KNDU: MBBS for the rich, crumbs for the poor

By RAMYA KUMAR

A regular day at work. A medical student, Niluka (not her real name), comes to my office to discuss the presentation she is due to make at a research symposium. In the middle of our meeting she is in tears. Her mother, a single mother, who works as a security guard in remote Polonnaruwa, cannot afford her boarding fees as she has to cover her sister’s A/L tuition classes, as well as her brother’s medicines for a recent health issue. Niluka is unable to focus on her presentation because she is worried about her financial situation. She has a year and half to go.

This is the picture of Free Education that many do not see, of students struggling to make ends meet. Such stories are commonplace at our non-fee levying state universities; as Sumathy Sivamohan wrote recently, “free education does not serve everybody equally, but over the years and across decades, it has come to represent the hope of a vast majority for a better place in society.” However, this aspect of Free Education is obscured by images of protesting students “wasting tax-payers’ money,” constructed by the media in the service of the state. While Colombo-based elites (and others) may be duped into seeing the Kotelawala National Defence University (KNDU) Bill and military repression as solutions to the problems in higher education, this article explores what the Bill really means, especially its implications for medical education.

No vision, no imagination

Free Education, despite its marginalisations and exclusions, is etched in our nation’s consciousness, so much so that governments have been reluctant to overtly dismantle the public education system. Instead, they have stealthily underfunded the system, while incentivising expansion of private education. With inadequate public investment, the state universities under the UGC are floundering to service demand, while the fee-levying Kotelawala Defence University (KDU) and non-state fee-levying higher educational institutions, such as SLIIT, receive state subsidies to finance infrastructure as well as student loans.

Fee-levying universities are simply not affordable for the vast majority in this country. To flourish, they require public-financing, both for their establishment and for student loans, to make them accessible to the masses. While escalating investment in KDU and private fee-levying universities through public funds, the government has adopted a zero-investment policy for state universities under the UGC and increased admissions by a third, this year. The fallout of increasing admissions without budgetary allocations is most felt by universities in peripheral districts, already running on meagre resources.

A government’s vision for education is inextricably linked with its economic policy. While lacking a credible vision for education, successive governments have been equally unimaginative in attempts to improve the economy. Sri Lanka relies on imports for day-to-day essentials, such as lentils, pulses, and milk, with little investment in agriculture or agro-industries for value addition. Meanwhile, billions of rupees are lost in tax incentives to attract (elusive) foreign direct investment, including in education. The Board of Investment expanded its purview to include the social sector in the 1990s, essentially opening education to the global market. The latter has changed the landscape of education in the country with international schools, private colleges and other higher education institutions proliferating in the decades since, and creating parallel systems of education for students from rich and poor families.

Enter KNDU

Faced by mounting debt, the government is desperately looking for avenues to build up its foreign reserves. In 2019, the incumbent government proposed a “free education investment zone” to attract investment from “top international universities,” with accompanying tax exemptions, yet another scheme to subsidise the private sector through public funding. With COVID-19, the plans for the investment zone fell by the wayside. However, just a few years after the SAITM debacle, the government is once again looking to expand private medical education, this time through the KDU.

In 2019, the incumbent President’s manifesto, which is the government’s policy framework, stated that “steps will be taken to expand the Kotelawala Defence University” (p.22). Why KDU? Because the majority of its students are enrolled on a fee-levying basis through mechanisms outside the UGC’s Z score-based system. Although seemingly catering to the military, a closer look at the statistics presented on the website of KDU’s Faculty of Medicine, indicate that the number of medical students recruited doubled, and then tripled, once the faculty began to enroll “non-military foreign students.” As recruitment was limited to foreign students, albeit loosely defined, KDU did not encounter too much controversy.

The KNDU Bill proposes to build a parallel militarised university system, and alternatively, a change to the Universities Act of 1978 aims to bring KDU under the purview of the UGC, as a university for a “specific purpose.” Clearly, the appeal of KDU and other “specific purpose” universities is not their potential to strengthen Free Education. That these reforms will increase the military’s involvement in higher education has been the focus of debate in recent weeks, but less attention has been paid to their implications for education opportunities for students like Niluka, and their potential impact on medical education.

‘MBBS Kada’

Both the proposed KNDU Bill and the amendment to the Universities Act can be viewed as attempts to create the conditions for the expansion of fee-levying MBBS degree programmes, which have been resisted since the days of NCMC. The KNDU Bill will give legal authority for KNDU to recognise and affiliate other institutions to KNDU, bypassing the UGC as well as the Sri Lanka Medical Council’s minimum standards. The Bill will ultimately result in the proliferation of poorly regulated ‘MBBS kada,’ and a decline in the overall standards of medical education.

Even the Association of Medical Specialists (AMS), a body not averse to private education, has made the following statement regarding the KNDU Bill: “On principle, the AMS is not against quality fee levying medical education…if it is regulated and monitored by the UGC and the Sri Lanka Medical Council. However, lack of proper process and transparency will prevent the establishment of such fee levying institutions in Sri Lanka.”

Could expanding medical education in this manner present opportunities to address problems in the health sector, such as the regional maldistribution of physicians?

First, if KNDU and its affiliates aim to attract international medical students, it is unlikely that these graduates would serve in Sri Lanka.

Second, as the Bill will enable KNDU to admit local students, if we assume the current fee structure of upwards of Rs. 1 million per year for the MBBS programme, the KNDU medical students would represent the elite who are more likely to immigrate to greener pastures.

Third, if the government intends to broad-base MBBS degree programmes, they would need to offer hefty student loans to our students. Evidence from other countries suggests that medical graduates with student loans are more likely to opt for higher paying specialties rather than work in primary care, and less likely to serve in rural areas.

It is therefore unlikely that the KNDU Bill would contribute towards advancing the health sector, except perhaps through its military cadets, who would most likely work for the Ministry of Defence and not the Ministry of Health.

Student loans may have other unintended consequences. Despite private practice being widespread, many doctors, especially women non-specialist doctors, do not engage in private practice. In fact, general doctors from peripheral districts often do return to their districts, although they may remain in urban centres owing to the poor education facilities available to children in remote rural areas. These doctors make up the physician workforce in base hospitals and above, as well as in the preventive sector, in all parts of the country. Having to repay a student loan may drive such doctors to remain in districts, where private practice is more available and lucrative, intensifying the regional maldistribution of physicians.

Crumbs for the poor

What of students like Niluka in the non-fee levying state university system? A quick perusal of the website of KDU’s Faculty of Medicine indicates that brain drain may have already commenced. Imagine the fate of our non-fee levying state medical faculties with the mushrooming of ‘MBBS kada’ across the country? They will inevitably offer higher salaries, as does KDU, attracting without any outlay teachers whose training was subsidised by state universities. Furthermore, as reported in the media, KDU has already seen massive state investment, much of it in its teaching hospital, far beyond investments in any single university or faculty of medicine under the UGC. The fate of medical education at non-fee levying state universities does not need to be spelled out here. With their weakening, the demographics of students who enter medicine are sure to change, with fewer and fewer opportunities for students like Niluka, not to mention the broader implications for medical education and the healthcare system.

Let’s stand together to protect Free Education and Free Medical Education!

(The writer is attached to the Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna).