November Issue 2014
The Healthcare Business
Instruments had miraculously appeared in the laboratories and dissection hall, every fan and air conditioner was in working condition, LCDs and personal computers were installed overnight in the faculty-rooms, the Wi-Fi had finally started to work, every member of staff was dressed to perfection, the algae-coloured water filters next to the water-coolers had been replaced with fresh cartridges, rickety chairs and stools had been exchanged for newer, shinier ones and there was not a single wayward student in sight. The usually empty hospital adjacent to the medical college building was suddenly bristling with patients who had been ‘borrowed’ from other hospitals. The institute had been transformed overnight.
In all, 100 MBBS and 50 BDS (Bachelor of Dental Surgery) students can be enrolled at this college at any one time. It was officially recognised as an institute in 2010, by the Pakistan Medical and Dental Council (PMDC), the body responsible for the registration of all newly-opened public and private medical colleges. There are 53 PMDC-recognised private medical colleges in Pakistan. The official criteria states that, “After two years of recognition, and once the students are in third year, a recognised institute may apply to the Council for an increase in its annual admissions and continuation of recognition, in fulfillment and in accordance with provisions of the Ordinance and regulations made thereunder.”
To upgrade the above-mentioned college to a 150-strong MBBS class, PMDC conducted a ‘surprise’ inspection on September 23, 2014. Only, it was not a surprise by any stretch of imagination. The staff had been informed about it beforehand, and preparations for the visit had begun much in advance. To comply with the specific requirements of PMDC, the college administration had called in several ex-employees (who were kept on the rolls despite their departure) on the day of inspection, to showcase them as current employees. Some ‘lecturers,’ brought in from other cities, had never even been a part of the faculty until that day. One lecturer, who had been temporarily recalled, used to be a senior teacher at the college, but was laid off after he was found guilty of harassing female students. Another senior faculty member, on leave because of mental health issues, was present that day just because of the inspection.
This college, like most other private medical colleges in Pakistan, is desperate to increase its number of admissions. More admissions mean a proportional increase in opportunities to fleece potential students. According to the Higher Education Commission of Pakistan (HEC) regulations, to gain admission to a professional (medical/engineering/law) college, students need to score at least 60 per cent in their FSc examinations. Other rules stipulate a maximum amount that can be charged per annum as tuition fee, and that a fixed number of seats be reserved for international students. The medical college in question flouts all these rules, and as long as one can cough up enough money, one’s offspring is guaranteed a place in the college.
The current admission fee for MBBS at private medical colleges in Pakistan varies between Rs 1.3 and Rs 2.5 million, depending on the marks obtained by the students in their FSc examinations, while the admission fee for BDS students ranges from Rs 0.7 to Rs 1.2 million. In addition to the admission fee, MBBS students have to pay Rs 0.7 million a year in tuition fees. Government-run medical colleges, on the other hand, are heavily subsidised and a student has to pay no more than Rs 25,000 a year as tuition fee (and a negligible admission fee).
In 2006, the average annual tuition fee at most private medical colleges was between Rs 0.25 and 0.5 million, but parents were paying up to a million rupees more each year at ‘donation hubs’ to keep their child in school. Those unable to gain admission to public sector colleges are lured by these private colleges on the promise of a medical degree, as long as they can cough up a healthy ‘donation.’ A ‘donation’ is paid by those parents of students who score low marks in their examinations, but still want to enrol in an MBBS programme (students with higher scores and those willing to make do with a Dentistry or Pharmacy degree have to ‘donate’ considerably less). The options available to students read like a take-out menu, with MBBS as the top deal and Dentistry and Pharmacy lower down the pecking order.
These money-making practices at private medical colleges have been underway for at least the last two decades, and a famous private medical college in Lahore is considered a pioneer in this skullduggery. The number of private medical colleges in Pakistan skyrocketed between 2008 and 2012. And in 2013, an audit report revealed massive corruption in the PMDC’s registration of medical colleges during this period. More than 14 medical colleges established in this period have now been de-notified by the authorities. The primary motive for setting up new colleges is greed on the part of investors, often in collusion with the regulatory authorities. During this period, medical colleges were being established with ramshackle infrastructure and profiteering was rampant with scant regard for societal responsibility. Of the students who took the entrance test for an MBBS or BDS, only four to five per cent gained admission to state-run medical colleges, while the rest had to either switch fields or try again later. This vacuum was filled by entrepreneurs — many with connections to the healthcare industry — who decided to set up private medical colleges to cater to the sub-standard students.
According to the owner of one medical college in Azad Jammu and Kashmir, who spoke to Newsline on condition of anonymity, setting up a medical college costs at least Rs 20 million. Overhead charges, like hiring a faculty and hospital staff, are an added expenditure. Getting the college registered by PMDC is another heavy expense as it involves more than the official fee. After all this hassle, owners are more interested in recovering their investment than in maintaining educational standards. The owner explained that medical colleges have proved a worthwhile investment for people with political clout and connections to the healthcare establishment. A few years ago, the HEC mandated Rs 400,000 as the maximum tuition fee that could be charged from private students. Private colleges have sidestepped this order by forcing parents to submit the fee (usually more than the prescribed amount) in separate accounts.
The commercialisation of medical education in Pakistan has priced out most students from the field. According to the Pakistan Bureau of Statistics, Pakistan’s income per capita for the year 2011-12 was $US 1,380 (Rs 140, 000). With such a meagre income, the average citizen cannot afford a private medical education for his offspring. The overall cost of healthcare has also increased tremendously due to the knock-on effect of an expensive education. A medical graduate whose parents have spent millions on his degree is not likely to resort to charity after completing his education.
According to a report compiled by the Sindh government, out-of-pocket expenditure for Pakistan’s health sector at 32 per cent of annual expenditure is the highest among regional countries. In simpler terms, for every Rs 100 spent by an average household in Pakistan, Rs 32 is spent on healthcare. Business Monitor International (BMI), a UK-based research and consulting firm, reported that Rs 665 billion were spent by Pakistanis on healthcare in the year 2011. The number of students pursuing a career in medicine is increasing every year, while the number of seats in state-run medical colleges remains the same. There is a visible lack of career counselling in Pakistan, and most students who actually make it to medical school have no idea of what it entails.
Medicine is not just a profession, it is a calling. It can consume a person due to its high emotional and physical toll. Parents, often the driving force behind their childrens’ career choice, need to be educated about the hazards and declining standards of this profession, and only the most committed students should be encouraged to take the plunge. Throwing money at the problem is only exacerbating the situation. Graduates of sub-standard medical colleges are a public hazard and the responsibility lies with regulatory authorities like the PMDC. Implementation of the maximum fee regulation and authentic inspections, which de-notify all sub-standard medical colleges and not just the ones meeting the regulatory bodies’ ‘donation’ expectations, should be a top priority for the PMDC.
This article was originally published in Newsline’s November 2014 issue.
The writer is a freelance journalist based in Lahore. He writes on History, Political Economy and Literature. Follow him on Twitter