pp. 74-76 in Bioethics in Asia

Editors: Norio Fujiki and Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute

Copyright 2000, Eubios Ethics Institute All commercial rights reserved. This publication may be reproduced for limited educational or academic use, however please enquire with the author.

2.3. The Implications and Obligations of Self - Financing Medical Education in a Southern Country

V. Manickavel & P. Rajaram.

College of Medical Sciences - Nepal, Bharatpur, Chitwan District, Nepal

Most countries of the South follow the Northern countries ; whether leading to perfection or disaster. Whatever the direction these Southern countries take, we must deal with the problems of development and some of the ethical implications. One of the problems of development, Health Care allocation, will be discussed here. The present improved health situation is attributed to modern technology oriented medicine. It is, however, expensive and tend to polarize the globe into pockets of ehavesf and ehave notsf. Whether it is north or south, availability of this technology oriented medicine depends upon the allocation of disposable income in a country. The division/allocation of the GNP pie for health care determines the longevity of a population of a nation and the populationfs ratio of death and birth. The larger the pie better the health of a nation . The race to defer or win the game of death is as old as humanity . The techniques and technology used at different times in this race may be different. At present , the technology and techniques used are available to everybody without discrimination on the basis of sex , caste , creed except for the resources which when we translate, it means, money.

If there are limited resources, what is the fate of these nations? Are they left out in the race? - Lost in the game? However still human resources are not scarce. There are means of including those who have been compromised in the allocation of resources, or for exploiting the resources in the race for development, and also to alleviate the fear of being left out.

One of the ways to bring the modern medicine within the reach of these Southern nations is to train the nationfs own people so that the transfer of technology will be easier and more effective, however it is hampered by the small portion of the pie. The cost of training in the modern medicine is prohibitive in these countries and also the transfer of technology is slow. Only a selected few are able to get the benefits of the technology, with the selection criterion passing to only individuals from advantaged groups having the resources. Training of this selected few is not fruitful because many of them wanted to be part of the resource rich society and desert the nation where they obtained their expensive training . So , it becomes critical to train, not those selected few from the resource rich population, but individuals from resource-poor backgrounds, so that their identification with the resource rich society will be only gradual and the longing to be a part of that society will be minimal .

However, until now, due to such nationfs limited resources, the training of deserving members of disadvantaged groups has not been possible in these resource compromised nations. One of the countries which is trying to solve this problem, that is to have more medical personnel while not loosing the benefits of these trained people, is Nepal. Here the health care allocation per annum is painfully below 3 dollars per person. Most of the terrain is mountainous and sparsely-populated with access to technology oriented modern medicine is very limited in such areas. With the recent democratization, there is more pressure for modernization and industrialization. Even before this change, modern medical education was accessible to only a limited number of people in one location. For the entire nation training 30 doctors per year have been trained, bringing the present ratio of one doctor per 2,3899 people.

The students selected under this system are mostly from individually resource rich families and from the dominant caste of the Hindu society. Nepal is a Hindu country. Most of the graduated physicians preferred to practice only in cities like Katmandu, Pokhara and other elite places. Leaving many of the primary health care centers unstaffed. The first medical institution was funded by the Nepal government with assistance from foreign government aids. Following this initial medical school, which was financed mostly by Japan, a second autonomous medical school was established in 1992 with Indian aid. At present , this medical school is staffed by Indian Doctors, who will be replaced gradually with Nepalese faculty as they become available.

To overcome the slow process and the future financial burden of running these institutions, His Majesties Government (HMG) of Nepal, through its parliamentary body, has decided to permit self financing medical institutions in Nepal . These medical colleges will receive no government aid but should build their own infrastructure including a large self hospital equipped with modern technology. HMG will monitor through several committees the standard of the facilities and the education offered by these medical colleges. International standards cure strictly enforced in the rules and regulations for the space, faculty and syllabus are strictly enforced. Many members from various bodies work as a single unit and allow no compromise on the rules and regulations. The HMG is very keen on providing quality medical education through these committees. These Committees will not regulate the fees collected by the college from the students, however, HMG will select 20% of the students on the basis of merit, who will get free education from these colleges, the entire cost of their education and training being borne by the rest of the students.

Another major requirement for obtaining permission for the college is the establishment of a modern well-equipped and staffed 700 bed hospital by the college. This hospital is to be a unit functioning 24hours a day and at any time at least 2,000 people are to benefit either through medical treatment or health counseling or economically by working in this hospital. Thus, most of these benefits go directly to the local people. Moreover 30% of the beds at any time is made available free to local impoverished patients. In addition to this, 10% of the beds will be accessible at a concessional rate to deserving patients. The obvious benefit to the region as indirectly resulting from the college is not discussed here. However, it is clear that because of these institutions, including their students, faculty, and staff, several thousand consumers will contribute to the growth of the local economy. Other allied educational institutions such as Nursing and Medical Technology colleges, will also be set up to take advantages of this situation.

These colleges, at present two, are run by societies and provide quality education according to the high standards set by the local regulatory bodies. At the same time, these privately funded colleges are a source of income for these societies. All the local regulatory bodies oversee these colleges to ensure that they function up to standard and not just to make profit. Profit-making without exploitation is the basic guiding moral / ethical principle in these situation.

Furthermore, allowing a business type operation in an exploitative situation is the ethical constraint in providing justice. In the Southern Countries due to advantages the ehavesf have over the ehave notsf will this education be beneficial only to this social and economic elite? The stringent conditions adopted by the independent committees and the conditions put forward by the government to obtain benefit from the institution for a percentage of the resource-poor part of the population give rise to justifiable benefits to the ghave notsh.

How is this aid program different from the normal procedure of inviting Multi National Companies on a silver platter in Southern countries? The basic difference, here, is that independent committees determine the conditions rather than the politician and bureaucrats. Here, in this situation, in addition to government committees academic bodies are also involved. The targeted main benefit is not of immediate nature and the immediate economic benefit is only an offshoot of the main developmental goal of improving health care.

In this situation , when we apply the philosophy of utilitarianism, justice is the primary ethical principle. However, in this case, in the absence of resources to provide quality modern medical education which will provide long term health care benefit to the nation, this form of self financing private entrepreneurial type of medical college in a Southern country does not compromise the principle of justice. By allowing this type of establishment, a country poor in resources can do justice to its citizens in a similar manner, by giving a modern medical education without spending valuable/public tax payersf resources. This may be a better route than aid programs where the aider dictates the terms to the aidee. However, the aid program which is discussed here is, new, where a southern/developing country helps a northern/developed entrepreneur, in what we may call entrepreneurial aid program. Here, the receiver dictates the terms and receives the aid in exchange for the entrepreneurfs personal development. The success of the entrepreneurial aid program lies in the implementation of strict rules and regulation which is the key factor .

Many different agencies under one central control should be involved, so that the various conditions imposed cannot be compromised. The basic difference in this aid program is that the donor is a private agency and gets benefits (profits) directly. However, due to the need to obtain that benefit from the receiver, the receiver can dictate the conditions of his/her benefit, In this way exploitation is averted.

In traditional aid programs, in order to receive the aid the receiver is always bound by conditions put forward by the donor. Most of the time these are ethical. However, sometimes they intrude into the receiverfs autonomy. This violation of the autonomy of a nation may be due to a lack of understanding of the culture or due to making them dependent on the providers of the aid. None of these serious ethical constraints will occur in the case of this new aid program, where the receiver retains their autonomy. The benefits are not given by the donor as in a traditional aid programme but are obtained in exchange for the aid given to the entrepreneurs (donors). Loss of autonomy for the sake of development in the alternatives is one of the key points to consider in favour of this type of aid program, where the receiver dictates the terms for reception of the benefits.

One of the objections that may be raised against this pattern is the giving of benefits or profits to the individual entrepreneur. In the traditional aid program, however, the benefit or profits were also channeled indirectly to entrepreneurs through a public agency, either Governmental or Non-Governmental. But in the system discussed here, entrepreneurs directly receive the benefits and thus is more transparent. This kind of transparency does not lead the receiver to a false view of aid as charity, when in reality it is an economic stimulation of the business enterprises of the host countries.

Simple value questions as advocated by Aristotle vis a vis Where are we going? Who is gaining ? Who is losing? Is it desirable ? Need to be asked about developmental issues (Bent Flyvbjerg). In this essay on a developmental issue of health care allocation, some of these simple value question are raised and discussed.

Acknowledgment

The Authors wish to thank Mr. Lok Bahadur Rana for his valuable discussions in developing this essay and Mr. Ashok Kumar and Ms. Chija Bhandari for their technical assistance. The financial support from the International Society for Medical Education (Regd. U.S.A.) is gratefully acknowleged.

References

Bent Flyvbjerg, Aristole, Foucault and Progressive Phronesis. Outlines of an applied ethics for sustainable development: In Moral Philosophy in the Public Domain. An international conference on Applied Ethics in Business, Medicine and Environmental Policy. Vancouver, B.C. Canada, 1990.

David Korten, Getting to the 21st Century - A global agenda.

Nepal Yearly Budget: 1996 to 1997 : Finance Ministry Report, HMG Nepal.

Statistics Year Book: 1991 - HMG Nepal.

Peter Singer, Practical Ethics, Cambridge University Press, 1979.


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