My opinion

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Abstract:
In the South Asian region a number of private medical schools have been opened recently. In many countries at present private medical schools outnumber government run schools. There are many opinions and concerns about private medical schools. There may also be advantages. Objective evidence for the opinions and concerns are lacking. In this article the author highlights the urgent need for research in these areas.
In the South Asian countries of India, Pakistan, Bangladesh and Nepal many medical schools have recently opened in the private sector. The same is true for nursing, pharmacy and allied health sectors. These schools receive little or no support from the government and are dependent on high tuition fees for their survival and development. In Nepal, medical schools charge between US$ 32000-40000 for Nepalese students, US$ 50000 for Indian students and US$ 60000 for students from other countries [1].
I am a medical educator and faculty member at KIST Medical College, Lalitpur, Nepal a private medical school in the Kathmandu valley. In this letter I intend to share possible implications of privatization on various aspects of medical education and medical practice and underline the urgent need for scientific research into these issues. There is a paucity of research on this topic. The author has read newspaper and media articles highlighting lacunae in private medical schools but was able to access very few journal articles on doing a Pubmed and Google Scholar search. Problems have been noted in private medical schools in India [1]. Similar problems have also been noted in Bangladesh, Nepal and Pakistan.
Selection process: Student selection procedures vary. In Nepal, private medical schools select students who have passed (secured more than 50% of the available marks) an entrance examination conducted by the respective affiliated university for self-financing seats. The university does not rank students and influences such as money, contacts and political influence can bias the selection process. The colleges are free to select foreign students after an interview.
Career plans: Informal interactions with students in my school reveal many intend to migrate to developed nations after graduation. Studies are required on whether private school students are more likely to emigrate compared to government school ones. Private, self-financing students constitute a large proportion of the student body. In Nepal around 70% of medical students are self-financing. The implications on the health system of a large number of doctors emigrating have to be studied. Private school students staying within the country are more likely to work in urban areas and specialized institutions. This was my impression on interacting with students and from preliminary analysis of a study being conducted by me and other authors on student perceptions about working in rural Nepal after graduation. In Nepal private medical schools have to provide 20% of total seats (in case of foreign owned schools) and 10% of total seats (for Nepalese owned schools) in full tuition feel scholarship to students selected by the Ministry of Education. These students have to work in rural Nepal for two years after graduation and are becoming an important source of support to the health system [2].This important phenomenon has again not been properly studied. There is a belief among the general public that treatments provided by private school doctors may be expensive due to overtreatment, use of more expensive medicines and diagnostic modalities to recover the high investment on their education. Hard objective data is lacking and may be difficult to obtain. This is another important area for research.
Economic benefits: Privatization of medical education has led to opening of a large number of medical schools. Medical schools with a large number of resident faculty and other staff, students and the teaching hospital with patients seeking treatment can play an important role in socioeconomic development of the area within which they are situated. There are employment opportunities for the local people and the investment of a large amount of money boosts the local economy. Most schools enter into agreements with the local community promising to provide a certain percentage of semi-skilled jobs in the institution to community members. In addition shops, restaurants and lodges are opened to cater to the requirements of patients, students, faculty and other employees.
Examinations: Concerns have been raised about standards of examination in private medical schools. The management has the objective to obtain the best results possible. Many want to attain it using the least resource outlay. In Nepal, Tribhuvan University has adopted the system of coding answer papers so that the examiner does not know the student identity. In many universities in India answer papers are sent to a different region of the country. In medical education there are also practical and viva-voce examinations which can offer scope for bias. Improving the assessment system to make it more objective and transparent is an important challenge.
College finances: Some schools are run by non-profit trusts while others are managed by businessmen and politicians. Most new medical schools are for profit and investors expect a quick return of investment. These schools have to raise their own resources and their main sources of income are student fees and income from hospital patients. Many private teaching hospitals attract much less patients than government hospitals and often schools cross-subsidize treatment using money gained from students to ensure good bed occupancy rates for teaching purposes. The first ten years require substantial investment to create academic and patient care facilities and other resources. After ten years colleges make a good profit with increasing student admissions and launching of postgraduate programs.
Greater commitment towards students: Private medical schools have greater commitment towards students as students are the primary source of revenue for these institutions [3]. Student requirements occupy an important place in the school’s priorities and colleges try to address student requirements as far as possible. The primary emphasis is on ‘good’ results in the university examinations and certain colleges also focus on good performance of their students in licensing examinations.
Other issues: The quality of prescribing and care provided by doctors who graduated from government and private schools has not been compared. Self-financing students have used their own money to finance their education and their obligations to the health system and the country may be less. Studying the impact of privatization on education and healthcare in south Asia and in other regions (through emigrated health personnel) may require development of new research modalities and cooperation between health professionals, health school faculty, social scientists and economists. Impact of transparent selection procedures, specialty, area and country of practice of government and private school doctors and cost and quality of healthcare provided by the two categories are specific study areas. Concrete data will enable educators and planners to make proper decisions and take steps to correct anomalies observed.

Reference(s)

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1.Vallyama P, Deshpande SR, Gayathree L. Mal-distribution of medical manpower resultant decay of the Indian medical education system: existing problems and possible solutions. British Journal of Medical Practitioners 2009;2 (1):46-49.
2.Shankar PR. Scholarship students in private medical schools an important source of support to Nepal’s health system. Australasian Medical Journal 2011;4:279-280.
3.Shankar PR, Thapa TP. Applying the concept of ‘field’ to private medical schools in Nepal. Medical Education 2010; 44: 1049.

Source(s) of Funding

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none

Competing Interests

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none

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