• Responsibility lies with universities, the UGC, the SLMC, political establishment

It is high time for the universities, the University Grants Commission (UGC), the Sri Lanka Medical Council (SLMC) and the political establishment to take concrete steps to solve the urgent human and physical resources' related issues in new outstation medical faculties.

This recommendation was made in an editorial on "Outstation State medical faculties in Sri Lanka: Nobody’s children when it comes to sustainability!" which was authored by the Editors-in-Chief of the Anuradhapura Medical Journal, A. Silva and K. Weerakoon (both attached to the Rajarata University's Medicine and Allied Sciences Faculty's Parasitology Department), and the Journal's Editorial Board Members J. Pushpakumara (attached to the same Faculty's Family Medicine Department) and S. Paththinige (attached to the same Faculty's Anatomy Department) and published in the said Journal's 17th Volume's Second Issue in July 2023.

On the trend of establishing new outstation Bachelor of Medicine, Bachelor of Surgery (MBBS) degree programmes, an extraordinary gazette issued by the Minister of Higher Education, on 20 March 2023, gave clearance to the Uva Wellassa University to establish a Faculty of Medicine under the Universities Act, and to run a MBBS degree programme. This is the 12th MBBS degree programme in the State university system under the purview of the UGC. These 12 MBBS degree programmes and the one offered by the Faculty of Medicine of the General John Kotelawala Defence University (KDU), which is established under a separate Parliamentary Act, are the MBBS degree programmes delivered by Government institutes. Of the 12 MBBS degree programmes under the purview of the UGC, six have been established over the last 17 years. Five of the recently established MBBS degree programmes are in outstation Universities (Rajarata, Eastern, Wayamba, Sabaragamuwa and Uva Wellassa), and the other is at the University of Moratuwa, located within the Western Province.

The demand for MBBS degrees

The MBBS degree programme is one of the most in demand undergraduate programmes in Sri Lanka, hence the recent wave of outstation Faculties of Medicine has undoubtedly expanded the free education opportunities in the country. Per the UGC's "University statistics 2010, 2019 and 2020", student enrolment in the MBBS degree programmes of the State universities has markedly increased recently, from 1,166 in the 2009 General Certificate of Education Advanced Level (GCE A/L) Examination (high school certificate giving university entrance) intake to 1,494 in the 2018 A/L intake followed by 1,967 in the 2019 A/L intake. The added number of MBBS undergraduates was distributed among all the State universities including the recently established outstation faculties. Of the 2019 A/L intake, 26%, and of the 2020 A/L intake, 28.5%, were enrolled in the five recent outstation MBBS degree programmes. While the establishment of new MBBS degree programmes has progressively shifted medical faculties and their benefits to communities in the peripheries, the matter of contention is whether enough attention has been paid to the sustainability of these programmes in the long run.

The learning related needs of MBBS undergraduates far exceed routine classroom based teaching and learning activities and require comprehensive learning opportunities through community and hospital-based clinical training activities. Further, these different teaching and learning activities should be meaningfully organised within the curriculum to provide early clinical exposure, and horizontal and vertical integration among the different disciplines for the acquisition and continuous enhancement of professional competencies and values expected of a basic doctor. The “Sri Lanka qualifications framework” and the UGC's Quality Assurance Council's "Subject benchmark statement in medicine" provide curriculum-related requirements in the local context, while the extraordinary gazette by the Minister of Health on the “Maintenance of the minimum standards of medical education” on 26 January 2018, presented the curriculum and resource-related requirements of the universities or institutions in the conduct of MBBS degree programmes.

Adhering to global standards

The World Federation for Medical Education's (WFME) "Global standards for quality improvement (Basic medical education)" prescribed standards for human and physical resources, clinical training, and information resources required to conduct medical undergraduate programmes effectively. These local and global standards and guidelines highlight the need for greater physical and human resources within the university system, teaching hospitals, and community health settings resourced enough to provide adequate training, with the involvement of external stakeholders such as specialist doctors, medical officers, other healthcare workers, patients and the community. Moreover, MBBS degree programmes should have the capacity to update the curricula with the rapidly changing trends of medical education, and the evolving healthcare context across the globe. Therefore, establishing a new MBBS degree programme should be a carefully made policy decision based on the inputs of all stakeholders, considering the quality of the programme and its outcomes, sustainability as well as continuous improvement. “Unfortunately, it is not well reflective as to whether such a thought process existed before the implementation of any of the recently established MBBS degree programmes in Sri Lanka,” Silva et al. observe.

The need for an increased healthcare workforce in the country is evident from the recent statistics (such as the high doctor-population ratio). However, it is likely that the establishment of the new MBBS degree programmes at outstation universities is not solely due to this national need, but also compelled by possible political intentions and imposed on the higher education authorities. These new faculties are compelled to develop an educational programme that is manageable with limited resources, recruiting a few staff members to somehow run the MBBS degree programme, and putting up a few buildings with lecture halls and tutorial rooms, and sending the students to surrounding health care settings and the community for training, and transforming a nearby hospital into a professorial unit that may not have adequate resources for comprehensive clinical training. What is more unfortunate is that achieving and maintaining the quality standards set by the national and global authorities have become an uphill task for these new outstation MBBS degree programmes in particular, even before the current drier circumstances in the country unfolded, with the increasing student numbers each year aggravating the problems faced by these faculties.

Challenges and opportunities for outstation faculties

Regarding the human and physical resources-related crisis, the attraction of qualified academics, especially those with medical training, has been a challenge for newly-established and outstation faculties due to many complex reasons such as salary discrepancies, schooling-related opportunities and options for children, and issues in the quality of the outstation living conditions. This greatly increases the workload of the existing staff and the chronically-unfilled cadre of academic departments force the existing staff to be overwhelmed by teaching, quality assurance and administration-related commitments, thereby limiting opportunities for research and professional development. For these enduring reasons, even those who are recruited as probationary lecturers, tend to leave for greener pastures once they are qualified, making these outstation faculties ‘human resource supply centres’ for established medical faculties. The situation has been further aggravated by the current economic crisis, with many qualified academics who have been shouldering the development of these outstation faculties opting to resign and migrate. Recent administrative decisions such as the suspension of new recruitments to universities and the recent changes in the Pay As You Earn Tax policy have further aggravated the staff issues in these faculties. One of the strengths of the new outstation medical faculties has been their teaching hospitals that facilitate robust clinical training for undergraduates with a rich diversity of patients. However, with the current human resource crisis faced by the health sector with many specialists working in outstation tertiary care centres opting to leave the country, these outstation tertiary hospitals are in a constant struggle to run some of their units even with temporary measures such as allocating acting consultants. This causes interruptions and creates inconsistencies in the clinical training, thereby compromising the quality of the MBBS degree programmes.

The lack of adequate funding is a vicious cycle as the funding-related allocation for essential infrastructure and the timely completion of such projects have been a major problem in the entire university system over the last decade. State universities are largely dependent on Government funding with a lesser contribution from self generated funds. There are no equal grounds for the outstation medical faculties compared to the established medical faculties in competing for opportunities to secure funding. The faculties with several degree programmes and a larger number of students receive the bulk of the funding. Outstation medical faculties are not in a position to get more funding by increasing the number of degree programmes or students due to obvious resource-related limitations. Moreover, outstation faculties are in a disadvantaged position in earnings mainly due to their geographical location. Income sources such as payments through students that are enrolled under foreign quotas are primarily directed to the established faculties, due to the inherent disadvantages in the new outstation faculties. Moreover, due to the resource-related limitations, the outstation faculties, which are already struggling to cater to the basic needs, are not in a position to expand or diversify the self-generated funding options. Therefore, these faculties are in a vicious cycle that prevents future earning opportunities and limits Government funding for them.

The selection of students to MBBS programmes must be merit-based, and must not be based on wealth. At the same time, the students who enjoy a quality free education directly sponsored by taxpayers need to be held accountable to serve the public, through a bond-based agreement. However, anyone having prior plans or a change of plans to proceed otherwise can be provided with options to pay for themselves, which can be an optional funding source for medical faculties. This will also alleviate the public impression of the potential misuse of free education by its beneficiaries.

The above issues in the new outstation medical faculties are likely to be aggravated by the current economic crisis in the country, negatively impacting them by several-fold, and widening the gap between the established and new medical faculties. To ensure patient safety and the competence of practising doctors, as well as to gain global recognition, it is crucial to maintain uniformly high standards in medical degree programmes, thus adhering to the recommendations of the WFME. This applies regardless of whether the programmes are held in outstation or central locations. However, maintaining such standards can be a daunting task, especially considering the challenges in obtaining sufficient human and physical resources for outstation faculties. Nonetheless, it remains essential to keep up with the WFME recommendations in order to guarantee the safety and quality of patient care and to establish a globally-recognised medical education system.