Sunday Times 2
Medical education in Sri Lanka: The way forward
View(s):- An evidence-based critical analysis
By Prof. Mohan de Silva
This article is a critical analysis of the current landscape of medical education in Sri Lanka—key strengths, weaknesses, opportunities, and threats (SWOT)—and examines the growing imbalance between the availability and demand for medical education.
The article evaluates the impact of private medical education and regulatory and quality assurance frameworks and analyses the need for aligning with the present global reality that no country trains doctors exclusively for employment in the state sector hospitals.
It highlights the need for a clear-cut policy directive with regard to private medical education to align with national healthcare needs and global trends: a new paradigm to compete for transnational medical education.
Understanding the evolution of medical education in Sri Lanka is useful for such an analysis.
Sri Lanka’s medical colleges enroll a percentage of foreign students on a fee-paying basis—but deny Sri Lankan students the opportunity to do the same.
District Quota System: Current relevance
Sri Lanka has long provided free medical education. To address the disparities in education prevailing between different districts, district quotas were introduced in 1972.
According to the district quotas, 40 per cent of seats are allocated on All Island Merit, 55 per cent are on districts based on the population of the district, and a further 5 per cent are allocated to 16 districts identified as ‘educationally disadvantaged’ districts.
Today, the education standards in all districts have improved. Tuition opportunities are available in all districts. Online tuition is conducted by local and even foreign teachers from the USA, the UK, and Canada, diminishing the original rationale for the rule. As a result of the quota system, presently, some students with superior results are denied admission over students with lower scores because geographical allocation is still given priority over merit, undermining fairness and meritocracy.
No data is available to justify this policy, and the District Quota System has not been revised for more than five decades.
Z-score and admission criteria
Current admission to state medical schools is based on the Z-score—a statistical formula using marks in Chemistry, Physics, and Biology. The Z-score was introduced to improve the fairness of selection. For example, if the average results for a physics paper for that year are poor, a good score for physics will increase that student’s Z score. However, selection to medicine is from three subjects, and the Z-score will not have a major impact on other students who have not done well in different districts. The Z-score is extremely useful for entry to arts or commerce degree programmes where different subject combinations can be used. So if a student has obtained good marks by selecting three ‘easy to score’ subjects, the Z-score will ‘standardise’ the results to be fair to students who have done ‘not so easy’ subjects.
Based on the Z score, the University Grants Commission releases ‘District Cut-off’ using the 40%, 55%, 5% formula to allocate seats for districts.
For the 2024 intake, the lowest cut-off used to enter a state medical school was 1.476.
There were 72 candidates who could not enter a state medical school, though their Z-scores were higher than 1.476.
Inconsistency in regulations
London A/L results of local students are not considered for entry. However, foreign students with London AL are eligible for a number up to 5% of the annual intake for a state medical school.
In 2024, 29 fee-paying foreign students were admitted to state medical schools, each paying USD 12,500 annually. These students receive training using patients in state hospitals.
It is ironic that foreign students are allowed to obtain medical education for a fee in Sri Lanka while it is denied for
Sri Lankan students.
Furthermore, while London AL is considered for foreign applicants, a local
Sri Lankan student with excellent results, 3 A Stars in London AL, is not considered as a fee-paying student at a state medical school.
It is also ironic that qualified students who fail to obtain a place for medicine must go abroad for medicine while private education is available for all other professional degree programmes, such as engineering, law, and accountancy, on a fee-paying basis.
Mismatch between capacity and demand
UGC data for 2024 reveal that only 7.4% of qualified applicants were admitted to state medical schools, leaving 92.6% with no opportunity.
This highlights the significant gap between the availability and demand and the urgent need to expand medical education in Sri Lanka.
Medical school capacity and policy limitations
Sri Lanka operates 12 state medical schools. Four were established during the past eight years. In the last intake (2024), 2,049 students obtained entry to state medical schools. The government has no plans to increase medical schools in the foreseeable future.
However, as pointed out, foreign students are allowed entry to state medical schools on a fee-paying basis and use state hospitals and Sri Lankan patients for their clinical training, but local students are denied.
It is difficult to comprehend the protests by some state medical students against establishing regulated private medical schools for local students deprived of admission to a state medical school when paid education is given to foreign students in the same medical school.
Global trends in medical education
Most countries restrict access to free medical education due to financial constraints. Even socialist countries like China, Cuba and Vietnam compete for transnational medical education by establishing regulated private medical schools.
Sri Lanka has no private medical schools and has no active strategy to establish them.
Furthermore, the country does not seek service from those who benefit from free medical education, a policy that was discontinued in 1979. The introduction of the Compulsory Public Service (Amendment) Act No. 11 of 1979 removed the mandatory service obligations for doctors.
Therefore, unlike in many other countries, a doctor who enjoyed free medical education in Sri Lanka can leave the country the day after receiving full registration from the SLMC. The same applies to medical specialists.
Consequences of policy gaps
Many local students with excellent London AL results are made ineligible for entry. They are Sri Lankan citizens, often from international schools.
Historically, international schools served the affluent society. However, today most students are in the ‘international schools’ not by choice but by necessity due to the unavailability of places in urban government schools. They are Sri Lankan citizens with legitimate expectations.
Meanwhile, foreign students with similar qualifications are accepted for a fee. This inconsistency forces local students to leave abroad. Their parents have to pay for their medical training in US dollars. Hard-earned foreign exchange from foreign remittances are flown out to other countries. Parents often lose their children to foreign countries, and Sri Lanka loses intelligent citizens. It is also interesting to note that these students left Sri Lanka after obtaining approval from the SLMC to study in foreign private medical schools.
In 2023/2024, nearly 800 to 1000 students sat for the ERPM examination conducted by the SLMC to obtain registration. SLMC conducts two examinations a year.
This data reflect the growing demand for medical education and the substantial foreign exchange loss. These students pursue foreign medical education not by choice but due to the absence of private medical schools in Sri Lanka.
Brain drain and workforce attrition issue: solutions
Access to medical education is a fundamental right of any citizen. Restrictive policies infringe on this right and contribute to the emigration of professionals.
Many Sri Lankan professionals, particularly doctors, emigrate for better educational opportunities for children. Expanding access to quality medical education within Sri Lanka could reduce the brain drain, retain skilled professionals, and help stabilise the healthcare workforce.
Establishing regulated private medical schools could reverse this trend and redirect transnational education towards
Sri Lanka, which is globally renowned as a popular tourist destination.
Neighbouring countries India, Pakistan, Bangladesh, Malaysia, Thailand, Singapore, and Nepal have well-established private medical schools to meet local demand and to attract international students. Lack of such a policy places Sri Lanka at a competitive disadvantage in the region. These regional countries attract Sri Lankan students, resulting in significant foreign exchange loss. Developing local private medical education could retain these students and dollar outflow.
Sri Lanka is the only country in the region that has no private medical school.
In the 2024 budget speech, India’s Finance Minister Nirmala Sitharaman outlined a plan to train 75,000 doctors over the next decade to work abroad to generate foreign income. Sri Lanka could adopt a similar strategy to boost our economy.
Attrition of doctors
Many doctors leave Sri Lanka after completing their state-funded education. Claims that Sri Lanka will soon face a surplus of doctors are unfounded, as medical graduates and medical specialists are needed to serve not only state hospitals but also the private sector, academia, and international markets. An accredited medical degree is a valued degree with global employment opportunities. Expanding medical education would align with these diverse employment opportunities. This supports the case for increasing capacity for medical training in Sri Lanka.
There is a lack of comprehensive data on the attrition rates of doctors and their professional trajectories, particularly those trained through free state education. Such data are critical for understanding and addressing the brain drain in the medical sector.
Delivering a keynote address at the recently held World Health Forum in Switzerland, the health minister emphasised doctors’ brain drain, underscoring the need for expanded medical education to meet both local and global demand for healthcare professionals and future use of healthcare professionals to earn foreign exchange.
Transnational education in Sri Lanka: Operational and Quality Assurance Landscape report; British Council 2024 reveals that, of the countries sending students to the UK for higher education,
Sri Lanka is ranked second only to China with a 1.3 billion population. This fact highlights the stark discrepancy between the availability and demand for higher education in Sri Lanka.
Due to economic challenges, a growing number of young doctors prioritise international registration exams, such as the UK’s PLAB, the US’s ECFMG, and Australian exams, over Sri Lanka’s PGIM exams, indicating a trend towards emigration. Countries like Australia and Denmark offer visas to Sri Lankan doctors to serve in remote regions, facilitating emigration.
Kotelawala Defence University
The abrupt halt in local student admissions to Kotelawala Defence University (KDU), a state-funded medical school operating below capacity, is counterproductive. Reinstating admissions and utilising its resources will meet demand and optimise investment.
Quality assurance and accreditation systems
Historically, the Sri Lankan Medical Council (SLMC) was responsible for the registration of medical degrees. In line with global trends, two major developments took place in SLMC.
First was the publication of Gazette Extraordinary No. 2055/54 – 26th Jan 2018, cited as the Medical (Maintenance of Minimum Standards for Medical Education) Regulations No. 01 of 2018, a comprehensive set of regulations applicable to both state and private medical schools.
Such a legal regulation was not available when establishing SITAM medical school.
Second was the establishment of a new unit within SLMC: Accreditation Unit of Sri Lanka Medical Council (AU-SLMC) in 2023 when SLMC obtained recognition from the World Federation for Medical Education (WFME). WFME is an affiliate of WHO, a global organisation for certification of quality assurance and accreditation for medical education. Any new state or private medical school in Sri Lanka needs to be established under the supervision of AU-SLMC.
The other regulatory body to obtain approval to award medical degree programmes is the Ministry of Education. Under Section 25A of the Universities Act No. 16 of 1978, the Minister of Higher Education is cited as the Degree Awarding Authority, and the Higher Education Ministry Secretary is cited as the Specified Authority. Establishing a new state medical school is done under the supervision of the University Grants Commission. For private medical schools, the responsible authority is the Ministry of Higher Education and not the UGC.
For this purpose, the Ministry of Higher Education (MOHE) has a specialised unit, the Standing Committee for Accreditation and Quality Assurance (SCAQA). After completion of a successful programme review by SCAQA, the ‘specified authority’ shall recommend to the Minister of Higher Education, ‘the Degree Awarding Authority’, to publish the Gazette granting permission to award MBBS degrees.
The way forward
To address the discrepancy between the availability and demand, two well-established local regulatory systems—the SLMC’s Accreditation Unit (AU-SLMC) and the Higher Education Ministry’s Standing Committee on Accreditation and Quality Assurance (SCAQA) and SLMC Gazette No. 2055/54—are now available to develop accredited private medical schools.
No country trains doctors exclusively for state hospital employment. Sri Lanka should align its medical education policies with this global reality by opening medical training.
Implementing a policy to establish private medical education, while maintaining strict quality standards, will redirect transnational medical education towards Sri Lanka.
Sri Lanka possesses ample high-quality, locally and globally recognised medical academics and clinicians to support such initiatives without compromising the academic human resources of state medical schools.
(Prof. Mohan de Silva MBBS, MS, FRCS Edin, FCSSL, is a renowned Consultant Surgeon, former Chairman of the University Grants Commission, Sri Lanka, former dean of the faculty of Medical Sciences, University of Sri Jayewardenepura, and former president of the College of Surgeons of Sri Lanka. He can be contacted via email at thathya.ds@gmail.com.)