Monday, January 27, 2014

Medical education needs to be accountable to society: Dr Sharad Onta,assistant dean at IoM

After 14 grueling days, Dr Govinda KC finally ended his hunger strike on Friday after government officials agreed to meet three of his seven demands, including autonomy for the Institute of Medicine (IoM). Dr KC went on a fast-unto-death after former IoM Dr Prakash Sayami resigned, citing undue pressure from various quarters to grant affiliation to private medical colleges, and Dr Sashi Sharma was politically appointed. In solidarity with Dr KC’s protest, the Nepal Medical Association, an umbrella body of doctors, shut down hospitals across the country. When officials continued to turn a deaf ear to their demands, doctors at the Tribhuvan University Teaching Hospital resigned en masse, forcing the government’s hand. Manish Gautam and Pranaya SJB Rana spoke to Dr Sharad Onta, assistant dean at IoM, about the circumstances leading to Dr KC’s protest, the row over affiliations and the state of medical education in the country.
Now that Dr Govinda KC has broken his fast, how do you see the way in which the whole incident progressed?

The issues that Dr KC raised definitely needed to become a matter of national interest. We had long been discussing autonomy for the IoM and demanding that affiliations be granted in an organised manner. It is unfortunate that such a great price had to be paid for these issues to be addressed. Dr KC stayed on a hunger strike for so many days and the general public was deprived of access to health facilities. But it is in the past so there is no sense in regretting it now. At least the issues are now up for national debate.

What exactly was it that led Dr Sayami to resign as dean?
At IoM, we begin our undergraduate classes on Mangsir 1 but this time, there were elections so we had to push back the date to Mangsir 6 (November 21) but since some students might not have had time to admit themselves, we increased the admission date for affiliated colleges to Poush 10 (December 25), an additional 35 days. But what was disheartening was that even after the school year had already begun, there was great pressure on IoM to grant affiliation to more colleges and let them start teaching from this year itself. This was unacceptable. We only asked for one small thing, that the affiliation be deferred to the next school year. But even that demand was unheeded so Dr Sayami felt forced to resign. 

Why did the IoM refuse to grant affiliation to these colleges?
Alongside the establishment of a medical college, we need to have certain rules and regulations, the college’s disciplines and clear guidelines for the monitoring of the college’s quality and capacity. Our universities—TU, and Kathmandu University—only have enough capacity to conduct academics. We cannot bear the additional load of monitoring the academics of other colleges. And this is not a problem that suddenly arose; it has been there since the very beginning. If certain frameworks and regulations for granting affiliations had been instituted ever since the first medical college was established, this problem wouldn’t have exploded like it did now.

But isn’t it an excuse to say that you don’t have the capacity? Can’t capacity be built by increasing the number of faculty members or contracting out to retired professors and doctors?

Yes, that is exactly what we have been trying to do. It would certainly have been better if the number of faculty members had been increased proportionally with the number of new medical colleges. But that did not happen. At minimum, we should be monitoring them once every three months. Right now, IoM is running around 54 programmes and private colleges are running around 25 other programmes. But we do not have the human resource required to evaluate these programmes and see how they are being run. So the bottom line is that need at least an additional 150-200 faculty members.

Why is there only talk of granting affiliation to private colleges? Can’t the government establish its own public colleges?

This is related to the political economy. If Nepal has fully embraced a liberal, market economy, the state will not start letting the market handle public institutions. But the state should continue to support the social sector, like schools and hospitals. Nepal, however, doesn’t have the financial capacity to run all medical colleges. It needs the support of the private sector. Even if the state replaced one or two private colleges with public ones, that would provide great relief to many ordinary students. It would be better if the private sector had to compete with the public but right now, the private sector has turned out to be far more powerful than the public.

Given the fact that every year, scores of Nepali students leave the country to study medicine abroad in China, Pakistan and Bangladesh because there aren’t enough seats in Nepali colleges, won’t the number of medical colleges have to be increased?

That our students are leaving the country to study medicine abroad should not be the only reason for us to open new medical colleges. Even if we open 50 new colleges, there still won’t be any assurance that students won’t leave the country. There must be more principled reasons than this. Medical education creates capable human resources and aids in the country’s overall development. It also provides a critical service to the people. So there must be some principles that cannot be comprised—the quality of the education provided, that medical colleges operate along the principles of social justice and that colleges be socially accountable. The quality of education also depends on the capability of those monitoring these colleges. Can a person living in the Far West get easy access to medical education? Geographical distribution needs to be kept in mind. Medical colleges also have to be accountable to society.

So medical education is not just about creating technically skilled professional but also about being accountable to society. 

Speaking of social accountability, was it ethical for doctors to shut down medical services across the country in support of Dr KC’s protest?

This is not an easy question and I don’t have an easy answer. Like I said earlier, this issue should not have come at such cost. We had been raising these issues for the last year or so and they were never addressed. I wish that we didn’t have to do what we did so I don’t have any space to say that this was an ethical move. But was it necessary? That is a hypothetical question. As long as we raised our voices, we were never heard. It was only after Dr KC started his fast and we shut down services that our demands were addressed. So in retrospect, it looks necessary. But the nation paid a great price and I don’t have the moral strength to attempt to provide a rationale or justification.

This is not the first time Dr KC went on a hunger strike for the same reason. What guarantee is there that he won’t have to do this again?
There is no guarantee. To prevent this kind of thing from happening again, we need to be more alert and active. But it is not just us doctors and office bearers who should be aware, we need a more diverse stakeholder body to be alert. This time around, civil society supported us and the media supported us. So we all need to be vigilant and act in a timely manner so that this doesn’t happen again.

On a final note, what is the state of medical education like in the country?

I think there are very few countries in the world that have increased the number of medical colleges in such a short time. The first college was established in 1979 and the second in the mid-90s. But since then, 16-17 new medical colleges have been established. These colleges have made their economic contributions but the quality leaves a lot to be desired. Second, the cost of medical education has also increased exponentially. I think it is cheaper for students to leave the country and study abroad than to study medicine here. Furthermore, there is a severe lack of monitoring and accountability. For example, we have a programme called the district health programme where MBBS students in their final year are required to go into the field and work there for nine weeks. This is worth 100 marks—the IoM awards 50 and the college awards 50. Till date, no private college has sent its students on this programme. But when these colleges award their students internal marks, the numbers are irrational. We know what they are doing but we can only sit back and watch because we don’t have the monitoring capacity.

source: the kathmandu post,27 jan 2014