Do we have a healthy doctor-patient ratio?

An Internet search on a website called ‘bigthink.com’ gives a patient per doctor map of the world, where the topmost country listed is Cuba, with a ratio of 170 patients per doctor. Belarus and Belgium come a close second with 220, while Greece and Russia are at 230.  

Georgia, Italy, Turkmenistan and Ukraine follow closely with a ratio of 240, while Germany, Hungary, South Korea and Spain are at 300 patients per doctor. The US is at 390 and Australia 400, the UK 440 and Qatar 450; Canada and North Korea are at 470 and 650, respectively.

The worst is Malawi and Tanzania with ratios of 50,000 patients per doctor. Sri Lanka, whilst nowhere close to the worst figure, has a ratio of 1800, the same as Honduras and the Philippines.

This writer cannot vouch for these figures but the Central Bank annual report 2016, ‘State of the Economy’, records that the number of patients per doctor in the government sector was 1079 in 2015 and 1036 in 2016.  Of course, these are statistics obtained from figures in the government sector, which obviously would be reliable. Therefore, the figure 1800 is probably accurate as the number of patients seen by the doctors in private hospitals is not properly recorded, as this remains a rather grey market, if not a very black one.

It is a known fact that patients pay cash only at many private medical practices and so saying, this writer does not mean only the main hospitals but every nook and cranny of suburban and rural areas, which are overrun with government doctors running private practices, most of which are well below the radar. 

Healthcare has become a big business around the world and Sri Lanka is no exception. It is a worthwhile fight to keep exclusivity as a priority, when one is defending one’s turf and that is what doctors, medical students and parents of medical students of the government sector are doing these days, when protesting against the government moves to have paid medical universities.

One probably cannot blame them, as the medical profession is no longer a hallowed vocation but a business – a trade and other methods to be used to see that proper demand and supply structures are maintained at all costs, to ensure that pricing stays at desired levels. The latest issue with the South Asian Institute of Technology and Medicine (SAITM), private medical education, doctors and state medical students agitating has more to it than meets the eye.

While one could look at the obvious and say that the government doctors don’t want an oversupply of medical practitioners in the market, which will obviously affect demand, there are other sinister motives at work.

Pre-medicine classes 

Although the aggressive move by the state faculty medical students to throw a spanner in the works of private medical education may on the surface appear quite chivalrous; there is another side to this entirely.

We are generally given the view that these activist doctors are fighting for the standards of medical education and the need to have ‘good’ doctors on the hospital beat but there are other hidden agendas at play here. These protests may well be an attempt to control certain aspects of medical education in the form of tuition. What is not known to the outside world is that there is a huge private education industry lurking in the twilight zone, invisible and promoted by word of mouth and through under-the-radar web pages. In fact, the next batch of medical students is being lured into what is called pre-medicine classes by a whole host of medical and non-medical practitioners.

Even though most of the reputed individuals who conduct these ‘pre-medicine’ classes at well-known private institutes are government registered doctors, it’s not hard to find hundreds of advertisements for pre-medicine classes hosted online, some handled by doctors, some by pre-interns and many by medical students still studying in universities. 

However, some of them are not qualified or authorised to conduct such classes that they claim cover the first year curriculum of local medical faculties and therefore a necessary step.

Institutes and individuals conduct these classes in areas such as Nugegoda, Gampaha, Kurunegala, Kandy and Ratnapura. Most students are made aware of these institutions or individuals giving premed lessons at different costs through word of mouth or certain websites they frequent.   

More often than not, these lessons are conveniently held at the homes of students who sign up for them, which explains why the word doesn’t get out much about their whereabouts. News of these private lessons are meticulously circulated via social media (WhatsApp and Facebook), amongst close groups of science students who have just got their GCE AL results and hopeful of attending state medical faculties.

In such cases, even the student is unaware of how the news actually originated and at which point, he or she was singled out from the rest of the batch. Tuition websites and sites that promote buy and sell can be cited for their abundance of such advertisements, which appear something like this:

“Conducted by medical student. Rs.2000 for three hours”

“Conducted by a medical student from Faculty of Medicine, Ragama. Lessons with PowerPoint presentations and PDF files of all the standard books for free. Anatomy dissection pictures will be supplied. Practicals and MCQ discussion. Rs.1000 per hour”

“By a medical student from Faculty of Medicine, Colombo. For whom have got qualified for medical faculties. Special tips and tricks to catch the system of learning” 
“An intelligent medical student with 3.9 GPA conducts pre-medicine classes in Kandy. Group classes Rs.2000, individual Rs.3000 monthly”

Doctors’ hidden agendas 

This whole hoo-ha about private medical education is stacked with agenda and is the remnant strain of a bygone era, where state and socialism wanted control over our daily lives. Not that there’s anything wrong with socialism but it cannot claim to have the absolute formula.

Socialism has to learn to live side by side with other formulas in the same manner we brand Sri Lanka - as a Democratic Socialist Republic. Democratic socialism is a political ideology that advocates political democracy, alongside social ownership of the means of production with an emphasis on self-management or democratic management of economic institutions within a market socialist or decentralized socialist planned economy.

Yes, that is a mouthful but what it boils down to is that socialism, democracy and market forces have to act together for the success of a nation and this is the reality everybody has to live with. It would be good to remind these doctors and medical students that as doctors in government hospitals, they are allowed to do private practice.

This is because the market forces permit it and as for medical students, they are permitted to run unmonitored tuition classes without any proper standards, while in the same breadth protesting that there has to be standards for private medical education. This, to some, may seem unfair but that is democracy for you.  

However, all of these protesters need to understand that a republic is a state in which people elect their representatives. Therefore, a small section of its public cannot hold the rest of the state hostage, without considering the greater good of the entire nation.  

Meanwhile, there is the question, do we need more doctors? Is the 1800 to one ratio a good figure to have?  By reducing that ratio, would we be able to manage the health indexes of the country better? And the big question – can the state afford to produce more doctors under a free education system or do we need some help from outside?  

(Michael Soris can be contacted at [email protected])