Private Medical Schools: An Educationist's Perspective

[The text of the Inaugural Lecture of the Forum for Sri Lankan Medical Educationists, delivered on 9 January 2012, at the Postgraduate Institute of Medicine]

The opening of a private medical school in Sri Lanka has created a great deal of interest and anxiety in the medical profession. Such a reaction is coloured by an earlier experience, but it is important to realise that there are several types of private medical schools in the world. The useful discussion of this topic is often hampered by misunderstanding and emotion. As I have been associated with medical education in Sri Lanka for over half a century, and have it very much at heart, I attempt here to take an unbiased look at the issues from an educational, rather than an emotional or political, perspective.

Stated simply, a private medical school is one funded by a private party, while a public medical school is aided by government funding. The distinction is not that simple, however, as there are some private institutions, such as in the US, which are partly funded by the government.

It is neither correct, nor desirable, to state that private medical schools are entirely free of government influence, as government-appointed bodies do and should have some control on the standard of education imparted at all schools. Nevertheless some private medical schools are totally autonomous. Private medical schools may be profit-generating or non-profit oriented, the latter usually targeted to a particular social group.

Private medical schools are not a new phenomenon. Medical education has been in private hands for a long time, particular in the US, as in Harvard (1782) and Johns Hopkins (1894). At the turn of the 19th century they increased at such a rate that grave concerns were held for the standards of medical education in North America. At that time Abraham Flexner classified medical schools into

1. the clinical type, native to France and Great Britain, where students learnt both basic and clinical sciences in an apprenticeship system;

2. the university type, where the medical school was part of a university and was taught the basic sciences by specialists in those sciences, and clinical sciences by clinicians who, while part of a teaching hospital, taught medical students in the hospital; and

3. the proprietary type, rapidly developing in North America at the time, where medical schools were becoming trade schools. This caused grave concerns about the standards of medical education in North America and triggered the extensive study commissioned by the Carnegie Foundation from which emerged the oft-quoted Flexner Report. The latter resulted in a significant decline in the number of sub- standard private medical schools in North America.

A closer scrutiny and rating of the quality of education imparted by medical schools through visits by the American Medical Association brought about two significant changes:

1. a dramatic reduction in the number of schools from 160 in 1890 to 85 in 1925

2. an increase in Class A schools (rating 70% or more) from 66 in 1915 to 76 in 1925, with corresponding decreases in Classes B (50-69%) and C (less than 50%).

The clinical type was common in Britain earlier. Oxford University was established in 1770 and Cambridge University in 1540, but they both devel- oped comprehensive medical curricula later in conjunction with established hospitals. Our own school in Colombo was established on similar lines in association with a public hospital, gaining university status much later.

Over the past two decades there has been a significant increase in the privatisation of medical education. This trend is evident globally. Table 1 is adapted from a recent review of the literature conducted by Shenaz Ilyas, a postgraduate student of mine.

The Philippines has the largest proportion (84%), most of them of recent origin, as there were only 10 medical schools in the country until the mid-1970s, of which 5 were government schools. India tops the list with the largest number of private medical schools: 137 out of 271 (51%), with the US in second place: 62 out of 131 (47%). Australia and the UK have only recently ventured into the field of private medical education, while in China, France, Greece, The Netherlands and Canada all medical schools are public.

A lesson to be learnt from history is that no medical school worth its salt can survive and train doctors of quality unless it has strong basic science and clinical departments, with the latter working either in collaboration or as part of a teaching hospital. In spite of the recent trend to move clinical education to community settings, there is no doubt that a hospital with staff committed to teaching is a sine qua non for any medical school. This has an important bearing for the establishment of private medical schools.

Many socio-economic, political, educational and technological forces operate, to varying degrees in different countries, to bring about the trend of privatisation of medical education.

1. The demand for places in medical school is universal but particularly acute in developing countries where government schools are inadequate to cope due to limitations of funds and resources. Private schools are a means of meeting such a demand.

2. Developed countries face a workforce shortage, particularly in unpopular regions. One solution is the creation of privately funded schools to counteract the diminishing academic dollar. Funding cuts in higher education have been a well-known phenomenon in the short- sighted policies of many governments, and the public sector has stepped in to fill the void so created.

Developed countries also aim to benefit from “medical exports” from developing countries to resource underserved areas within their borders, and developing countries set up medical schools to meet this demand, sometimes in collaboration with reputed medical schools in the former. This practice has recently been frowned upon by accrediting bodies, such as the General Medical Council in the UK, which insist that minimum standards be met in the less recognised school before granting accreditation.

3. Increased mobility across countries with improved communication has facilitated the migration of doctors. To meet the increased demand new schools are opened in many developing countries, which continue to lose their human resources in health to the more affluent countries. Consortia of countries, such as the European Economic Community, facilitate such migration. The development of international standards in medical education was partly triggered by the need to ensure minimum standards across countries in this era of globalization.

4.The term “medical tourism” refers to the increasing tendency for patients to seek cheaper options overseas, in the face of increasing costs of healthcare in many developed countries. India has been the leading country to cater to medical tourism, which may have led to the mushrooming of private medical schools to meet this lucrative demand.

5.In many countries medical schools are being established to cater to the needs of specific communities, such as minority, ethnic or disadvantaged groups. Some countries reserve seats for lower socio-economic and minority students, the US schools being a notable example of this practice.

6.Undoubtedly, a potent force that drives the opening of private medical schools is the potential for income generated from such schools. Large businesses have seen a lucrative source in the privatisation of medical education. Unfortunately many have under-estimated the cost of instituting and maintaining a medical school of high quality. As a result they either run at a loss or lower their standards, even though intentions might have been good initially. Charging tuition fees is a two- edged sword: higher fees can be afforded by a minority of the population, while lower fees cut down on profits. Something has to give, and often it is the quality of the product.

In the search for the much wanted academic dollar resulting from cuts in funding for higher education, many developed countries have resorted to an aggressive search for income from other countries through such means as attracting international students for medical education, and opening of private medical schools in partnership. Prestigious schools have created departments of International Medical Education partly, at least, for this purpose. Others have opened branches in other countries at considerable expense to the latter, and lent their prestigious name to encourage students to attend, even before minimal requirements, such as adequate staff, have been addressed. As a result the standards of the curriculum in the earlier years of operation are in jeopardy.

What are the pros and cons of private medical education?

In the face of difficulties faced by governments to meet the ever-expanding demands of increasing populations, privatization has the potential to contribute to increasing the access of healthcare to all sections of society, if it is implemented with the benefits of the community in mind. However, there are hidden dangers.

Many countries depend on expatriate doctors. Unfortunately the migration of physicians is such that the flow is, generally, from the more to the less needy countries. Countries in the Arabian Gulf Region, for example, depend heavily on expatriate doctors. Over the past decade a number of private medical schools have been operating, and more continue to be opened. The demand for expatriate doctors is likely to diminish when the products of these medical schools are available. However, foreign students admitted are unlikely to remain in the country after graduation, returning home or to another country for postgraduate education.

Private schools compete with public schools and with each other. If the standards of the former are high other schools would aspire to reach them. As alternatives become available for students, faculty and the community, the monopoly exerted by state schools will diminish.

With strong financial backing, private schools are likely to have up-to- date facilities and resources, which can reach the students without much redtape, as is often evident in state schools. The private school has the opportunity to be freed of the burden of the bureaucratic machinery of the government, and can use this freedom either to the advantage of the students or of the investors.

Fundamentally, many private medical schools are set up as business ventures for profit, despite the stated intention of alleviating human suffering. If this “business mentality” pervades the institution, many disadvantages would accrue.

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