Is Pakistan producing enough doctors? Most people involved in healthcare will say no, we don’t have enough doctors. It is correct we have fewer doctors than we should considering our population. However, over the last two decades the number of public and private medical colleges has increased tremendously and with it, the numbers of doctors produced annually. Yet we have not seen any real improvement in the quality of healthcare available to ordinary citizens of this country.

Even so, our politicians, private medical entrepreneurs and the healthcare bureaucracy keep pushing the idea that more medical colleges and more doctors will fix the problems of a nationwide lack of adequate healthcare delivery. Having more doctors graduating from medical colleges every year does not automatically translate into better medical care. There are many reasons for this and I will discuss some of the more obvious ones.

At the present time, almost two thirds of graduating doctors are women, and of these women doctors a distinct majority will never practice medicine. The reason is that once married, most women will defer to their husband’s wishes and refrain from working. It is a cultural imperative in our society that a husband that makes his wife work is somehow ‘inadequate’. Then there are also religious reasons that make ‘devout’ men prefer to keep their wives at home, away from the ‘public eye’. Exceptions, as the adage goes, are there.

If most women will never practice medicine then why do so many of them pursue such a relatively arduous academic career in the first place? The answer to that question is quite interesting. Many men prefer women who happen to be doctors as ideal marriage partners. Not because these women will go on to earn a decent living and perform a useful function in society but because having a doctor as a wife is thought of as a matter of some pride and superiority. Parents realise this and push their daughters to become doctors so that they will have a better chance of marrying well.

It would then seem that more than a third of all graduating doctors in Pakistan will never practice medicine. And that all the new medical colleges being established in the private as well as the public sector are really catering to the ‘marriage market’rather than the need for better healthcare. Of course, our medical entrepreneurs in the private sector realise that all they need to do is produce more female doctors and make money doing it. The quality of medical education being of secondary importance, all that is needed are women with an MBBS degree.

Even though most female doctors will never practice medicine, the total number of doctors that graduate every year and go on to practice medicine is still much larger than it was even a decade ago. So the next question is why has this increase in total number of doctors not translated into better healthcare? This brings us to the real problems facing healthcare in Pakistan.

It is important to realise that doctors do not work in a vacuum. They need hospitals/clinics, functioning laboratories, well-stocked pharmacies and trained pharmacists, nurses, and all other support systems to be able to take care of patients. And yes they need a ‘living wage’ to function as individuals with families.

The real shortage in Pakistan is not just of doctors but also of all the other ancillary medical personnel and the facilities that I have mentioned above. On top of having a dysfunctional public healthcare system we also have a rather spotty and at times entirely inadequate system of post-graduate medical training. I have already alluded above to the rather inadequate medical education being provided in our medical colleges.

So what we now have is a large number of poorly educated doctors being produced by what can only be called ‘medical mills’, who then go on to train in poorly supervised training programmes and then go out and work in difficult situations for little money and are expected to take care of a multitude of sick people. And that is the tragedy of our system of medical education and healthcare in the public sector. Poorly trained and underpaid doctors working in impossible situations cannot be expected to function at any decent level of competence or with any dedication for that matter.

Here I must admit that within this morass of inadequacies, there are some medical institutions and training programmes that actually produce well-educated and well-trained doctors. What happens to these well-educated and well-trained doctors? The best of them, especially if they manage to get some foreign training, almost always end up in the private sector. Of the rest, an ever-increasing number leaves to work in Middle Eastern countries where they are paid at least three times as much if not more than what they get paid in the public sector in Pakistan.

I have painted a rather dismal picture and sadly it is just that. Can things get better? Of course they can and building more medical colleges is definitely not the answer. The first thing that needs to be done is to declare a moratorium on building new medical colleges both in the public and the private sector. Then all the existing medical colleges should be examined critically and those not up to snuff should be closed.

The next step is that the Pakistan Medical and Dental Council (PMDC), the College of Physicians and Surgeons of Pakistan (CPSP), the provincial directorates of health and health departments should create a collaborative body that objectively examines the healthcare system as it exists in the public sector and determines what needs to be done to improve the quality and the ‘amount’ of healthcare that can be provided in the public sector.

The collaborative body I have suggested should determine what sort of manpower and facilities are needed and can be provided at the budgetary allocations available. In terms of doctors, it is imperative to determine what sort of doctors we need. It would seem to me that what we need most are ‘general physicians’ that after graduation from medical college spend two or three years in different subspecialties so that they can take care of a variety of patients at a basic level.

The existing network of the rural healthcare centres, basic health units, and smaller hospitals should be revamped and fully manned and equipped and the general physicians, male and female, should be encouraged to work in these institutions. Of course, it will be necessary to assure appropriate remuneration, incentives, and facilities to attract and keep these physicians in these places, at least for a few years.

The number of ‘specialists’ being produced should be controlled to match positions available for them in the public and the private sector with some built in redundancy. Of course, the total number of physicians being produced in all specialties will have to be re-evaluated periodically and increased as demand for their services increases and new hospitals are built to accommodate them.