While the private health sector is battling for foreign consultants, the State health sector is faced with a serious dearth of specialists The contentious battle between the private medical sector and the Sri Lanka Medical Council (SLMC) over temporary registration of foreign medical consultants, recently reached the Supreme Court. Foreign doctors who come to Sri [...]


Endemic Catch-22 within local health sector

The country faces a dearth of specialists due to lack of training, funds and facilities, while foreign consultants come under SLMC’s microscope.

While the private health sector is battling for foreign consultants, the State health sector is faced with a serious dearth of specialists

The contentious battle between the private medical sector and the Sri Lanka Medical Council (SLMC) over temporary registration of foreign medical consultants, recently reached the Supreme Court.

Foreign doctors who come to Sri Lanka for various reasons such as health camps, medical faculties, NGO arrangements, to serve in the post-war North, and over the last decade as foreign consultants (mainly from India) in private hospitals, are permitted by the SLMC to work up to 12 months under Section 67A of the Medical Ordinance. The problem arose when the SLMC began reducing the hitherto one-year foreign consultant contracts to a couple of months.

Shorter registration periods are disrupting the services offered at private hospitals, Navaloka Hospital Director and Association of Private Hospitals and Nursing Homes President-elect Dr. Lal Chandrasena said.

“Who will come for three months?” he asked. “They are professionals who have jobs there, with school-going children, maybe. Good consultants won’t leave their jobs and training for three months.”

“Private hospitals recruit foreign consultants because State doctors are not available from 8 a.m to 4 p.m,” said Dr. Chandrasena. Certain patients, especially postoperative, need 24-hour care.

“For example, a cardiac surgeon must be available all day after an operation. We cannot expect a specialist who has worked all day in a State hospital, reporting for private practice and answering an emergency call at 2 a.m. Nobody can work like that. Being responsible for the patient is our primary concern, if the doctor is away.”

According to Private Hospital Association statistics, 70% of patients at private hospitals are under the care of in-house foreign consultants. Dr. Chandrasena said that consultants are recruited under Board of Investment regulations that vacancies can be advertised overseas only after they are locally advertised.

Patients waiting their turn at a clinic. File picture


SLMC Registrar Dr. N.J. Nonis said the shorter contracts were prompted when the Council found that some applicants didn’t have enough qualifications and training compared with the local qualification standards.

“It’s our responsibility to ensure that those who come are fully qualified,” Dr. Nonis said. “In one instance, a person with only a diploma in nephrology was passing as a specialist nephrologist. Even in India, a specialist holds a MD. People who come here are those who cannot get a job in India or another country. That’s why specialists need proper procedure for assessment. Even for local specialists we’ve begun a registry for public information if someone claims to be a specialist.”

“Some foreign consultants are not Board-certified, but pretend to be anyway,” Government Medical Officers’ Association (GMOA) Vice President Dr Saman Vadanambi said. “Out of the recent applications, only one or two had worked as consultants before, and others have been practising here for years without full certification, and claim the years make them qualified,” he said.

“We don’t oppose anyone to come here, as long as they meet our standards,” Dr. Vadanambi added. “Previously, the SLMC used to give automatic extensions without evaluation. If a local citizen cannot work without the eight years of training, following the MBBS, how can a foreigner? This mainly affects the patients. We also suffer because we depend on private practice.”

Ministry of Health (MoH) Private Medical Institutions Development Unit Director Dr. Kanthi Ariyaratne said the Ministry supports the private sector but would not minimise standards.
“The MoH will not, in any case, stop private hospitals hiring foreign consultants,” she said. “MoH supports private sector development and providing quality service to patients.”

Dr. Chandrasena said that, “Despite allegations, they hire the best people, adding that the scarcity of specialists in Sri Lanka has also compelled the private sector to hire foreigners, specifically for sub-specialities like radiology and in vitro fertilization.

“Take cardiothoracic surgeons,” he said. “There are few of them and they have their hands full in general hospitals. There’s a huge backlog of poor people waiting, and some even die waiting. Until Sri Lanka is proficient, we need to get foreign specialists. We have to accommodate our patients, unlike for thousands of people waiting to see government doctors.”

Dr. Nonis said, “Even if local doctors are available, private hospitals discontinue their services and give preference to foreign consultants. Dr. Vadanambi said there are enough doctors but private hospitals have a “hidden agenda.”

“They drain patients by sending them to specialist after specialist, test after test; these are unethical practices,” Dr. Vadanambi said.

The root of the problem 

There is a serious deficiency of consultants in the sub-specialist fields in Sri Lanka, that leave many patients without specialist care or getting referred to the private sector. Doctors claim the problem is caused by insufficient training, while Ministry officials claim that doctors refuse to opt for sub-specialities that are in demand.

Some doctors are pointing fingers at the Postgraduate Institute of Medicine (PGIM) for not producing sufficient specialists to meet patient demands, since its inception 30 years ago.

“The PGIM doesn’t train enough doctors to meet cadre requirement,” a doctor in training at the PGIM said. “Even if doctors pass, cadres haven’t been revised.”

According to cadre projections for 2015 (prepared in 2009) acquired by the Sunday Times, compared with the PGIM’s trainee statistics, the country will not have enough specialists for most medical specialities.

Neuro-surgery has 31 projected cadres for 2015, six practising Neurosurgeons as of 2009, but the PGIM has only trained 15 Neurosurgeons since 1992. Cardiothoracic surgery has 26 cadres, nine practising in 2009, but only three were trained since that year to 2011. Medical microbiology has 40 cadres, 16 practising in 2009, and only nine trained from 2009 to 2011. Paediatric Intensive Care has three cadres, no practitioners and only one specialist trained in 2010. Paediatric Neonatology, Haemato-oncology, Paediatric-oncology, Child Psychiatry, Forensic Psychiatry, Addiction Psychiatry, Sports Medicine and “other” Radiology have a number of cadres, no current specialists and none trained since 1980.

The Health Ministry has new cadre projections for 2020, but failed to disclose the statistics to the media after ample time to do so, even after the Sunday Times got Ministry Secretary Nihal Jayathilaka’s approval.

The PGIM’s Board of Management Chairman Dr. Lucian Jayasooriya said it’s the Ministry’s responsibility to train sufficient doctors.

“Even if our Board of Study says we can train 20, we have to go by how many doctors the Ministry approves for training and which fields the doctors choose,” he said.

Before they begin fulfilling cadre requirements, The PGIM is in need of new buildings and instructors. The institute has no instructors at the moment, and three are pending approval, Dr. Jayasooriya said.

“We need training centres,” PGIM Director Dr. Jayantha Jayawardana said. “For example, an eye surgeon won’t come here to train without a proper eye hospital or ward for training. We need specialists and examiners. If the PGIM was improved, we won’t have this problem in the country.”

Dr. Jayawardana added that some sub-specialities don’t have sufficient doctors because many doctors don’t choose that specialisation.”

“There aren’t many cardiothoracic surgeons because doctors prefer to be cardiologists, where there’s a good private practice,” he said.

Far from fulfilling the Ministry cadres, the PGIM does not even consider the private sector cadres, leaving many graduate specialists clueless about private sector job prospects, a PGIM graduate said.
“As far as we are aware, the PGIM does not take requirements from the private sector into consideration,” Dr. Chandrasena said. “We wonder whether even the government requirements are fulfilled by this programme. This really contributes to the shortage of consultants in the private sector, thus forcing us to recruit foreign consultants.”

Advisor to the Health Minister and former Education Training and Research Deputy Director General, Dr. Upali Indrasiri said it’s untrue, if anyone says the PGIM has failed to train specialists, as the institute has gradually trained doctors over the past 30 years, adding that, that PGIM being free of charge, contributes to its limited ability to expand.

“Due to limitations, the Government cannot sponsor everyone,” Dr. Indrasiri said. “To fulfill the national requirement and not just the Ministry requirement, we need private sector people to pay and enroll. Now we’ve allowed few private sector people to train.”

Paralleling insufficient training, lack of infrastructure is keeping specialist numbers at a minimum in the country. Doctors have to choose specialties that have Ministry cadres. For example, doctors are reluctant to choose cardiothoracic surgery as a speciality, because there are only a handful of operating theatres available, and cadres are issued according to availability, even if patient demand is high.

“The Government can’t increase cadres for eye surgeons, ENT surgeons, cardiothoracic and similar highly-specialised fields, because there are no facilities and infrastructure,” a doctor said. “Some ENTs in outstations don’t even have the equipment to check ears.”

The situation is worse in distant areas such as the North-Central Province, as most medical centres with facilities are concentrated in Colombo, Kandy and Galle. Certain doctors, when informed of an outstation appointment, opt to work abroad instead.

“A neuro-surgeon was appointed to Anuradhapura which had no facilities, so he had to transfer the patients to Colombo for treatment,” Dr. Nonis said. “Also, when surgeons don’t operate, they lose their skill. It’s an extremely costly affair to develop facilities,” Dr. Indrasiri said.

“People always say, why can’t you train people, why can’t you put up a building, but it’s not as simple as that,” he added. “Over the years, the Ministry has upgraded hospitals. Developing facilities and training has to happen simultaneously. An immediate goal would be to have qualified foreign consultants come work here,” he said.

Doctors claim the Government has not allocated funds for training and facilities in proportion to population growth, while cadre approval is subject to Treasury allocations for those professions.
“Then again, you can’t blame the Government entirely, as it spends so much money on healthcare already,” Dr. Vadanambi said. “This is a global development issue, if the country develops, these problems would improve.”

Health Minister Maithripala Sirisena and Health Ministry Secretary Nihal Jayathilaka were not available for comment.

PGIM and the Emergency Medicine catastrophe 
In Sri Lanka, Preliminary Care Units (PCUs) function as mini-Emergency Rooms, but there are no Critical Care specialists, called Intensivists, unlike in many other South Asian countries, including Bangladesh. The Postgraduate Institute for Medicine (PGIM) began a diploma in Critical Care, but the University Senate-approved MD programme was unexpectedly postponed, with the institute accused of deliberately hindering specialist training for emergency medicine.“This happened because, in Intensive Care Units (ICUs), anaesthetics who are in charge now, don’t like specialist physicians coming in,” a doctor waiting for Intensivist training said. “Specialists get appointments in Colombo and closer hospitals. It’s a kind of professional jealousy.”

Health Minister Advisor Dr. Upali Indrasiri said that, when it comes to Emergency Medicine, authorities should also consider political issues.

“When there’s a new speciality, there are people watching, wondering how it is going to affect their profession,” he said. “It should be anticipated. Anaesthetics are trained to look after PCUs. When a new Critical Care speciality comes in, where do they to fit in? Whatever we do, we cannot have consultants adversely affecting someone else’s career. The PGIM has to work with the Ministry, to see where Emergency Medicine will work within the system.”

Emergency Medicine is not the only programme to put the PGIM in hot water recently. Students in the Medical Administration MD are in courts fighting the PGIM for unexpectedly changing the curriculum midway.

“Also, the MSc in Medical Informatics and Diploma in Psychiatry stopped this year,” a PGIM student said. “Clinical Nutrition was postponed. Sports Medicine specialists have 10 positions for 2015, but no MD training.”

PGIM Director Dr. Jayantha Jayawardena was not available to specifically comment on this issue.

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