Hamza Hayat 20110154

Taaha Awan 20020418

Ahmed Hussain 20020371

Muhammad Hamza 20100072

Adeel Faheem

Contemporary Social Policy

Ahsan Rana

Deficit in Healthcare Provision

Background and Causes:
Efficient provision of healthcare services comes under the domain of state responsibility as this non-
economic variable for development and growth of any country plays a pivotal role. Almost every country
across the globe faces this common challenge of ensuring well-performing workforce of healthcare either
in the times of existing shortages or the projected ones. According to the criteria recommended by World
Health Organization (W.H.O) for the doctor population ratio in developing countries like Pakistan is 1
doctor for a 1000 individuals. The statistics evidently paints out an alarming picture where registered
doctors especially the females do not practice their profession leaves out 1 doctor for 1800 persons. Over
the past few decades this shortage of doctors in Pakistan is a threatening problem. Non-availability of
doctors especially in the government hospitals, brain drain of doctors due to their bright career prospects
and rural areas being deprived of hospitals are the news that rings up ears of every Pakistani continuously.
In order to bridge the healthcare gap between doctors and citizens Pakistan needs to increase the
production rate up to 1.8 times than it is producing currently. The primary concern of the government
healthcare agencies should be to impede the low doctor density and ensure that these doctors practice in
Pakistan.  
The problem being faced by Pakistan for a long time is the lack of doctors in the profession which
consequently lowers the per capita doctor ratio and unfortunately Pakistan has one of the lowest doctor
densities on the planet Earth. How can 232,986 registered PMDC doctors (MBBS & BDS including the
specialized ones) cater to the healthcare needs of population mounting around 208 million? 
  
 However, studies depict that most of the female doctors instead of practicing their profession they drop
out due to several reasons discussed in later part of the report. In 2014 Pakistan Medical and Dental
Council approached Supreme Court in over the gender-based merit list issue and proposed 50% male and
female ratio which had to face a backlash from all over the country. PMDC revealed an eye opening stats
to back up their argument that out of all medical dental practitioners 50% were females. The
upsetting part is that only 50 percent of them are working. This decision according to them was made in
National Interest since 70 percent of students admitted to medical colleges were females and the deficit of
marketplace is taken into account is around 25%.  
According to Registrar PMDC Dr. Amjad Mehmood, “moreover, majority of women doctors do not work
so an amount of over Rs2 million spent on them by the government goes to waste.” Their
proposition wasn’t put into practice as it was unfeasible considering in the cultural and social norms of
society where only two professions i.e teaching and medical are socially acceptable. According to the
current policy, students are not bounded over to practice in their country after graduating from the
medical university. Furthermore, the high dropout rate of female doctors is due to no legal constraint that
prevents them.  
There are several reasons for low doctor density in Pakistan and the aftermath of these poor healthcare
causes is aggravating and has plague this country which we need to get rid of. The very first on the list of
problem analysis is the high cost of medical profession. In medical universities of Pakistan there are two
types of seat i.e open merit and self-finance. Since the Open Merit seats are considerably very low and are
charged with lower fee and on the other hand not everyone can afford self-finance that costs around 50
lac for the MBBS degree. The brain drain of self-financed doctors from Pakistan to the first world
immediately after graduation is because of their huge investment of money and aren’t willing to work on
low wages.  
According to study, “In Aga Khan, 900 out of 1100 graduates left Pakistan in 2004 for further studies.”
(Masood, 2017) Secondly, the career stability time for a doctor spans along the course of a decade. It
includes 5 years to complete the MBBS program, the house job and then clearing of Medical Licensing
Test is a whole process of years itself. To increase the worth and credibility some go for specialization it
takes another half decade as compared to their batch mates who presumably settle in a course of 5-6 years
only, loses charm in the medical field. Tracing out the link, this can be a reason of substantially less
number of male admission in this field the degree is quite long, challenging and demanding.  
 
 
 
These statistics from Lahore Board showcases the common trend in Pakistan where boys have the pre-
conceived mindset of pursing Engineering as a major as the time to get stable is less as compared to the
majority of girls who opt for medical after intermediate.  
 
 
 
The notion of ‘Rishta Bahu’ is prevalent in Pakistan. It unpacks the concept of a female who after
completing her qualification from PMDC settles and get married after graduation and do not practice their
profession. The socially stratified patriarchal society confirms that medical degree of a woman is used to
increase the prestige of the family she plans of getting marrying into. The chances of getting a good
proposal highly increases and ‘catching a good husband’ is often heard this is the part of this concept.  
The low wages of doctors even after getting their qualification compels them to settle aboard and
continue their practice there. According to the OECD Health Statistics, “As of 2013, there are over
12,000 Pakistani doctors, or about 5% of all foreign physicians and surgeons, in practice in the United
States. Pakistan is the third largest source of foreign-trained doctors. India and Pakistan also rank as the
top two sources of foreign doctors in the United Kingdom.”   

Effects and Evaluative Criteria:

Social and Economic implications 

Currently Pakistan faces an acute shortage of doctors, nurses and other medical professionals. The
exceedingly large ratio of patients to doctors has led to a number of problems. Doctors have increased
workloads, greater time constraints so they have to spend less time per consultation, They are also
overworked which leads to poor quality care. Furthermore, there are greater wait times before
consultations and it not unheard of for people with serious injuries or in serious pain to have to wait for
several hours before a doctor is available to see them. This has manifested itself in the social indicators of
Pakistan. For instance, the infant mortality rate in Pakistan stood at 61.2 deaths per 1000 live births in
2017 according to World Bank. Contrast this with the nearby countries of Bangladesh 28, Afghanistan 53,
Iran 13 and India 32. The male and female life expectancies were 68 and 66 respectively compared to 
71 and 74 in Bangladesh and 75 and 77 in Iran. These indicators paint a bleak image of Pakistan’s Health
care. Twenty eight percent of deaths (Ischemic heart disease, Lower respiratory infections, stroke and
Diarrheal diseases) ,according to CDC, can be prevented by a responsive health care system. With the
current rate of growth of the population these figures are likely to grow even worse. 

As a developing country Pakistan does not have sufficient funds for an extensive health care system.
Indeed Pakistan spent 12,944 million rupees on health affairs services in the year 2017-2018  which was 3
percent of the total budget. With a shortage of funds it becomes harder to train more and more doctors.
However, currently a large portion of the doctors educated under a subsidized program choose not to
practice medicine all together, while many other opt to leave the country. According to a report in 2014,
the government spent nearly 2.4 million rupees on each student over a matter of five years. If graduating
students do not practice medicine this leads to a huge deficit in the already meagre funds allocated to the
health care system. As the number of female medical students increase, the chances of a large number of
them not practicing due to societal pressure early marriages etc means this problem of graduating doctors
not practicing will grow even more. Thus there is a money drain in the health sector. 

Evaluation criteria 

This report provides several policy alternatives in an attempt to mitigate the problems discussed above. In
order to judge each policy recommendation this report will set a criteria to judge the effectiveness of the
policy. The criteria covers Brain drain, i.e the phenomena of doctors choosing to immigrate and practice
medicine in another country; cost, i.e how much money and effort in terms of time and human resources
it would take to implement the policy; increase in the number of doctors that are practicing in the field,
decrease in doctor patient ratio that currently stands at 1:1762 and finally the wasting of doctors who
choose not to practice medicine either because they do not want to or because of societal pressures such
as marriage or taking care of kids. We will also judge different alternatives on the basis of their impact on
the general health of the populace and ultimately on the GDP growth. A good policy consequently will be
one which scores favorably on all the positive measures such as increase in number of practicing doctors,
decreasing brain drain and waste, while also scoring low in terms of cost.  

Policy alternatives, assessment, implementation and evaluation

Flexible working hours and Hourly Contracts

To facilitate, motivate and utilize the female doctors who have been either forced to quit their
jobs because of societal pressures or due to increased responsibilities, we need to look at certain measures
that would encourage them to achieve a work-life balance that enables them to re-enter the health
workforce whilst giving them incentives. Majority of female doctors in Pakistan quit their practice after
marriage. This is largely because their In-Laws do not permit them to work 8-hour shifts plus
overtime daily, due to the fear that they would not be able to take out time for their familial
commitments. 
One initiative which the Health Ministry could undertake, is to introduce the concept of Flexible Working
Arrangements especially for female doctors.  
Flexible Working Arrangements are arrangements that give employees the opportunity to make changes
to their work schedules, the times they work or where they work. Flexible work enables employees and
businesses, both to benefit. (“Flexible Working Arrangements.”) 
One way to implement this is to enable the female doctors, that instead of doing 8-hour shifts
daily, they could work for 4-5 hours during the school timings of their children which could enable them
to work a considerable amount of time while not interfering with their familial commitments. Working 2-
3 days a week instead of the orthodox 5-day work-week could also prove beneficial as it would
considerably reduce the amount of work. These measures would result in reducing the Doctor to patient
ratio in hospitals, enabling the hospitals to have a larger pool of doctors available to treat patients,
thus reducing the burden on doctors and lead to more efficient management of resources. 
Hourly contracts instead of the orthodox monthly or yearly contracts, coupled with the flexible working
hours arrangements can prove to be a great incentive for those doctors who either have other
commitments or are planning to further their qualifications.   
Globally, flexible working hours have resulted in increased employee productivity and increased
engagement. Part-time doctors show greater enthusiasm resulting from a better work-life balance which is
invaluable in the workplace environment. (“Do Part Time Women ….”)

Childcare Centers in hospitals:  
Female doctors struggle to continue professional practice with long working hours and a major part of
this struggle is the severe shortage of childcare facilities in workplaces. Globally, we see that an increased
availability of childcare facilities increases women participation rate in the workforce. Moreover, as we
observe in Pakistan, long working weeks that are coupled with little or no childcare facilities in hospitals
in general and government hospitals in particular have negatively influenced the motivation of the female
doctors to work. Thus, increased burden of family responsibilities has been termed as the major reason
why female doctors find it increasingly difficult to pursue professional practice after having children.  
To tackle this issue, the Health Ministry needs to set-up childcare facilities in the hospitals so to
encourage female doctors to continue their professional practice after having children. For this, the
government must increase the Health Development budget to make these facilities in the government-run
hospitals. 
Through the introduction of Childcare facilities, female doctors would be given an incentive to pursue
their practice in a way that would entail that they do not fail with their maternal responsibilities.
Although, it would cost a lot to the government, but the long-term benefits would outweigh the costs. 

Telehealth & Home Clinics: 

We can also look at examples of how the Western countries have tackled the issue of a deficit in health
provision. Since the use of Internet has transformed modern life, employing it for better provisioning of
health is a suitable endeavor. One such technique, employed in the West, is Telehealth.  
Telehealth is the use of digital information and communication technologies, such as computers and
mobile devices, to access health care services remotely and manage your health care. (“Telehealth:
Technology ….”)  
Telehealth has a wide variety of advantages especially in a country such as Pakistan. It reduces the
number of visits for health services. It requires fewer space demands and can be operated in smaller
health facilities.  
In Pakistan, telehealth has been pioneered by a startup called Sehat Kahani, which aims to empower
female doctors across Pakistan. (“Sehat Kahani, a Startup ….”)
It primarily is trying to produce an all-female provider network which connects home based female
doctors to patients in far-flung and remotely accessible areas using modern technology. Sehat Kahani has
worked to connect out-of-work female doctors with patients from extremely under-served parts of
Pakistan. 
Contracts/ Awareness/Loan Schemes:

As discussed above the main problems surrounding the healthcare sector of Pakistan have been the
prevailing trend of “Brain Drain” and the fact that most people do not practice medicine after they have
completed their degree. A comprehensive solution to these could be to establish contracts between future
doctors and the State at the time of admissions into public sector medical colleges. The nature of these
contracts would revolve around gently compelling doctors to serve the people of Pakistan through public
hospitals for a specific period of time (3-5 years) after they have completed their studies as a way of
repaying the funds expended on them by the state, which by a recent Supreme Court trial was estimated to
be Rs 0.4 million/year on each student. The implementation part of these contracts require special
attention as the limitations placed by it should not be too harsh as to discourage people from pursuing the
medical profession altogether. Reducing the health benefits that Doctors and their immediate families
receive could be a possible penalty that would discourage them from not respecting their contracts. The
main cause of “Brain Drain” has been the feeble working conditions and the meager salary paid to
Doctors in public hospitals. According to estimates by World Academy of Science, Engineering and
Technology almost “1000-1500 physicians leave Pakistan annually out of which only 10% return to
Pakistan” this would constitute to about 25% of Doctors lost to emigration till now. Another survey
conducted by Agha Khan University revealed that 95% of the student body at AKU and 65% of students
at BU wanted to emigrate due to low salary. Thus, it is imperative that Doctors are provided with better
salary packages and working infrastructure to incentivize them to stay.

Another harrowing statistic that we came across was that only 28% of females that graduate medical
colleges are present and practicing in the field. This coupled with fact that there are many un-employed
Doctors in Pakistan piles more misery on the deficit in healthcare provision. These however, are not
beyond the realms of being solved. As mentioned earlier in the report the main cause of female doctors
missing from the field was the fact that they got married and preferred to stay home by their own accord
or for the wishes of their spouses. An initiative needs to be taken by the State to run awareness campaigns
that would help the patriarchal society of Pakistan to understand the importance of having female doctor
participation in the field. The campaign would also focus on providing information on the transition from
unemployment to Self-Employment. Self-employment in this regard refers to the State facilitating people
especially women to open House-Clinics. This would not only extend health provision to a larger
populace but also conform to the prevailing societal norms. House-Clinics help Doctors to keep flexible
hours. Numerous first aid emergencies require straight-forward prescriptions but in Pakistan every
emergency is treated at hospitals which increase the burden on them and people with more complicated
problems are left unattended, the presence of simple house clinics would solve this problem. Furthermore,
building hospitals require huge capital as compared to facilitating the construction and running of
multiple house-clinics simultaneously and at different locations, even remote areas that have been
previously neglected. An extremely effective initiative that is being taken in this regard and needs to be
promoted more, is the workings of departments like the Punjab Healthcare Foundation (PHF). PHF
provides interest-free smart loans to professionals from various healthcare categories, which by data
provided by the organization is 45 in number. The foundation provides loans in three packages i.e. Rs 2
Lakh, Rs 7 lakh and Rs 25 lakh. The repayment scheme has been closely planned with Akhuwat
Foundation and reports suggest almost 97% of loans are repaid. The scheme has completely
revolutionized the concept of Entrepreneurship in the private sector. It has created more jobs, employed
more doctors, provided healthcare to more people and has also increased accessibility to healthcare in
remote areas.
 Works Cited
 “Flexible Working Arrangements.” Negotiating the Agreement » Employment New Zealand,
www.employment.govt.nz/workplace-policies/productive-workplaces/flexible-work/.

 Yong, Jean, et al. “Do Part Time Women Doctors Make a Positive Contribution to the NHS?”
The BMJ, British Medical Journal Publishing Group, 17 Feb. 2015,
www.bmj.com/content/350/bmj.h774.

 DW, Dawn.com |. “Sehat Kahani, a Startup Aiming to Empower Female Doctors across Pakistan,
Raises $500,000 in Seed Funding.” DAWN.COM, 24 Mar. 2018, www.dawn.com/news/1396670.

 “Telehealth: Technology Meets Health Care.” Mayo Clinic, Mayo Foundation for Medical
Education and Research, 16 Aug. 2017, www.mayoclinic.org/healthy-lifestyle/consumer-
health/in-depth/telehealth/art-20044878.