Solving Pakistan’s Women Doctor Shortage

Asif, along with his wife, Iqra, had been waiting in a packed room for almost two hours for their turn to see the doctor – a gynaecologist at the Lahore General Hospital. But it is worth the wait. The young couple has travelled almost 150 kilometres from the neighbouring city of Kasur only so that Iqra, who is three months pregnant, can be inspected by a female doctor.

Like Asif, scores of Pakistani men want their wives to be treated only by female doctors. Yet these same men and the social structures they stand for prevent women from becoming working doctors.

Last year, according to figures by the Pakistan Medical and Dental Council (PMDC), around 23 per cent of registered doctors in Pakistan were women – this despite the fact that an overwhelming majority (almost 70%) of medical students in the country are female. This trend has pursued consistently over the years, with recent statistics from the PMDC suggesting that half of all female medical college graduates do not practice their degrees even for a single day.

Wastage of resources

In an interview with Dawn in 2014, president of the PMDC, Prof Dr Masood Hameed, laid bare exactly how much brunt the national treasury was bearing due to a large number of female medical graduates not entering the profession.

“Students who got admission to medical colleges on general merit seats paid around Rs15,000 to Rs20,000 fee a year, so they completed their Bachelor of Medicine and Bachelor of Surgery (MBBS) by spending around Rs100,000.

“On the other hand, the government spends almost Rs2.5 million on each MBBS student. Unfortunately, after completion of the course, most of the female medical graduates never worked. Those who want to work try to leave the country and settle abroad, especially in the US, Saudi Arabia,” he said.

Ultimately, despite the extraordinary subsidy provided by the government, Pakistan’s citizens suffer in the form of an acute shortage of doctors, as Dr Hameed points out: “There are around 50,000 to 60,000 medical practitioners against a demand of 600,000 in the country.”

Doctors or homemakers?

Gender roles in modern day Pakistan are highly conservative. “For Pakistani women, their domestic, parental, and conjugal roles have the highest priority, whereas the occupational and community roles are secondary,” writes Iffat Hussain in her book ‘Problems of Working Women in Karachi, Pakistan’.

Hussain adds: “Traditional gender roles dictate that a wife’s job is to look after the home and family, and a husband’s job is to earn the money. Women are expected to submit, men are expected to dominate. Because of this practise, the differentiation between genders in access to social and economic opportunities is obvious.”

This gender disparity in access to economic opportunity – as Hussain puts it – and how it manifests in Pakistani society is aptly captured by the life trajectory of some of the smartest minds in the country. It is no secret that getting into medical school in Pakistan is demanding; only the best and the most disciplined students are able to land a place in the prestigious government-run institutions. Rubina

Tahir, a professor of obstetrics and gynaecology at Karachi Medical and Dental College, told Al-Jazeera that 90 per cent of her students are girls. When asked why, she said it was because “medical schools in Pakistan recruit on grades alone, so the majority of medical students end up being women as they make better grades”.

So what happens when women leave medical school?

Bina Shah, a Pakistani novelist and columnist for the New York Times, identifies the issue in a column on missing doctors: “The problem isn’t what happens during the five years of medical school. It is what happens almost on the day after she graduates: she’s pressured into giving up the house job that a young medical graduate must undertake before being able to specialise.” Yet others look at it differently.

In a BBC report on the issue, vice-chancellor of Shaheed Zulfiqar Ali Bhutto Medical University in Islamabad, Dr Javed Akram, touched on the same point, albeit in a different tone: “Some female students are more keen on catching a husband than on pursuing a career”.

“It’s much easier for girls to get married once they are doctors and many girls don’t really intend to work as professional doctors,” he says. “I know of hundreds of female students who have qualified as a doctor or a dentist but they have never touched a patient.”

Dr Akram views the problem as a micro one, where the agency, not the structure, is the root cause. The individual choice of female graduates is to blame for the trend, according to him. Shah, on the other hand, is referring to the overarching social structures at play, which condition and pressure women into choosing family life over their careers as doctors. Whichever view one accepts, individual choice or social structures, there is no dissent on the consequences: a severe shortage of doctors in an already fledgling health system.

But even women who, against all odds, persist with their profession, often bow out later in their careers. “Long working hours, especially on-call days, affect family life and can lead to problems between husband and wife,” says Dr Asma Saeed, a young practising doctor in the south Punjab city of Multan.

“It’s a tough ask to cook and care for a household after a 12-hour shift. If the husband is not compromising, many female doctors stop working. I have seen numerous cases of women doctors leaving work, or halting for a year or two, after having a child,” she says. Dr Saeed said a lack of day-care facilities exacerbated the situation for women doctors with children. “If day-care facilities are provided at public hospitals, many female doctors could avail them and continue working.”

Aside from quitting because of marriage, some also seek jobs in other fields such as in pharmaceuticals or hospital administration, because those jobs pay better, Dr Tahir tells Al-Jazeera.

Quota system

Eventually, in an attempt stop the drainage, the PMDC made a policy change in September 2014, abolishing merit-based admissions to government medical colleges and instead reserving 50 per cent seats each for boys and girls. But that did not go well in many sections of society, most of which saw the move as penalising women for “being too smart”.

The regulatory body’s new rule was immediately challenged in court and in a landmark decision, the Lahore High Court abolished the quota system. Justice Ayesha A Malik in her judgment pointed toward the discriminatory nature of the quota and more importantly, rather than accusing women for creating the problem, asked the body to find out how the working environment could be improved.

“[I]t is alarming that merit has been wasted and compromised, which ultimately means that the quality of doctors in the medical and dental profession has also been compromised. This affects the public at large. Furthermore it goes against the very spirit and purpose of the mandate of the regulator PMDC whose job is to ensure optimum results from medical and dental colleges as well as the medical profession. In the very least they should have conducted a study to ascertain the problems and their reasons and then worked on solutions and improvements.”

Justice Ayesha A Malik

Back to square one

With the PMDC’s move quashed in October 2014, the core problem – that of scarce doctors, especially female doctors – remains unsolved and with each passing year, more and more trained female doctors are staying out of the system.

For many who had criticised the quota policy, including renowned columnist Fasi Zaka, the crux of the matter lay in how policymakers viewed the problem. Talking to BBC, Zaka said, “Yes, doctors are leaving, but the restrictions should be at the point of exit rather than entry.” In other words, new policy should be aimed at preventing trained doctors from leaving, rather than closely guarding who gets to enter.

Surprisingly, PMDC president, Dr Hameed, in his 2014 talk with Dawn had said he was “formulating a proposal under which every student who got admission to a medical college on general seat would be bound to work in the government or private sector in the country for at least three years after graduation. Those who want to go abroad would have to pay the amount of subsidy - Rs 2.4 million - paid by the government for their medical education.”

Yet three years on, no new policy measure has been put forth by the regulatory body despite its supposed remedial measure having been outlawed by courts. Neither has it funded or carried out an official study, as advised by Justice Malik in 2014, to “ascertain the problems and their reasons”.

Cure: compulsory service with incentives

Most countries have faced in some form or the other shortage of doctors or healthcare workers, reveals a 2010 study sanctioned by the World Health Organisation (WHO).

Titled “Compulsory service programs for recruiting health workers in remote and rural areas: do they work?” the study identifies 70 countries that have used law or policy to implement mandatory deployment and retention of health workers in the underserved and/or rural areas of the country for a certain period of time.

“Depending on the country, doctors, nurses, midwives and all types of professional allied health workers are required to participate in the programme. Some of the compliance-enforcement measures include withholding full registration until obligations are completed, withholding degree and salary, or imposing large fines.”

Having closely looked at the cases of mandatory service requirements in the 70 countries, the study concluded that these policies, “if well planned with incentives, can contribute to a nation’s plan for health workforce capacity development, distribution and retention”. Examples of success stories include countries such as Ecuador and Thailand, where programmes combine incentives for education, employment and living provisions. In Thailand, public medical school graduates must perform compulsory service for three years. They may supplement their public salaries by concurrently practising privately, or they can receive US$ 250 per month if they agree only to work in the public system, the report reveals.

Instances of mandatory service and fines for violating contracts have been imposed in several Indian states as well. As recent as last week only, the Indian state of Bihar implemented a new policy whereby post-graduate medical students will have to work for the government, in rural and urban areas. Those who opt out will be liable to pay 2.5 million Indian rupees in fines.

But in Pakistan’s case, no such policy has ever been seriously considered, despite the multiple success stories from around the world and in the neighbourhood. Any suggestions to this effect, such as the one made by Dr Hameed in 2014, seem to have been rhetoric alone. In the meantime real problems plaguing the sector remain untreated, as Bina Shah illustrates in her column: “The principal of SMBB Medical

College Lyari, Dr Anjum Rehman, told the panel that rates of female-specific cancers and subsequent mortality rates are shockingly high, especially for women living in rural areas and the peripheries of the big cities of Pakistan, because there aren’t enough female doctors to treat them.”

Dr Seemin Jamali, Executive Director of the Jinnah Postgraduate Medical Centre – Karachi’s largest government-run teaching hospital – agrees that mandatory service requirement is the need of the hour for Pakistan. “Of course there should be a minimum mandatory service setup for all doctors in Pakistan. Not using the skills that students acquire is a great loss to the government and the country,” she remarks.

“Women in Pakistan work harder than men. Such policy measures will mean they need to be a hundred per cent certain that they will pursue their career as doctors before choosing to study medicine so that the country’s resources are not wasted”.

Unless such measures are adopted, couples like Asif and Iqra will have to make arduous journeys from city to city in search for female doctors.