Muhammad Hanif Shiwani ( Barnsley District General Hospital and University of Sheffield, Gawber Road, Barnsley, S75 2EP, United Kingdom. )
September 2007, Volume 57, Issue 9
Opinion and Debate
Although the ratio between available health facilities and the population has recorded a slight improvement over last years and the number of doctors has increased but it is still below the recommended ratio of one doctor for 1,000 patients. This suggests that Pakistan needs to produce more doctors.
There is a rapid upsurge of private medical institutes in the country in the last two decades. At present there are 57 medical and dental colleges recognized by the PMDC and about half of them are in private sector. About 6085 students get admission per year in these colleges. Though the numbers of private medical colleges in the country are almost similar, however, only about 30% medical students get admission in the private medical colleges. This is due to the significantly lower numbers of the available seats in the private sector.2 A significant number of doctors emigrate and few hundreds physicians per year stop practicing for various reasons.3
Pakistan's population is over 165 million in 2006. With rapidly growing population and rapidly growing field of medicine there is an inevitable need of medical practitioners, both generalists and specialists in the country. The current ratio 0.473 physicians per 1,000 population in Pakistan is inadequate to maintain the nation's health.3
There are many postgraduate medical centers in Pakistan, that are providing excellent training programmes, better than some training hospitals in developed countries. However, there is no standardized and structured postgraduate medical career programme at provincial or national level. Private medical institutions are flourishing in Pakistan, especially in Sind and Punjab and many postgraduate training institutions have been upgraded to university status and are getting more autonomy. The availability of up-to-date medical facilities and well remunerated highly qualified faculty helps in providing a better quality post graduate training in some of these institutions. However, training of doctors in some of the public funded postgraduate medical institutes without any remuneration and exploitation of postgraduate doctors is a well known fact. Funding for training is a major issue in Pakistani health system. There have been major changes in the health service in Pakistan over the last few years. The emphasis has shifted from tertiary care to primary and secondary care. However, due to lack of careful planning and financial restraints, funding for the teaching hospitals has reduced. The teaching hospitals are less willing to pay the salaries of the trainees. This is particularly true for new trainees who do not have longstanding posts as medical officers. Most of the trainees therefore fund themselves. Recently the College of Physicians and Surgeons have put a ban on having unpaid trainees in the training centers. This may result in future reduction of training posts.4
Majority of Pakistani doctors wish to go abroad to obtain training. Many want to continue working there due to better financial rewards and many do not want to come back to Pakistan due to inadequate facilities and poor working conditions. A significant proportion of these doctors prefer to go to UK and USA. Overseas doctors make up about one third of the junior doctors work force in United Kingdom.5 Over the past few years significant changes in the immigration and training system in UK has seriously caused concern to non-EEA International Medical Graduates (IMG) to seek training post in UK. The recent changes in the immigration rules in United Kingdom came into effect in April 2006. Accordingly all postgraduate medical and dental training positions are now defined by the Home Office as employment posts and would require work permit. To obtain a work permit, employers have to make sure that there is no EEU national available for the post before they can offer it to a non-EEU IMG. Some doctors and dentists may have been accepted onto the Highly Skilled Migrant Programme (HSMP). Doctors and dentists who have worked under HSMP can take up any training or employment posts.6
The recent introduction of the foundation programme in UK has worsened the situation for non-EEC IMGs. In past medical students graduating after four-six years in medical school were allocated a one year placement working in a hospital as a pre-registration house officer. After one years training they could obtain full registration with the general medical council.7 A significant number of Asian doctors after passing PLAB used to seek a clinical attachment. Subsequently they got Pre Registration House Officer and Senior House Officer jobs. Majority of these doctors had already spent some length of the time in training after graduation in their native countries. This relatively new training system vitally closed the door for junior doctors to enter into the medical training system of UK. This is because their training renders them overqualified for foundation year one and two jobs.
The current situation in UK and USA is not conducive for Pakistani doctors due to tight emigration rules and now changing medical training policies. Opportunities for the Pakistani doctors to get specialized training and experience of good medical practice have diminished. The report of one Pakistani doctor committing suicide in UK recently, after a failure to thrive in the system for the reasons mentioned above is a dreadful example.8 Facing the dilemma of staying in Pakistan or explore the avenues in UK and US, doctors have been advised to obtain training at home.9 This will certainly reduce migration of medical graduates. More and more doctors will be looking to find opportunities in other countries or staying at home. The competition for the good training programmes will increase in all specialties in Pakistan. Psychiatric training in Pakistan is at the very early stage and requires major changes.4 According to a statement made by the president of Society of Surgeons of Pakistan, the status and future of the surgeons to be and the surgical trainees is very worrying and appears bleak.9 The situations in other specialities would presumably not be different than psychiatry and surgery. If the working environment will not improve, doctors would either develop serious psychiatric illnesses or have no way out except to sidetrack and join politics and media or leave the profession. Time has come for the government authorities to provide better working conditions and improve the postgraduate medical training structure in Pakistan.
Many public and private hospitals provide medical services but do not have satisfactory infra structure for the training. The junior medical staff provide bulk of the services therefore, a structured postgraduate training programme would result in good and safe medical practice. The Higher Education Commission (HEC) has been encouraging highly-qualified Pakistani doctors working abroad to come back to Pakistan, by offering them higher salaries and professional status. This will help in increasing the number of faculty for postgraduate training if there is a system existing. The training requirement for the post graduate examinations imposed by the College of Physicians and Surgeons of Pakistan helps in maintaining the quality of the production of specialists in the country. It has been recognized now that postgraduate qualification and postgraduate training are two distinct entities. A board eligible doctor is as well trained as a board certified in US. Similarly a doctor on the specialist register of GMC is considered equally experienced even without attaining an exit exam. Therefore, a structured training programme would provide benefit to all in teaching or non teaching hospitals. The non-teaching hospitals could be given a title of associate teaching hospitals and appropriate honorary titles provided to the faculty members will raise the professional profile of the faculty. Provincial and federal governments need to consider increasing the health budget to provide training to doctors and utilizing their expertise to obtain better health care for the nation.
It is high time that authorities start to consider developing standardized and structured training systems at a national level to meet the local needs. The working conditions for postgraduate training in public and private hospitals require significant input from medical educationalists. The principles of medical training in UK or structure in US could be adopted to meet the local requirement. As it has been suggested before that the medical system in Pakistan needs appraisal and overhauling in the light of changes and demands as in the developed countries.10 The institutions like HEC of Pakistan, PMDC, CPSP and the deans of medical universities who are setting up high standards, should consider collaborating with the medical institutions and take serious actions for a future better health of the nation.
Medical schools, teaching hospitals, and policymakers will need to address several major questions. They will either confront or address these issues in the next few years or they will be forced to change by others in the future.
References
2. http://www.pmdc.org.pk/list_colleges.htm, accessed on 23rd February 2007.
3. Talati JJ, Pappas G. Migration, medical education, and health care: a view from Pakistan. Acad Med 2006;81(12 suppl): S55-62.
4. Naeem F, Ayub M. Psychiatric Training in Pakistan. Med Educ OnlIne 2004; 9:19.
5. http://www.ind.homeoffice.gov.uk/lawandpolicy/immigrationrules.
6. http://www.mmc.nhs.uk/pages/about. Accessed on 23rd February 2007.
7. Dyer C. Court rejects doctors' challenge to UK work restrictions. BMJ 2007; 334;333.
8. Gadit AA. Medical system: need for appraisal and suggestions. JCPSP 2006; 16: :680-2.
9. Gadit A A. Dilemma facing IMGs from Pakistan. BMJ Career Focus 2006;333:179.
10. Saleem M. Status of surgery and surgeons in the society: Time to reflect at the Silver Jubilee. Society of Surgeons of Pakistan. Presidential message. http://www.paksurgeons.org. Accessed on March 2007.
Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees:
