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