8th August 1999
By Tharuka Dissanaike
It was a dream turned into a nightmare. Most parents' ideal-to see their child become a doctor-ending up in a slogan-shouting, placard-carrying protest against the government. Many of the students and parents who gathered at Tuesday's protest opposite the Ministry of Health were still hopeful. Surely this can't be true. Surely our children will be employed.
But the government, pushed to a corner and forced to look the problem in the eye, pleads a lack of funds to employ all the students who pass out of the country's six medical faculties. "We will not be able to employ all the young interns in state service. They will have to look towards the private sector for employment," said C. Abeygunawardana, secretary to the Health Ministry.
For the students and parents this is like a slap on the face. "Why?" asked B. Suriyaarchchi, former Principal of Royal College, whose daughter is a medical student. "Why were we not given an inkling of this problem five years ago before we encouraged our children to go into medical college?"
"There is a high degree of frustration among medical students," said Dr. Maxi Fernandopulle, a senior paediatrician. "To have no guarantee of employment after five years of rigorous study is a crushing feeling."
But even the private sector employment is too minute to absorb the kind of numbers that are streaming out of medical colleges in the country. Here lies part of the problem. Taking in large numbers of students into universities without any idea of how they can be employed afterwards. It is purely a lack of proper planning and national policy on doctor need and training. It is quite an expensive form of bureaucratic bungling as well. It is estimated to cost Rs. one million to put a student through medical college. An average 950 medical students pass out of the six faculties every year. A further 200-300 come from abroad with foreign medical degrees, looking for employment.
Sri Lanka employs 5600 doctors in the state sector. Unofficial estimates say another 1500 are employed in the private sector, as private practitioners or in hospitals and clinics. But the concentration, almost 80 percent of this membership is in the Western Province, leaving the rest of the country save for a few big cities like Galle, Kandy and Anuradhapura high and dry. The lack of medical care in these areas has led to quacks setting up thriving business. "We think there are about 40,000 quacks practising illegal medicine in the country," Vice President of the Colombo Medical Faculty Students' Union Kelum Wimalarathne said.
The doctor-population ratio of Sri Lanka is much debated and differs widely from source to source. But a simple calculation of the number of doctors in state service as against a population of 18.5 million gives a figure of 1:3300. The actual situation is better because of the private facilities and the wide network of RMP/AMPs. But in developed countries, even Singapore, the figure is around one doctor to 500-800 population.
All this points out to a definite need for more doctors. Forget the statistics, simply walk into any government OPD and witness the chaos. "The Lady Ridgeway Hospital treats 1000 out- patients a day," said Wimalarathne. "But only 3-4 doctors serve them. The service could be improved by adding more doctors. They would only need a few desks and pressure meters."
The students' union say many more doctors can be absorbed into the state health mechanism without drastic changes in the infrastructure.
Dr. Fernandopulle said the government has a duty, if state employment is not viable, to see that these doctors are helped to set up private practice in areas which are not serviced adequately by the present health system. He said the country needs good tertiary care centres for cancer, and neurosurgery. Present base and district hospitals should be enhanced. But this will not happen if doctors are not willing or appointed-to work in distant places.
"There is no dispute about the need for doctors," Abeygunawardana said. But money is the problem.
He said the health budget of 1.4 percent of GDP has stagnated for the last four years. This year the government cut down on drug purchases. "There are hospitals in need of equipment and no money is available. This year's budget promises no increase. We have now agreed to employ the present batch. But we will have to work out their salaries according to the treasury allocation. The decision is almost out of our hands."
"The problem has to be looked at on a national policy level," Abeygunawardana said. It involves two key ministries dealing with human development. The issue is all about the welfare of the population and justifies a high level think tank on the future of these medical graduates. Unless of course the government prefers to ignore the problem until the next batch of interns pass out and take to the streets demanding employment.
The country's medical colleges are severely overcrowded, says Dr. Lucien Jayasuriya, Chairman of the Sri Lanka Medical Association's Committee for Health Management.
"We have been warning of this since 1992. But the University Grants Commission has just kept increasing the intake of medical students. Successive Education Ministers had taken it upon themselves to increase the numbers of medical students due to pressure from parents, without any consideration as to the students future role."
"There has to be a well thought- out policy on where to fit these graduates in. The problem is upon us now. But any solutions have to be compatible with future development of the health sector," he said.
The second concern is that due to the increased numbers, the quality of medical education has decreased. "Lecture rooms, libraries and even toilets are not enough," said Dr. Jayasuriya.
"What is important therefore is to ensure that the medical student intake is controlled so as to ensure they all receive sufficient training," he said. If we continue this trend, Dr. Jayasuriya warns, "There will be doctors driving taxis or becoming medical reps just for employment."
Does the country need more Deputy Ministers or Doctors, asked one placard touted by medical students at Tuesday's noontime rally.
"An intern is given an allowance of Rs. 9000. A new doctor is paid in the region of Rs. 12,000 a month. This means the government's spending on new doctors' salaries is not more than the cost of a few Pajeros," Kelum Wimalarathne said.
"The same government that does not have money to pay doctors, has recently employed so many more Deputy Ministers. We ask the people to decide, do they want more doctors or Ministers?"
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