The Doctors’ Conundrum

Recently I had a discussion with some young doctors who were very upset that their salaries were too low and felt rather strongly that the government owed them to increase their salaries. Ironically all of them had graduated from a public sector university which meant that they had received a Rs. 2+ million education for nearly nothing at all. Lets be fair, if I were in their shoes, I too would demand higher salaries and guaranteed jobs.After all they see everyone else in the society looking for government privilige as the way to make it in the society. But that is not how the world works.

Although there aren’t good data on how many healthcare providers work in Pakistan, the best estimates suggest that perhaps there are around 300,000 healthcare providers (around 1.6/ 1000 population) of which around a third are doctors. Doctors and doctor groups often cite the WHO which recommends that there should be at least 2.2 healthcare providers per 1000 population. The government obviously supports this argument since it subsidises the education of over 6000 new doctors each year. In fact more than 12000 new doctors are educated each year, slightly more in the public sector (for nearly free) than in the private sector.

This is where it gets really interesting. There are only 130,000 doctors currently registered with the Pakistan Medical and Dental Council. This registeration is mandatory for all doctors to be allowed to practice or receive the mandatory “house job” training. If we have been producing 12,000 doctors annually for 50+ years, even accounting for death and retirement, there should be at least 300-400,000 on PMDC registers. Even those who proceed abroad for education or migration must surely have done their house job training and hence must have registered with the PMDC. And yet there are only 130,000. This suggests that the vast majority of doctors who start their medical education never intended to practice in Pakistan and don’t even bother to do house jobs or register with the PMDC. To me this suggests that most of the medical students understand that their prospects in Pakistan’s job market are unacceptable and never even try to take their chances with it.

So what happens to those doctors who do practice in Pakistan. In our own research, those that practice in extremely poor communities such as urban slums and the rare few that work in rural areas, do so for very low rates. In one study in Rawalpindi and Tando Allah Yar districts, the average doctor saw 16 patients a day and charged Rs. 65 if they only gave pills and around Rs. 125 if they gave injections. Even specialists in big cities work very hard for their seemingly high incomes. Most of my surgeon friends that earn close to Rs. 900,000 to a million a month, work close to 90 hours a week. This comes to around Rs. 2,500 per hour. Professionals with similar length of training and experience that work in the corporate sector, earn at least 2-3 times more than that.

These factors combine to confirm that there is a glut of doctors in Pakistan, i.e. there are too many of us and Pakistan’s current healthcare markets can’t absorb all of us. Young doctors know this and many don’t even test the markets. More senior ones do and sometimes earn a good living but at the expense of tremendous working hours. It is not surprising then, that the most doctors I meet are dissatisfied.

One must ask, why then is the government producing so many doctors when there is a glut. Surely the argument that we need them in rural areas has worn thin. No one who has dedicated 16+ years of their lives on receiving an education and more years of professional training wants to work where basic amenities such good schools, social life and a decent income are unavailable. We have not found a solution for rural placement, producing doctors in glut is surely not the answer. A better option to Pakistan’s very skewed healthcare provider mix is to concentrate on producing more mid-level providers who feel more comfortable in rural or remote placement and stop the subsidy – i.e. free public sector medical education – to produce more doctors.

Since writing this, I found the following oped from 2013: The Doctor Glut by Rafia Zakaria, Dawn 19 July 2013

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Independence Day 69 – Thanks for Our Home

Yesterday was Pakistan’s 69th independence day. Some celeberated exuberantly, while others remembered the ongoing sorrows. However, in the balance there was more cheer on the street than in recent years. And why not. Our independence day should be celebrated, if not for any other reason than the fact that we are free; for people without a land have wretched lives. Unhomed are never welcome anywhere.

That there were more people out in the streets than in recent years is good. Recent years have seen ordinary citizens abdicate public spaces to those who kill, terrorise or loot. For that reason alone it is good that so many Pakistanis felt safe enough to start reclaiming these spaces. It would be even better to have more places and activities where people can celebrate. But even when there are such few outlets for their joy, people turned out, claiming Pakistan as their own.

I see this as a slow and subtle turning point. Pakistan has not been easy for its citizens. Even today, a woman dies every half hour while giving birth and over half of our children and mothers are malnourished. Fewer than half the children study beyond secondary level and even when they do, they can’t read or write at that level. Nearly half of the population lives below the poverty line. 68 years later, this is not what nearly 2 million of our ancestors gave up their lives to achieve. They would want more prosperity for their children. So one may ask where is the turning point.

Slowly, things are improving. One sees the prosperity in the cities. The middle class has expanded. The GDP has more than doubled in the past decade. Indicators for development, health and education have improved albeit slowly. One felt that much that could have been possible in the past decade was squandered while the state played the militant game. This year, it appears that this game may be winding or at least tempering down. Any way, with a marked reduction in terrorist attacks on civilians and in public places this year, the change is noticeable and people are feeling a sense of safety.

Hopefully this will continue. People will continue to reclaim public places back from the militants and terrorists. The expressions of celebrations will transform from these forays into public spaces and flag waving to more constructive “owning” of the country. But this will take some time. People still have to feel that the country is their’s because it benefits them. Not a place where they pay all kinds of taxes while they also take care of their families and loved ones. All that will take time and will require continued stability, safety and some measure of economic independence. People need to continue to feel that their efforts can consistently give them returns and not be arbitrarily taken away from them at someone powerful’s whim. This feeling is still too strong and with good reasons. The state and its government remain whimsical and arbitrary. But even that is slowing down as people have learnt to protest and make it heard. Hopefully this trend grows, driven by increasing autonomy and economic power of the people and the resultant ability to be heard by their leaders.

Still the road is long. But in the meantime, let us be thankful. We have a land that is ours where all this can play out. Onwards to another decade. May its end see us better off than now, by far.