• The state has its role in delivery of basic health, education

Jan 4, 2015-

Last week, the Committee on Women, Children, Elderly Citizens and Social Welfare in the Constituent Assembly directed the Ministry of Education to allow medical colleges that have acquired the Letter of Intent to operate. The order came at a time even as the debate on the inability of the regulatory authorities to monitor new colleges and the latter not meeting set criteria rages on. Manish Gautam and Darshan Karki spoke to Dr Ramesh Kanta Adhikari, former dean of the Institute of Medicine, about current problems in medical education, the need for a strong regulatory body and the growing interest of various stakeholders in the health sector.

Can you give us an historical overview of medical education in Nepal?

The MBBS programme in Nepal began in 1978 and until 1993, the state had a monopoly in this sector. There was only one Institute of Medicine which started with 22 students and we later expanded it to 60 students. At that time, health and education were understood to be the responsibilities of the state. After the 1990 movement, as the government adopted neoliberal policies, the entry of private capital in health and education was perceived as helpful for development of the country.

Back in 1995, as President of the Nepal Medical Association, I was a member of the Faculty Board under the Tribhuvan University (TU). We received a proposal from DY Patil and Manipal University. Both wanted 100 medical seats on the grounds that anything lesser than that would not be financially viable. The Faculty Board asked them to start with 60 students instead as they did not have the infrastructure, the teachers and neither a hospital. They did not like the decision and they withdrew their proposal from TU and went to Kathmandu University which did not even have a medical faculty then. The government told KU to help Manipal while DY Patil left.   Perhaps the government had a reason for it. Girija Prasad Koirala, while talking about his time as prime minister boasted of opening seven new medical colleges in his term considering it to be an achivement. Things were still fine until then.

When did problems begin to arise?  

Both KU and TU had somehow managed to carry out the regulatory works relating to affiliated colleges until then. But in the past three to four years, the practice of giving Letter of Intent has increased. Many institutions came forward saying they need affiliation as they had already begun preparations for establishing medical colleges. This put the regulatory bodies in great difficulty. In particular, officials at the Institute of Medicine face a huge resource crunch. Its faculty is already stretched in inspections, conducting exams elsewhere instead of focusing on their own programme.

What exactly does it mean when you say that the concerned authorities do not have the capacity to monitor new medical colleges?

Building physical infrastructure is the easy part; once you have the money you can buy land and construct buildings. The second thing you need is academic leadership. Then we need people who can teach. Medical education is an apprentice-based education. A teacher leads a group of five students and teaches them by literally holding their hands. It is not possible to teach students by showing them PowerPoint presentation and videos. The current problem is, we are making apprentice-based education theory-based. So students might know the theory, cause, symptoms but on seeing the patient, she cannot diagnose

the disease. How can we push medical education towards that direction? What if the student I teach today kills someone tomorrow? This worries us. Furthermore, investors hire professors not on the basis of their intellectual capacity but because they just fulfill minimal criteria of being one or because the Medical Council accepts them as one. Their attitude is, why do more if this much is enough?

We also hear of a lack of faculty members of basic science which has resulted in the khade baba phenonmena (bringing teachers from India just to stand around for a few days of the monitoring period).

This has its roots in the prevalent mindset of society. Between teachers and doctors, the latter is considered more respectable as their demand is high. But it is teachers who shape the future of our society. In developed countries, all development in medicine is because of advances in basic science. Surgeons and physicians do not usually figure in the list of Nobel prize winners. It is the biochemists, microbiologists, physiologists who get awarded as they come up with new ideas.

But our society does not yet know their value. There are a few ways to change this. First, allowing those with a BSc or MSc to teach anatomy, physiology. Such people are now available. Second, engage medical MBBS doctors and those with non-medical basic science degrees in problem-based learning.

Lately, there has been a surge of interest of the Commission of the Investigation of Abuse of Authority, the Supreme Court in medical education.

I will tell you two stories. In the mid-1980s I met a dental surgeon in Sri Lanka who was more of a philosopher. He believed that the fees and remuneration of the doctors should be reduced. “If you want to improve the state of health, doctors should not be seen as moneymakers. This has destroyed the health sector,” he said. “They have put a businessman’s mind in medicine.” This utopian idea impressed a minister there who called him for discussion. Apparently, he was almost beaten up by members of the medical association in the meeting.

In the 1900s if 100 people got admission in the medical department of John Hopkins University, only 75 of them would pass out. Twenty-five of them would be dead by the end of the course. Medicine was a dangerous profession as diphtheria, tetanus, tuberculosis did not have medical cure. Only those who were dedicated to helping people joined the course. Now, it is more about being able to pay for it.

So what would the role of the state be in the health sector in a free market economy?

The state cannot abandon its role in basic health and education. All the achievements Nepal has made in terms of increase in average life span is due to the public health sector. Polythene pipes which brought clean drinking water to households, oral rehydration programmes, wider immunisation

coverage and Vitamin A supplementation, among others, reduced mortality rates. So the government must continue to support public health institutions. Second, medical education should aim to produce leaders to guide public health.

How do we ensure the formation of an honest and competent regulatory authority at a time when the work according to two reports submitted to the government after Dr Govinda KC went on a hunger strike is yet to begin?

We are rethinking the process of formation of regulatory bodies—university faculties and medical council—which is currently formed through election and some are appointed by the ministry. There is a need to strengthen organisations like the Medical Council and establish a think tank which publishes a white paper on the status of medical education every year. Money needs to be spent on generating research based information in health sector. As of now, there has not even been an independent research on it. There are researches on numbers of seats in medical colleges and bed strength of hospital but not on what is happening in medical education.

But why have things not changed despite so much pressure is this resistance to change?

This is not resistance but lethargy. The government has a habit of responding to immediate problems. Had Dr Govinda KC not raised such issues, things would have continued as they are. Without people like him, who are the conscience of society, malpractices in the medical sector would go unchecked. But the problem is that the government is yet to internalise that the issues Dr KC has raised are indeed problems and need to be resolved.

So what could be a way forward for investors who already have a Letter of Intent?

First of all, the government must be held accountable for handing out the Letter of Intent. Second, just because you have the Letter does not mean the idea could work out. To put it bluntly, not all business investments yield returns. If you want to recover investment why not talk to colleges currently in operation which could perhaps make use of it? For instance, in the UK, seven medical colleges were merged and converted into three. And if banks can be merged, why cannot private colleges?


Published: 06-01-2015 15:16

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