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Tackle the many-pronged crisis in state health sector before it collapses
View(s):By Kumudini Hettiarachchi
The state health sector is in crisis, with many predicting an “imminent” collapse if remedial measures are not taken immediately.
Many experts reiterated that the crisis in the state health was many pronged – a dearth of medical specialists; a shortage of medicines, consumables and devices; serious questions on safety and quality of medicines; and non-working vital equipment.
The brain drain of medical specialists is trammelling the state health sector severely, the Sunday Times understands, while experts made very strong allegations that there is no data “about anything” at the Health Ministry.
Many specialists said that there seems to be an exodus from the following categories:
Young medical specialists who are working in Sri Lanka but leave for greener pastures.
In-training medical specialists who go abroad for their foreign training and do not return to Sri Lanka.
In-training medical specialists who return after foreign training, get their Board-certification from the Post-Graduate Institute of Medicine (PGIM) but do not seek a job station. They simply “disappear”, most probably, once again in search of better prospects.
The Sunday Times on July 9 (last Sunday), in a report headlined ‘Experts call for urgent steps to save sinking state health sector ship’ extensively covered the multi-pronged causes for medical specialists to leave the country, along with an analysis of their remuneration.
More were the tales of woe this week. A not-so-young medical specialist said how he and his doctor-wife were each earning around Rs. 300,000 a month in the state health sector.
“We were managing quite well,” he said. But now, each of them is foregoing two months’ salary per year as taxes and with the high cost of living they are finding it difficult to manage.
Explaining the procedures that need to be followed by post-graduate trainees, a source said:
Medical students when they get through the final MBBS, have to do a year of internship.
Next they serve as medical officers (MOs) and if interested in becoming a specialist, sit the entry examination for the course of their choice (anaesthesia, surgery etc.).
Once MOs pass the entry examination, they are eligible for registration with the PGIM and are called ‘Registrars’ in that particular field.
After they serve as Registrars for three years, they are eligible to sit the exit (final) examination of the PGIM and once they pass it are called Senior Registrars (SRs).
SRs work for a year in Sri Lanka and seek training either another year or a maximum of two years abroad.
Once they return, they have to seek Board-certification which makes them eligible to apply for a Consultant post.
Here are some specific pointers on the departure of medical specialists the Sunday Times found:
Anaesthesia – This is the “worst” affected, many confirmed, at the same time stressing the importance of these specialists for other fields of medicine such as all surgeries and gynaecological & obstetric procedures including caesarean sections (C-sections).
Psychiatry – This is also badly-hit, it is learnt, with 25-30 specialists leaving the country in the last two years. This has caused a “huge” treatment gap, many stressed as their role is multi-pronged including community-based and medico-legal work.
Neurology – The cadre needed is about 50 of which there had been only 29 neurologists. In the past two years, of these 29 too, 5 have left Sri Lanka. This is while 8 who had gone abroad for post-grad training, only 2 have returned home.
Ironically, sometimes the specialists in Sri Lanka get to know that their juniors have left the country through Facebook, one pointed out.
Many also spoke of the loopholes that young specialists use – some of them when they return to Sri Lanka after their post-graduate training abroad, do not seek immediate Board-certification. This is a ruse to stay as an acting Consultant to get to a better posting than they would if they go in for immediate certification, because as an acting Consultant, they do not lose their seniority.
Several specialists also blamed the poor management of human resources by the Health Ministry – sending specialists to smaller hospitals when there were bigger hospitals close-by which would be easily accessible.
An example was the Trincomalee Hospital under which comes a vast area which is being manned by a Senior Registrar (SR) who is awaiting his post-grad training abroad. The smaller hospitals could be managed by an SR with Consultant Anaesthetists making a weekly visit and some patients being transferred to the bigger hospital when needed.
The Mirigama Hospital which was so close to Colombo not needing a Consultant Anaesthetist was another example, while Anuradhapura Hospital which is a “big one” having only 2 Consultant Anaesthetists with Tambuttegama Hospital which is close by having 1 Consultant Anaesthetist.
“Mismanagement of precious human resources,” stressed one source, adding that easily in a small country like Sri Lanka, a cluster system, where several smaller hospitals come under one big hospital should be implemented urgently. Even in a developed country like the United Kingdom (UK), every hospital does not have specialists from every specialty.
Another said that doctors should also be given a work week which has “decent” work hours and includes training and teaching time. In the UK, for example, a Consultant Anaesthetist has only three sessions per week in the Operating Theatre (OT). “We don’t even have time to go to the bank here,” the doctor said, adding that audits of the work done and also what a specialist has contributed towards the development of his/her hospital are very important markers.
A major bone of contention among young specialists was the delay in implementing the Annual Transfer List.
Many said that with regard to the Transfer List for 2023 (of which seven months have already passed), the Health Ministry in a strange and foolish move, without any basis, has “temporarily withheld” three posts for general surgeons in Kegalle, Matale and Negombo respectively.
“While these three vacancies had been filled last year (2022) through that year’s Transfer List, they have once again fallen vacant due to various reasons – the surgeon being appointed to Negombo securing his end-post at the Ragama Hospital; the surgeon who was sent to Kegalle resigning and joining the Sri Jayewardenepura Hospital; and the surgeon in Matale moving over to Kandy for his end-post,” a source said.
The excuse for blocking the vacancies at these favourable stations of Kegalle, Matale and Negombo is that those in peripheral hospitals will clamour to move in to them, one said, while many alleged that this has been done without permission from the Public Service Commission (PSC).
Many were strident in their criticism that it was “very unfair” for surgeons in peripheral hospitals who have to remain in unfavourable stations for longer.
The Government Medical Officers’ Association (GMOA) has eight mitigatory proposals to stop the brain drain, said its Secretary Dr. Haritha Aluthge, underscoring that the health service was facing many critical challenges due to doctors of all categories leaving the country in an “unprecedented” manner. Last year alone, over 700 doctors had departed Sri Lanka.
The main reasons for the brain drain and solutions to rectify them were given by Dr. Aluthge follows:
Reason: Failure to provide a proper value in keeping with current “market trends”, to the services provided by all categories of doctors.
Solution: Introduce an exclusive salary structure for doctors considering performance and market value of services provided, while increasing the internship allowance proportionately.
Reason: Poor quarters and other facilities for doctors.
Solution: Upgrade and expand quarters and facilities within a specified time frame with emphasis on difficult peripheral hospitals.
Reason: Failure to pay attention to upgrade doctors’ transport facilities.
Solution: Amend the Disturbance, Availability and Transport Allowance (DAT) of doctors in keeping with current parameters immediately. This should be looked at every three years and amended according to the situation. Place on par, senior doctors with other senior government officials in the Ministry of Public Administration Circular No: 22/99.
Reason: Failure to provide proper schooling facilities for the children of doctors who face compulsory transfers every 4 years and for those returning after completion of foreign training.
Solution: Set up a mechanism to address this issue, with special emphasis on requests from doctors serving in the peripheries.
Reason: Absence of an incentive scheme for doctors serving in difficult peripheral hospitals.
Solution: Formulate and make effective an incentive scheme with financial and non-financial benefits for doctors serving in difficult peripheral stations.
Reason: The unfair tax policy.
Solution: Declare and implement a fair and professional-friendly tax policy
Reason: Failure to declare a mechanism for professional development of doctors.
Solution: Introduce a ‘Supra Grade’ for all categories of medical officers, expand post-graduate opportunities beyond the PGIM of the Colombo University and include Grade Medical Officers in an ‘end-post’ scheme as provided for Specialist Medical Officers.
Reason: The unsatisfactory service environment created by the current shortage of medical drugs and consumables.
Solutions: Take immediate steps to solve the crisis with short, medium and long-term mechanisms based on the proposals forwarded by the GMOA.
| Expert report on how to halt brain drain due in two weeks An urgent report on how to halt the brain drain of doctors, particularly medical specialists, is due in two weeks from a committee set up within the Health Ministry, the Sunday Times understands. The committee to study the ‘Effects of brain drain on the health system’ had been set up by the Health Minister in May, with the first meeting taking place on the 25th of that month. “The committee was set up on the request of the Government Medical Officers’ Association (GMOA). We requested the inclusion of all stakeholders including the Association of Medical Specialists (AMS) and the badly-hit professional colleges,” said GMOA President Dr. Darshana Sirisena. The GMOA and the AMS along with numerous other doctors have warned of the imminent collapse of the state health sector if immediate action is not taken to address the issues faced by doctors. Dr. Sirisena said that all submissions to the committee were finalized on Thursday (July 13). The committee is chaired by the Director-General of Health Services, Dr. Asela Gunawardena. It comprises the Convener & Acting Director of Medical Services, Dr. Ayanthi Karunarathna; the Director of Tertiary Care Services, Dr. Priyantha Atapattu; GMOA President Dr. Sirisena & four GMOA representatives on behalf of specialists and medical officers; AMS Secretary Dr. R. Ghanasekeram & AMS representative Dr. Rasika Gunapala; Consultant in Medical Administration Dr. Upuli Wijemanna; the President of the Sri Lanka College of Psychiatrists, Dr. Kapila Ranasinghe; and the President of the College of Anaesthesiologists, Dr. Anoma Perera. | |
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