Does Sri Lanka need more doctors?
With medical education in Sri Lanka being swirled around in controversy along with many myths and misconceptions, there is a vital need to focus on that all-important question ‘Is there an urgent need to increase the production of doctors for Sri Lanka?’ and several other questions that would follow.
How many doctors do we have?
This is a very basic question. However, given the complexity of the present situation, the answer is not very straightforward!
According to a recent update, the current number of active registrations in the Sri Lanka Medical Council ( SLMC) is 25,600. These medical graduates may work primarily in one of five different employment sectors -- ( 1) the Ministry of Health, (2) the university sector, (3) the private sector, (4) defence services and (5) overseas.
In 2006, a study by De Silva et al, estimated that 70 percent of active registrants are employed in the Health Ministry, 3 percent in the universities, about 12 percent in the private sector, and the remaining 15 percent are overseas. Analysis of the data during the last 10 years (2006-2016) confirms that these percentages are still applicable. Employment within the defence services was not considered here since it accounts only for less than 1 percent.
Calculations based on the above will provide us with an estimate of about 18,000 employed with the Ministry of Health, 2,500- 3,000 working full time in the private sector and 700 to 800 in the universities. The number of those who have migrated or working overseas could be estimated as 4,0005,000. The actual data obtained from different sources and estimates arrived at with more complex human resources in health (HRH) modelling are on par with these figures.
Based on the active registrations, the current doctor-population ratio in Sri Lanka can be estimated as 1.04 per 1,000 population. What does this mean? Does this ratio indicate anything about the adequacy or inadequacy of doctors to provide optimum care for the Sri Lankan population? This is a difficult question to answer, because the optimum ratio would be dependent on factors that are as diverse as the health system and its ability to expand, the economic state and its growth, the disease patterns of the country and the social structure, etc.
Therefore, we will draw from different sources of information to attempt a reasonable answer to this
If a doctor shortage is not a critical issue for Sri Lanka, what causes crowded hospitals/clinics and long waiting lists for surgeries and investigations?
difficult question. One can only compare likes with likes.
What can states/ countries that are comparable to Sri Lanka tell us?
Sri Lanka’s doctor- population ratio is much higher than situations with comparable health indicators (eg. Kerala in India), the countries in the region with a comparable Gross Domestic Product (GDP) per capita and per capita expenditure on health (eg. Indonesia) and the countries with comparable rankings for health systems ( eg. Bangladesh).
Is there a World Health Organisation (WHO) recommended doctor-population ratio?
The WHO does not recommend a universal doctor-population ratio. What it suggests is the identification of the effective need, based on the health- system requirements and the capacity for the country to recruit doctors. Most importantly, the WHO does not identify Sri Lanka as a country with a critical shortage of doctors.
Then, what would be more pertinent issues?
If a doctor shortage is not a critical issue for Sri Lanka, what causes crowded hospitals/clinics and long waiting lists for surgeries and investigations? Firstly, rather than a shortage, a maldistribution of doctors remains a serious concern in this issue. It is evident that the problem has not been corrected by the rapid increase of the number of doctors joining the health sector during recent years (nearly a threefold increase of doctors in the last 25 years). Conservative estimates suggest that the doctor-population ratio in the Colombo district is over 2.5/1,000, which is higher than the ratio in Singapore. This is in comparison with Nuwara Eliya district, which recorded the lowest value of 0.37 doctors per 1,000 population in 2015.
Secondly and more importantly, the slow expansion of physical resources and infrastructure in the health care system and its uneven distribution seem to contribute to these service dynamics. This has indirectly supported the maldistribution of doctors, as they are invariably located in places where more service delivery is available. The reasons for the slow health sector expansion could be due to the country’s’ unfavourable GDP growth rate in the recent past and the curtailed allocation for healthcare which was maintaining less than 4 percent of the GDP. This allocation is even less than in countries in the region such as the Maldives, Bhutan and Afghanistan.
What may happen to the current doctor-population ratio in future?
The average number of new registrations with the SLMC is around 1,500/year in the last five years. This number is expected to increase further due to the large number of students who are studying medicine in foreign universities (estimated to be around 6,000). Based on these trends, active registrations with the SLMC will reach 35,000 within the next five years. This would give Sri Lanka a doctor-population ratio of 1.6 per 1,000 for the Sri Lankan population projected for 2022.
Moreover, 70 percent of these new registrants can be expected to join the Ministry of Health, according to the trend in the past 10 years. If the Government is to maintain absorbing 70 percent of the medical graduate output, the medical officer cadre in the Health Ministry will have to increase by about 1,300 each year. This would also mean that budgetary allocations for the salaries of doctors and other cadres, service improvements and infrastructure development need to go up annually. Given the current state of the economy and low budget allocations stagnating around 4 percent over the past years, this rapid expansion in the number of doctors does not appear sustainable.
Furthermore, if we assume the estimate of the 15 percent migration rate to remain constant and the Ministry of Health continues to absorb 70 percent of the new SLMC registrants, there will be more than 250 graduates opting to join the private sector annually as full-time practitioners. This is in addition to the government doctors who will continue to join the private sector as part-time practitioners.
At present, this proportion is estimated to be around 60 percent. That means that the private sector capacity for employment has to increase by at least 20 percent each year based on the current estimate of 2,500 doctors working in the private sector. However, when considering the trend of government salary revisions as well as the expansion of capacity and revenue in the private sector during the last 5 years, this may not be a likely scenario.
With these projections and comparisons, it is possible to predict that Sri Lanka’s current health system, both public and private, will be saturated with medical doctors within the next five years.
What are the possible scenarios thereafter?
Even if the private health sector grows significantly, if there is no guarantee of state sector employment, the proportion of medical graduates seeking employment overseas is bound to rise above the current level of 15 percent. Doctors are more likely to start migrating to more lucrative countries that offer better remuneration when compared to the private sector in Sri Lanka. The classic example would be that of India, a country with a doctor-population ratio below Sri Lanka but has become the world’s largest exporter of doctors.
The argument that migrant doctors would bring foreign exchange to Sri Lanka is not necessarily true. As was seen through the 1970s exodus of graduates, except for some indirect family support and occasional small-scale investments, many would utilise their earnings in the country they reside in.
Having doctors in excess of a country’s health system may have certain benefits such as doctors being compelled to maintain better efficiency and work ethics to retain employment and employers having a wider choice when recruiting doctors according to task requirement. However, there are concerns that excess numbers could lead to de- stabilisation of the health system, through factors such as an increase in internal and outward migration, underutilisation of skills and more commodification of healthcare.
Health economists argue that the competition occurring due to excessive number of doctors may not bring down the cost of care, due to the fact that market forces of healthcare are not mainly determined by consumer decisions and choice. Underemployed physicians are a costly resource to maintain.
Will healthcare be improved by only increasing the number of doctors?
Absolutely not! Numbers are only part of the story. Increasing the number of doctors alone has never solved HRH issues. In fact, uncoordinated, unplanned expansion of medical education has worsened the situation as illustrated by many examples worldwide. For example, Malaysia, a country with a much higher GDP per capita, higher ranked health system and higher budgeted allocation for health than Sri Lanka has reached a situation where the health system cannot absorb the increasing number of medical graduates and had to issue a moratorium on starting new medical schools or courses. We need to act before we reach such a situation.
The ultimate goal should be the improvement of the quality of healthcare. Patients expect better accessibility to health, acceptable cost, caring and skilled doctors and lesser waiting times. HRH means that the right persons should be in the right place in the right numbers with the right skills and attitudes.
To achieve this, there is a need for an improvement in the quality of training, proper coordination between training and recruitment, career development, reward management, need-based deployment, better facilities, infrastructure and health system changes.
This is what the Government should focus on. These are the areas in which the intellects should be lobbying for policy changes.
(The ‘Academic Circle on HRH’ is an interest group of academics who believe that development of national policies on human resources in health should be based on evidence. The y include Prof. Indika Karunathilake, Prof. Varuni De Silva Hanwella, Prof. Wasantha Gunathunga, Dr. Sameera Gunawardhana, Dr. Sisira Dharmaratne, Dr. Chathuranga Ranasinghe, Dr. Chamindri Witharana, Dr. Pushpitha Ubeysiri and Dr. Malith Yeshan.)