Features
How to minimise medical negligence or error
by Dr K. M. Wasantha Bandara
This is a humble effort to build up on the article titled, ‘Medical negligence or error’, published in The Island on 18th July. The author of the article, Professor Susirith Mendis, who is a well reputed medical professional and an academic, has drawn our insight into unfortunate events taking place in the health system. That is very important at this time, because certain sections in the society are trying to insult and disintegrate our health system, obviously for narrow, political gains. As Prof. Mendis has emphasised it is an accepted fact worldwide that medical errors and negligence do occur in any system, although there is lack of information except for emblematic cases like the death of a young girl. However, in my opinion, any citizen may have a right to criticize any undesirable event, taking place in the process of delivery of healthcare to people, but it is very unfair to undermine the public confidence in the system. That is because our health system is considered to be Noble in terms of equity and geographical and financial access, when compared with so-called systems in most parts of the world.
I am sure there will be no one in our country to challenge the credentials of Professor Mendis to give a learned opinion on the issue. While being very much grateful and thankful to him, I must apologise to him for presenting my credentials to add some thoughts to his work as to how to minimise such incidents in the future. I am a dental surgeon who has postgraduate qualifications in three different fields, namely, Health Systems Management, Financial Management and Quality Management. I was certified as a quality manager in health care in New Zealand, and also have more than eight years of experience as a health programme manager overseas, including in certain projects funded by WHO and UNICEF. I also have participated in a number of international workshops designed to train “economic hit men” who are used to promote subtle strategies to expand the healthcare market in the name of improving the quality of care.
As such, I have personally experienced sinister attempts to disintegrate public funded health systems in favour of markets. There was one thing common in those attempts, which is what we see in our country today. These days, the attack on healthcare systems is much easier because of Zuckerberg’s army of mental slaves who can be used for the purpose free of charge. We also have experienced the role played by them to pave the way for regime change in the name of system change in Sri Lanka. The other feature which is common in these sinister attempts in exaggeration of undesired outcomes is willful cover-up of actual reasons for poor performance of the system. However, in my opinion unethical, unaccounted and corrupt practices of doctors and medical administrators do more harm to the system than errors or negligence. For example, prescribing habits of the majority of doctors are influenced by commercial interests of pharmaceutical companies, leading to over use and irrational use which is a cost to the patient as well as the nation. The corrupt practices of medical administrators in the procurement process of pharmaceuticals have undermined public confidence in the system.
I also have contributed to a research project where legal frameworks governing the healthcare delivery systems in 40 countries, including Sri Lanka, were studied. That was about more than 25 years back, and I was proud to be a Sri Lankan among western colleagues, because our system was considered to be one of the best, in terms of equity, geographical and financial access, responsiveness and relative cost of care or in other words efficiency versus effectiveness. It was also understood that remarkable performances in our health system can be attributed to free education, and civilizational inheritance, where empathy and kindness are guiding principles in social interaction in our country. Anyway, it is a fact that our people have enjoyed free healthcare, and free education ever since the origins of our civilisation.
It is obvious that we as a nation were able to achieve excellence in key aspects in our system, because of the national policy of free healthcare and hard work of health administration we had in the 70s and 80s. When compared with today’s administrative structure and the administrators themselves, the excellence of the old generation is well proved, although at that time they had no postgraduate qualifications in management, but professionalism and humanism. They took great pain amidst all constraints, especially lack of available resources, to build a system that was so effective and efficient to a level to be admired in international forums. Unfortunately, today’s generation of administrators, having postgraduate qualifications, training, and a comfortable lifestyle, have failed to uphold what their Predecessors built at difficult times than today in terms of resources. Anyway, one must be fair by accepting the fact that generational gap or deterioration of social and professional values in our society may have contributed to overall degeneration of the values in the health system.
As Professor Mendis has mentioned, and I have pointed out above, Zuckerberg’s army contributes to further deterioration of the system by posting irresponsible and indiscriminate comments in social media. In our country, although we have 6 million households, there are 8 million social media accounts and as such, there is a reasonable leverage to manipulate social opinion, and thereby social systems by a centralised system operated by external forces.
However, I will not go into details of how medical negligence or errors take place in the system, since Professor Mendis has dealt extensively on that aspect, I would like to draw the attention of the administrators and the public on the aspects of how to prevent or minimise them. Irrespective of the fact, whether the issue is negligence, error, or a kind of contributory, negligence or error, for which patients are also responsible partly or unpredictable mishap, medication error, Or poor reconciliation of medications prescribed by multiple specialists independently of each other or whatever other undesired outcome; definitely there will be a certain degree of dispute between the provider of the service and the recipient.
If the dispute is not managed properly, a minor negligence can be interpreted as criminal negligence will lead to litigation, creating more problems in the system. In the USA, it is well known that there are legal firms spying on undesirable events, taking place in hospitals and offering litigation services on the basis of sharing the compensation equally. This situation has led to unnecessary investigations and other defensive actions by the medical professionals and finally extra cost to the patient as well as the nation. That is the main reason why the US is classified as the highest spender on healthcare with poor outcomes. Healthcare spending in the US is amounting to 13.5% of the GDP, although 20 million people have no insurance cover at all for healthcare and for those who have insurance the overhead or the cost of insurance is 35%, which does not cover the cost of care.
To cut it short to be fair with The Island newspaper, which is always open for discussion, on issues of national importance, I would like to present in point form as to how to prevent or minimise undesirable outcomes in a system. Irrespective of the underlying cause of the poor outcome in the system, we could categorise those remedial measures into threefold. The first and foremost is protection of the noble fundamentals of the system, where equity, geographical and financial access is guaranteed and cost of care is contained to have justifiable balance between the efficiency and the effectiveness. People must be aware of subtle strategies, introduced to address the issue of being responsive to the expectations of the people, and finally how they facilitate expansion of the healthcare market, depriving sections of the society of basic care.
One of those subtle strategies recommended by international funders, is to divide or split the funder and provider. For example, at present, both the funder and the provider are department health, whereas if those functions are separated public and private providers have equal access to the public funds. If that is facilitated by insurance, 35% of the funds will be wasted as insurance admin cost or overhead. However, there is a need and an opportunity to improve the system further, mainly by addressing interconnected issues in the present system. One is the continuity of care and the other is a referral mechanism for specialist care, both of which can be addressed by establishing a General Practice sub system integrating the public and private out patient care.
The second approach to minimize undesirable outcomes is strengthening of legal frameworks to regulate medications, devices-etc., and to improve the accountability of medical manpower, as well as prevention and settlement of disputes. It is obvious that doctors individually cannot guarantee the safety and efficacy of medications and medical devices they are supposed to use and as such the NMRA act should provide for that. But in the present wave of allegations and counter allegations, the need to amend and strengthen the legal framework is not highlighted.
Although the draft of the amended act is in the drawers without being presented to cabinet and Parliament. Obviously, it is a well-known fact that the so -called pharmaceutical mafia takes decisions over and above the politicians and officials. That is the very reason as to why state pharmaceutical corporation is reluctant to intervene in the market to bring down the prices of essential drugs, which is contrary to principles of its founder Prof. Senaka Bibile. Also, countries like New Zealand have an independent body called health and liability commissioner established by law to intervene and settle the disputes as a mediator and to improve the accountability of medical personnel. But unfortunately, that kind of third-party approach to minimize disputes and public unrest as well as need for litigation is not discussed in the noise created by various interested parties. When there is a permanent independent mechanism established by law, it is not easy for interested parties to undermine the confidence of the people in the system.
The third approach is to improve, modify or optimize the knowledge, skills and behavioral aspects of the key healthcare personnel, for which multiple strategies can be used, including strengthening of clinical processes and practices as well as changing of management culture. There is a long list of interventions to that effect with evidence which can be easily applied in our system. Even simple measures like multidisciplinary ‘grand ward rounds’, case reviews, death reviews, medical audits in emblematic cases, and related clinical or process audits to identify common weaknesses would make a big change in the minds of the medical manpower. There is very remarkable evidence of improvements achieved by way of introducing complaint and incident registers with transparent inquiry and reporting mechanisms. Also, introducing protocols and practice guidelines to guide and unify practices that can lead to questionable outcomes have shown remarkable results.
Besides, in order to restore the public confidence a comprehensive financial and quality audit must be done to identify the weaknesses and corrupt practices in relation to registration and procurement of pharmaceuticals. It should also be mentioned that prices of medicine cannot be reduced only by price controlling mechanisms alone. In the present economic crisis, the US dollar went up by less than 50%, yet the prices of essential medicines went up in a range of 80% to 300%. Those greedy pharmaceutical traders must be countered by adequate market intervention by the state pharmaceutical corporation, which was created by Professor Senaka Bibile, for that purpose.
But, unfortunately, none of these remedial actions to improve and protect the system is not discussed by the medical associations and trade unions, except for individuals like Professor Mendis. If the fundamentals of discussion on this matter is not corrected, it can be predicted that we would get a “Gota go home – Ranil come back” type of solution to the problem.
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 . )
