Doctors were accepted as noble practitioners

Kusal Perera.                                                                      

Recent media reports say the GMOA has decided to keep away from private practice and channelling for 02 weeks from 30 March. Available numbers in past years show the month of April as a lean month for both private and public healthcare. Probably the habit of seeking medical treatment even for the common cold is overtaken by the festive mood, especially in the first two weeks up to Sinhala and Hindu New Year. The GMOA has thus chosen that lean period for their protest while proving they were desperate now.

Not surprisingly, they don’t say they would stop private practice altogether on principle. That they would never say. In fact their slogan of “free” education with no private sector medical faculties is to continue monopolising the lucrative private medical sector and not strengthen “Free” health in any way.

Sri Lanka’s proud achievement in life quality was gained through national health programmes carried within “free health”. What we have gained on the mortality rate, life expectancy at birth, infant mortality rate, live births, eradication of Malaria, Poliomyelitis, etc. were on the strength of the network of trained field staff. Public Health Inspectors, Medical Officers of Health, Family Health Officers (previously known as mid wives) and also Apothecaries (RMPs) who were posted to outpatient dispensaries in rural areas played vital roles in making life healthy and above average. National “free” education played a catalytic role. This very effective healthcare system with emphasis on preventive community health evolved after the State Council was established under colonial rule and was strengthened and expanded post independence, during the first decade.

In these early post independent period, government medical doctors were accepted as noble practitioners, with private practice (PP) being more a personal pasttime than another income source. In mid 60’s with more government doctors taking to PP, then government banned PP to ensure government hospitals remained the main curative health service provider. Private medical practitioners were no doubt there outside the government service, a few in mostly urban areas, where the middle class preferred to have a “family doctor”.

The open market economy after 1977 once again allowed PP. Free market economy cultivated new “choices and needs” within a growing middle class. It led not only to private clinics that mushroomed in city kerbs, but also in remote villages too. There was no effective regulatory mechanism to keep a tab on PP and “channel” practice that emerged.

Growth and expansion of private medical practice during the next decade did not mean, government medical professionals left the service for private employment. Instead, they spent more time in private practice and channel service to earn more and more for a fast and fastidious life. This also changed attitudes and priorities of the medical profession. As observed in the working paper ‘An inquiry into the regulation of pharmaceuticals and medical practice in Sri Lanka’ co-authored by Nimal Attanayake and Laxman Siyambalagoda, “….the opening up of the economy along with the rapid expansion of private practise resulted in a new behaviour pattern among medical practitioners. Initially, a hidden effort seems to have existed amongst professional bodies to safeguard their members from allegations.” (HEFP working paper 05-03, LSHTM, 2003 / page 16)

That cannot be contested and it is no more a ‘hidden effort’. It is worth asking the SLMC, how many complaints on medical negligence and unethical practices they receive annually and how many were found guilty. There cannot be  any in this set up, with investigators, witnesses defending the accused and the accused, all being medical professionals who “safeguard their members from allegations”.

Another quote from page 10 says, “….the extensive competition emerging in the medical market, particularly due to the escalation of private practice, gradually changed the attitudes as well as behaviour of public medical doctors who were engaged in private practice. The medical profession is now moving sharply towards a pure profit oriented venture by neglecting its ethical considerations.” (emphasis added)

Who are these “public medical doctors”, after all? Pubic medical doctors are all government employees. Employed by the Health Department, they are paid and maintained by taxpayers’ money. Their salaries, their allowances from DAT to telephone to travel, scrounged from successive governments holding patients’ lives to ransom, their 120 hour personally calculated overtime, their duty free vehicle permits, their children’s education with exclusive rights to very popular, privileged government schools are all borne by the Citizens of this country who contribute 80% indirect and 20% direct taxes. Before that, these doctors are educated from Grade 1 to the MBBS Final examination with taxpayers’ money, the GMOA says is “free” education. Thus people have paid for 13 years of their formal education and 05 years of medical college education and thereafter they are also paid and sustained with undue privileges and perks from people’s money as government doctors. Do they have any moral right to charge these very people for medical care after all what the people have done for them?

Medical doctors should be morally, economically and duty bound to first serve the people free and safeguard “free health”. Yet that is no more their calling and not their preference either. Increased involvement of government medical doctors in the private medical service turned the early channel and private practice into a huge private medical industry in just 20 years. Private hospitals increased from 66 in 1990 to 125 in 2011 and they keep growing and spreading. They now have modern laboratories equipped with state of the art facilities and they train their own nurses. But they are yet unable to turn out medical professionals of their own due to government restrictions pressured by GMOA.

In 2011, according to numbers given by the “Private Health Sector Review 2012” (revised in August 2015), only 424 medical doctors were employed full time in private hospitals while 4,845 “worked part-time”. These part-time medical doctors no doubt are all government medical doctors. That same year there had been 266,000 admissions the private hospitals wouldn’t have ever coped with their 424 doctors. That makes government medical doctors who “worked part-time” in private hospitals almost indispensable.

For that sole reason, “The biggest risk faced by the private hospitals is the shortage of trained medical practitioners. Most specialist consultants are with the public sector….” says Fitch Ratingsof September, 2015.

These private hospitals, now service 27% of hospital services. They are very much concentrated in and around Colombo, with expansions to Gampaha, Kandy and Matara according to ‘Fitch Ratings’. Of all available private hospital beds, Western Province accounted for 65% and also 88% of all private sector revenue says, Private Health Sector Review – 2012.

This is how SAITM becomes a threat to the GMOA. Private hospitals need permanent medical doctors to serve them and there is potential for growth if they can employ full time doctors. If SAITM is allowed to produce medical doctors it would then become a precedent with other major players also establishing their own medical colleges. That would then provide the private medical health sector with medical professionals available full time.That would make government medical doctors qualifying fromState universities unimportant inthe private medical sector.

For that sole reason GMOA would not allow the private sector to produce medical doctors. That depends on government policy.The GMOA for over 02 decades has forcibly entrenched itself in the health administration in influencing government policy. Now it is no easy task for any Health Minister to decide independently of the GMOA. It is this unholy strength within the administration and not so much the strength of its membership that still holds the health ministry from taking a straight, clean decision on SAITM.

This stranglehold on health administration has also allowed government medical doctors to hang around in hospitals in and around Colombo and its periphery where private business is most lucrative. This is an anomaly highlighted by Fitch Ratings. It says, “Furthermore, physician distribution is highly skewed towards the Colombo district, while 73% of the population is faced with a physician density much below the national average…..”

It is for all these reasons the GMOA wants a hold in medical administration and Free Education given total monopoly in producing medical doctors. They don’t want to leave government service as that denies them the strong hand they now have in policy making. They don’t want the government to change policy to accommodate private medical faculties as that would provide private hospitals with permanent medical professionals.

If private hospitals can have their lot of medical doctors, government doctors become nonentities in the lucrative private health sector.They would therefore go to any length in keeping their hold on policy making and selfishly denying permission for private medical colleges.

This medical mafia can only be challenged by the people. People have a right to do so and tell them “public policy” is what’s best for the people. A call to ensure public interest on it is quite easy. “People fund their education. People pay their salaries. People have a right to supervise their service”. It is therefore time now to organise “People’s District Supervisory Committees” with the RTI Act in hand, to keep check on daily attendance of medical doctors, their availability in hospitals and other related issues. It is time now to organise a referendum in government hospitals to ask patients if they want their doctor to do PP and channelling. It is people’s intervention that could stop medical professionals turning butchers of “Free Health” under cover of “free education”. (Daily Mirror)

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