With growing consensus on the declining quality of medical education in the country, the government had formed the Mathema Commission in 2015, an expert panel, to formulate a policy on medical education. The commission advised the government to form a Health Profession Education Commission to deal with issues of medical education including their university affiliation and quality control. The policy also clearly mentions that no new medical college should be established in the Capital for the next decade in view of them being concentrated in a single place. Despite serious reservations on the bill to replace the Medical Education Ordinance, the government has registered a bill on Health Education Act in the Parliament Secretariat altering major provisions of the ordinance so as to allow establishment of new medical colleges in Kathmandu Valley. Against this background, Binod Ghimire and Avasna Pandey spoke to Prof Kedar Bhakta Mathema—former vice-chancellor of Tribhuvan University, and a widely respected educationist regarding the new bill and the quality of medical education in Nepal. Excerpts:
As the chair of the Mathema Commission, how do you feel that the report has not been implemented even after three years?
The Mathema Commission Report on Health Profession Education Policy was submitted to the government in 2015 but it took a long time to be endorsed and then registered in Parliament. First, it took a while to form the task force. Once the task force was formed, we submitted the report to the government. But we had to struggle even to make the report public. Following that, there were coordination issues from a member of the planning commission, which caused problems too. So obstruction and delays have happened continually. There is life beyond the medical education report and the members of the taskforce under the commission have to move on. Yet, we have been stuck here for long.
The committee was an excellent team—people who have led universities as vice-chancellors, deans and directors. The team had people who were already involved in drafting public policies. This report was born out of such prolific, experienced team members. And yet, it is in a limbo which is quite disheartening.
You have seen the draft registered in Parliament. How different is it from the report your team submitted?
The report has two fundamental elements. One is the quality of medical education and the other access. Quality is of utmost importance since medical education will have a direct link with people’s well-being. If there are quality doctors, then the health services provided will be of quality too; and quality health service will ultimately benefit citizens. On the access front, the report stressed that medical education should not be available only to a few who are financially strong or, say, to those who reside in the Capital and urban parts of the country. Rather, everyone, regardless of their financial background and place of residence, should have access to medical education.
For almost 20 years the government was inactive. Private players, barring a few public institutions like the Tribhuvan University Teaching Hospital, the BP Koirala Institute of Health Sciences (BPKIHS) and the Patan Academy of Health Sciences, dominated the medical sector. The report maintained that the government, rather than the private sector, should head the medical education sector. For example, in Canada and Sweden there are no private medical schools. Nepal’s law that time allowed the private sector to run medical school. Perhaps, because of that we have increased human resource in the medical sector, which is good. But it remained unregulated, ultimately raising concerns over the quality of education.
The concentration of medical schools in Kathmandu Valley was another factor. The layman understanding is that more medical schools means more hospitals; and the more hospitals, the better for them. But, as medical schools mushroomed, patients started getting divided too. In fact, in many medical schools, there are not even enough patients. A medical school thrives on more patients, complicated cases, etc. Only then can medical students learn since medical education is as much practical as it is theoretical.
The dearth of patients interfered with the medical students’ learning ability. Too much concentration in one place caused a shortage of teachers too. Also, too many medical schools made their monitoring difficult as well. The quality of education has thus plummeted. Keeping this in mind and after much deliberation, the report recommended no more medical colleges in the Valley for at least five years.
Does it feel in any way that the Mathema commission was formed just for the sake of temporarily averting the pressure the government was facing then?
The protest by Dr Govinda KC was instrumental in formation of this task force. The Oli-led government has sold hope to the people and the people are rightly expecting from them too. But their lacklustre attitude and then taking the recommendations in the report lightly frustrateses us. If the government is not implementing the recommendations and is sidelining the report, then they owe an explanation to the people.
The government maintains that the Mathema Commission has suggested forming a strong commission which will take care of everything. Is that the spirit of the report?
No. The members of the taskforce strongly believe that there has to be a Health Education Commission. But forming that commission alone will not suffice. The commission has to implement our recommendations.
So if the recommendations are not included in the Act itself, on what basis will the yet-to-be-formed commission work to reform the medical education?
The commission will come under immense pressure. This bill will serve as a test case for the government. People are observing the actions of the Oli-led government. People will take note of how determined this government is to get rid of say, crony capitalism, nepotism etc. and to go against the vested interests of a few people and take decisions that are pro-people. People will evaluate everything and draw their conclusions.
If this government that enjoys a two-thirds majority also fails to perform then who will bring about change? The government might not be popular in its coterie while taking difficult decisions but it is here to ultimately serve the people. As long as it takes decisions in the larger interest of the people nothing else will matter. So this will be a litmus test for the government. The people who voted for them will not forget it. But perhaps, when people get into positions of power, they tend to forget their responsibilities.
Then is it that once people get into positions of power they shun their responsibilities, or that there are many circumstances due to which they succumb to the wants and needs of different stakeholders?
The people elect a government. Therefore, the government has to prioritise its citizens over anyone else and work in their interest. The sole existence of the government is to serve the people. Like Robert Frost said, two roads diverge in the wood. There are two paths—the good path and the bad path. It remains to be seen which road the government will take.
Paying no attention to widespread criticisms, the government on Friday registered a new bill on Health Education Act. How hopeful are you that your recommendations will be implemented as the government doesn’t seem to be concerned with the criticism?
The recommendations of the report are prepared by a task force whose members have enough experience when it comes to medical schools and medical education. The report was prepared in the country’s best interest. Sidelining it and going against it will not bode well. This need not be politicised so much sinceit is not a political issue, but rather a public issue. We want the medical bill passed and the commission formed consequently. But we also want our recommendations to be included in the bill for the sole purpose of maintaining the quality of education.
The education minister recently said that some of the provisions were agreed upon only so that Dr KC, who has been on a hunger strike for days, can be saved. Some of the recommendations of the report cannot be implemented and if it is to be implemented in the medical education sector, similar recommendations have to be implemented in other streams too. What is your take on this?
Out of the total university population, 43 percent students graduate in management, five percent in medicine, around 4.5 in engineering. But not even one percent in agriculture. So yes, what the minister has said is valid to some extent. Dr KC has been fighting for the cause of the people by taking to the streets, while we are having closed-door discussions. If the government feels other streams need changes too, then that has to be managed by the people who are at the helm of the affairs. After all that is what running a state is all about.
Now this report too has come to be associated with Dr Govinda KC. While preparing the report, we consulted with him like we consulted with any other doctor, but besides that, he has no other contribution to this report. But yes, for the task force we formed, Dr KC has to be credited. When the report came out and Dr KC went through it, he felt the recommendations of the panel were in consonance with his demands. He expressed full solidarity with the report demanding its implementation as it is. In a way, he has taken more ownership of the report than us.
Report on Health Profession Education Policy was formed independently after much deliberation, taking into account the interests of the people and the country. It also sets a precedent for future public policies. Policy corruption is scarier than anything else. We feel that the state should be in the driving seat, not the private sector, when it comes to medical education since it has a direct connection with the health of the people. While talking about sambriddhi, the government is still talking about the growth of private sector. The communist party adheres to a socialist ideology, but their actions show otherwise.
The government maintains that every year five to seven hundred youths fly abroad for studies. The previous government issued many letters of intent (LOI) and the huge investments that have already been made need to be safeguarded. What would say about this?
We too are concerned about the investments. Since day one the members of the task force have maintained that no one’s investment should go down the drain. But it is up to the government to manage that. That may be compensating them or devising any other measure. Also, the report only suggests not opening any more medical schools in the Kathmandu. It does not say anything about not opening medical schools outside the Capital. Concentration on one place only will not maintain a regional balance either.
We are embarking on a journey to a new Nepal so development and facilities should be equally distributed. Therefore, the government can come up with many ways to safeguard previous investments. It cannot get away by saying that it is not following the recommendations of the report since it has to safeguard the huge investments.
Three years since the recommendations were made, does the committee feel that the bill has to implement them as they are or is there any room for compromise?
The recommendations of the report are not carved in stone. We are open to making amendments according to the changing time and circumstances but the essence of the report—quality education and access—should not be distorted. For example, the report says that a hospital not operational for three years is ineligible to apply for affiliation as a medical college. Every recommendation was made thoughtfully so that students benefit from it. But since the government has removed the recommendations, it is making things easy for the private sector, not the people.