisdom (A Christian Experience of Buddhism, 10) Fire and Water 11) God’s Reign for God’s poor, 12) Our Unhiddden Agenda (How we Jesuits work, pray and form our men). He is also the Editor of two journals, Vagdevi, Journal of Religious Reflection and Dialogue, New Series.
Fr. Aloy has a BA in Pali and Sanskrit from the University of London and a Ph.D in Buddhist Philosophy from the University of Sri Lankan, Vidyodaya Campus. On Nov. 23, 2019, he was awarded the prestigious honorary Doctorate of Literature (D.Litt) by the Chancellor of the University of Kelaniya, the Most Venerable Welamitiyawe Dharmakirthi Sri Kusala Dhamma Thera.
Fr. Aloy continues to be a promoter of Gospel values and virtues. Justice as a constitutive dimension of love and social concern for the downtrodden masses are very much noted in his life and work. He had very much appreciated the commitment of the late Fr. Joseph (Joe) Fernando, the National Director of the Social and Economic Centre (SEDEC) for the poor.
In Sri Lanka, a few religious Congregations – the Good Shepherd Sisters, the Christian Brothers, the Marist Brothers and the Oblates – have invited him to animate their members especially during their Provincial Congresses, Chapters and International Conferences. The mainline Christian Churches also have sought his advice and followed his seminars. I, for one, regret very much, that the Sri Lankan authorities of the Catholic Church –today’s Hierarchy—- have not sought Fr.
Aloy’s expertise for the renewal of the Catholic Church in Sri Lanka and thus have not benefited from the immense store of wisdom and insight that he can offer to our local Church while the Sri Lankan bishops who governed the Catholic church in the immediate aftermath of the Second Vatican Council (Edmund Fernando OMI, Anthony de Saram, Leo Nanayakkara OSB, Frank Marcus Fernando, Paul Perera,) visited him and consulted him on many matters. Among the Tamil Bishops, Bishop Rayappu Joseph was keeping close contact with him and Bishop J. Deogupillai hosted him and his team visiting him after the horrible Black July massacre of Tamils.
Sri Lanka-Singapore Free Trade Agreement
By Gomi Senadhira
senadhiragomi@gmail.com
“You might tell fairy tales, but the progress of a country cannot be achieved through such narratives. A country cannot be developed by making false promises. The country moved backward because of the electoral promises made by political parties throughout time. We have witnessed that the ultimate result of this is the country becoming bankrupt. Unfortunately, many segments of the population have not come to realize this yet.” – President Ranil Wickremesinghe, 2024 Budget speech
Any Sri Lankan would agree with the above words of President Wickremesinghe on the false promises our politicians and officials make and the fairy tales they narrate which bankrupted this country. So, to understand this, let’s look at one such fairy tale with lots of false promises; Ranil Wickremesinghe’s greatest achievement in the area of international trade and investment promotion during the Yahapalana period, Sri Lanka-Singapore Free Trade Agreement (SLSFTA).
It is appropriate and timely to do it now as Finance Minister Wickremesinghe has just presented to parliament a bill on the National Policy on Economic Transformation which includes the establishment of an Office for International Trade and the Sri Lanka Institute of Economics and International Trade.
Was SLSFTA a “Cleverly negotiated Free Trade Agreement” as stated by the (former) Minister of Development Strategies and International Trade Malik Samarawickrama during the Parliamentary Debate on the SLSFTA in July 2018, or a colossal blunder covered up with lies, false promises, and fairy tales? After SLSFTA was signed there were a number of fairy tales published on this agreement by the Ministry of Development Strategies and International, Institute of Policy Studies, and others.
However, for this article, I would like to limit my comments to the speech by Minister Samarawickrama during the Parliamentary Debate, and the two most important areas in the agreement which were covered up with lies, fairy tales, and false promises, namely: revenue loss for Sri Lanka and Investment from Singapore. On the other important area, “Waste products dumping” I do not want to comment here as I have written extensively on the issue.
1. The revenue loss
During the Parliamentary Debate in July 2018, Minister Samarawickrama stated “…. let me reiterate that this FTA with Singapore has been very cleverly negotiated by us…. The liberalisation programme under this FTA has been carefully designed to have the least impact on domestic industry and revenue collection. We have included all revenue sensitive items in the negative list of items which will not be subject to removal of tariff. Therefore, 97.8% revenue from Customs duty is protected. Our tariff liberalisation will take place over a period of 12-15 years! In fact, the revenue earned through tariffs on goods imported from Singapore last year was Rs. 35 billion.
The revenue loss for over the next 15 years due to the FTA is only Rs. 733 million– which when annualised, on average, is just Rs. 51 million. That is just 0.14% per year! So anyone who claims the Singapore FTA causes revenue loss to the Government cannot do basic arithmetic! Mr. Speaker, in conclusion, I call on my fellow members of this House – don’t mislead the public with baseless criticism that is not grounded in facts. Don’t look at petty politics and use these issues for your own political survival.”
I was surprised to read the minister’s speech because an article published in January 2018 in “The Straits Times“, based on information released by the Singaporean Negotiators stated, “…. With the FTA, tariff savings for Singapore exports are estimated to hit $10 million annually“.
As the annual tariff savings (that is the revenue loss for Sri Lanka) calculated by the Singaporean Negotiators, Singaporean $ 10 million (Sri Lankan rupees 1,200 million in 2018) was way above the rupees’ 733 million revenue loss for 15 years estimated by the Sri Lankan negotiators, it was clear to any observer that one of the parties to the agreement had not done the basic arithmetic!
Six years later, according to a report published by “The Morning” newspaper, speaking at the Committee on Public Finance (COPF) on 7th May 2024, Mr Samarawickrama’s chief trade negotiator K.J. Weerasinghehad had admitted “…. that forecasted revenue loss for the Government of Sri Lanka through the Singapore FTA is Rs. 450 million in 2023 and Rs. 1.3 billion in 2024.”
If these numbers are correct, as tariff liberalisation under the SLSFTA has just started, we will pass Rs 2 billion very soon. Then, the question is how Sri Lanka’s trade negotiators made such a colossal blunder. Didn’t they do their basic arithmetic? If they didn’t know how to do basic arithmetic they should have at least done their basic readings. For example, the headline of the article published in The Straits Times in January 2018 was “Singapore, Sri Lanka sign FTA, annual savings of $10m expected”.
Anyway, as Sri Lanka’s chief negotiator reiterated at the COPF meeting that “…. since 99% of the tariffs in Singapore have zero rates of duty, Sri Lanka has agreed on 80% tariff liberalisation over a period of 15 years while expecting Singapore investments to address the imbalance in trade,” let’s turn towards investment.
Investment from Singapore
In July 2018, speaking during the Parliamentary Debate on the FTA this is what Minister Malik Samarawickrama stated on investment from Singapore, “Already, thanks to this FTA, in just the past two-and-a-half months since the agreement came into effect we have received a proposal from Singapore for investment amounting to $ 14.8 billion in an oil refinery for export of petroleum products. In addition, we have proposals for a steel manufacturing plant for exports ($ 1 billion investment), flour milling plant ($ 50 million), sugar refinery ($ 200 million). This adds up to more than $ 16.05 billion in the pipeline on these projects alone.
And all of these projects will create thousands of more jobs for our people. In principle approval has already been granted by the BOI and the investors are awaiting the release of land the environmental approvals to commence the project.
I request the Opposition and those with vested interests to change their narrow-minded thinking and join us to develop our country. We must always look at what is best for the whole community, not just the few who may oppose. We owe it to our people to courageously take decisions that will change their lives for the better.”
According to the media report I quoted earlier, speaking at the Committee on Public Finance (COPF) Chief Negotiator Weerasinghe has admitted that Sri Lanka was not happy with overall Singapore investments that have come in the past few years in return for the trade liberalisation under the Singapore-Sri Lanka Free Trade Agreement. He has added that between 2021 and 2023 the total investment from Singapore had been around $162 million!
What happened to those projects worth $16 billion negotiated, thanks to the SLSFTA, in just the two-and-a-half months after the agreement came into effect and approved by the BOI? I do not know about the steel manufacturing plant for exports ($ 1 billion investment), flour milling plant ($ 50 million) and sugar refinery ($ 200 million).
However, story of the multibillion-dollar investment in the Petroleum Refinery unfolded in a manner that would qualify it as the best fairy tale with false promises presented by our politicians and the officials, prior to 2019 elections.
Though many Sri Lankans got to know, through the media which repeatedly highlighted a plethora of issues surrounding the project and the questionable credentials of the Singaporean investor, the construction work on the Mirrijiwela Oil Refinery along with the cement factory began on the24th of March 2019 with a bang and Minister Ranil Wickremesinghe and his ministers along with the foreign and local dignitaries laid the foundation stones.
That was few months before the 2019 Presidential elections. Inaugurating the construction work Prime Minister Ranil Wickremesinghe said the projects will create thousands of job opportunities in the area and surrounding districts.
The oil refinery, which was to be built over 200 acres of land, with the capacity to refine 200,000 barrels of crude oil per day, was to generate US$7 billion of exports and create 1,500 direct and 3,000 indirect jobs. The construction of the refinery was to be completed in 44 months. Four years later, in August 2023 the Cabinet of Ministers approved the proposal presented by President Ranil Wickremesinghe to cancel the agreement with the investors of the refinery as the project has not been implemented! Can they explain to the country how much money was wasted to produce that fairy tale?
It is obvious that the President, ministers, and officials had made huge blunders and had deliberately misled the public and the parliament on the revenue loss and potential investment from SLSFTA with fairy tales and false promises.
As the president himself said, a country cannot be developed by making false promises or with fairy tales and these false promises and fairy tales had bankrupted the country. “Unfortunately, many segments of the population have not come to realize this yet”.
(The writer, a specialist and an activist on trade and development issues . )
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