The World Economic Forum’s (WEF) Gender Equality Report released in December, 2018, demonstrated Pakistan to be the second worst performer, just behind Yemen, in the Gender Equality Index, which tracks disparities in four areas including education, health, economic opportunity and political empowerment. Although Pakistan made some progress in the education sub-index, this was subverted due to various factors including stagnation in the proportion of women in the workplace particularly in managerial positions. This supports the 2016 Asian Development Bank Report that whereas Pakistani women are increasingly pursuing higher education, only 25 percent of those who possess a university-level education work outside the home.

This situation is reflected in a wide range of professions, including medicine. Currently, women represent 70 percent of the student body in medical colleges in Pakistan. However, only 50 percent of them become practicing professionals after graduation.

Those who do practise tend to gravitate towards medical specialties which are less time-intensive and are also less lucrative. Research from Pakistan and other South Asian nations demonstrates that many women prefer teaching and administrative positions within healthcare organisations since fixed working hours permit women more time to shoulder obligations to family and children in addition to their professional duties.

Blame for the shortage of physicians in Pakistan is often placed at the feet of women, many of whom are accused of wasting their education in medicine by never practising as doctors after they get married. The reality, however, is not so simple...

In Pakistan, the failure of women to practice medicine following graduation from medical colleges is being highlighted as a problem, especially since public medical colleges are heavily subsidised by the government. Criticism is directed against women who fail to practice medicine since this is perceived as wasting national resources. This was also referred to by the Chief Justice of Pakistan during his speech at a graduation ceremony on December 29, 2018, at a medical college in Bahawalpur. The Chief Justice not only urged female graduates to practice medicine in order to “repay the resources provided to them by the state” but to also “convince their families” to let them work.

The failure of women to practice medicine is widely understood as the major cause of overall shortage of physicians in a country with a ratio of only 0.83 physicians per 1,000 population. In 2014, the Pakistan Medical and Dental Council (PMDC), the governing body of medical colleges, recommended that a quota be instated restricting female admissions to 50 percent of students admitted to medical colleges.

Such a system, in fact, was in place in Pakistan until 1989 when it was challenged in the Punjab High Court by female students, and abolished on the basis of it being unconstitutional. The recent PMDC recommendation was also challenged in the court and has since then been put on hold.

The issue of non-practicing women graduates continues to be discussed in the print and social media as a phenomenon dubbed ‘doctor brides.’ In this prevailing view, the medical degree is seen as a means and a ‘hot ticket’ for women to attain better proposals for marriage and thus become ‘trophy wives.’ Women are portrayed as possessing no real desire to serve as physicians but use admission into medical colleges as a way to improve their prospects in the ‘marriage market’ in Pakistan where bringing home a doctor bahu is the desire of every mother.

Whether the popular opinion of women entering medical colleges merely to acquire good rishtas [matrimonial match] encompasses the reality for women who gain admission to medical colleges has not been studied in a systematic fashion. We sought to address this deficiency through a study involving final-year female students and their male counterparts.

In the face of structural barriers, women often choose to forego their careers not because they “want” to but because they “have” to, as captured compellingly by a participant, “Should I listen to my heart or them [my husband and in-laws]?”

Between 2015 and 2016, we used in-depth interviews and focus group discussions with 33 students in two public and two private medical colleges in Karachi. Our aim was to understand their perspectives about why women do not practice and the reasons behind the shortage of physicians in the country. The results of our study (published in an international academic journal of medical education in July 2018) revealed a complex interplay of sociocultural and economic factors, some of which we share here.

Our interviews reveal that most women were actively encouraged into medicine by their parents in which fathers played the dominant role.

One of our interviewees reminisced: “My mom [a housewife] ... simply [said] ‘No, after FSc [Class 12] [a girl should] get married. Throughout, it has been my father who has been ... pushing me and saying that you have to do this [pursue medicine.]’”

Parental preference for medicine overall was strong enough that some girls were actively discouraged from choosing other fields. As a female participant stated, “My father gave me only two options, either it was engineering or medicine ... but about engineering, he said it’s not easy for girls.”

Another one recounted, “I wanted to go into nuclear physics ... but my dad did not let me” and since then her “dream has long gone.”

Parents saw medicine as a ‘respectable’ and ‘noble’ field for women compared to other professions including ‘office jobs’ that required proximity with men and also jobs in the media because that would mean that the “woman does not have a good character.” Medicine is universally regarded as a field with the greatest social prestige so it was not surprising that parents would channel their children towards this field.

In the case of sons, parents saw medicine as a pathway towards establishing a high-status, successful career. One male participant stated, “I was pushed into medicine. I had no love for it. My parents said ... look at your doctor taaya [uncle], he is so successful.”

No woman would want to leave a one-month-old baby at home. If there were day-care centres, then they could take one to one-and-a-half hours off from their duties to spend time with the kid and still be able to work. This would allow women to balance their personal and professional lives.

This was in marked contrast to expectations from daughters. A female participant stated, “I tell my parents that I want to support [them] but my abbu said, ‘No beti, you will be married. We do not need your money.’” She added that if her brother did not earn for the family following graduation, “they will not like it. They will say to him why have we educated you so much?”

Parents considered medical education of daughters as a ‘safety net’ for them if something went wrong following their daughters’ marriage. According to one female participant, “My parents’ viewpoint is that my beti should be stable enough so that if there are any problems created from the side of the in-laws, she is educated enough to take her life forward.”

Another explained, “Every father knows that if his daughter won’t be settled [in her married life] then she cannot earn money [without a degree] so how will she take care of herself.”

The medical degree was, therefore, to be utilised only in “times of crisis.” According to one female participant, “If we are financially bankrupt and money is needed. Otherwise, I don’t need to necessarily earn.” Another woman remarked, “If my husband is making five lakhs, why should I earn?”

The failure of women to practice medicine is widely understood as the major cause of overall shortage of physicians in a country with a ratio of only 0.83 physicians per 1,000 population.

This meant that many women regarded earning as “optional.” If the woman earned, it was “pocket money for shopping” for her, not to be used for the daily needs of the family, and if she spent it, then it was considered as non-obligatory “sadqa” [alms] towards her family. According to one female participant belonging to a Pakhtun community, men who “eat from the earnings of a woman” are shamed and shunned, since “this is against our ghairat [sense of honour].”

In this sense, the role of the man as the future breadwinner for the family was firmly entrenched in the minds of majority of our participants (both male and female). For men, it was simply not possible “to sit at home and break free bread. How can you be a man and do that?” and it was “simply unacceptable for men to not work.”

In contrast, the woman’s role as a mother was highlighted by many female participants, as stated by one female participant, “this is a system which is made by nature, the mother looks after the child, and the husband works for the family.” The role of the mother, religiously and culturally revered was perceived by many as something that placed women in a superior position to men in an otherwise patriarchal culture. Moreover, this was natural to women because “the way a woman brings up her child, no one else can,” otherwise, “our religion would have said that it is the father’s responsibility that he stays at home and looks after the children.”

However, several women also complained that their inability to practice medicine gets exacerbated following marriage, unsurprising given the responsibilities and uncertainties that marriage can bring. A female student engaged to be married spoke about her mother-in-law’s expectation from her to take care of the household following marriage to “lessen her burden.” Others spoke about the in-law’s expectation for a “riwaitee [traditional] bahu” who makes “gol rotis,” will have a “hot meal ready for the husband” and who will not work.

One woman spoke about a friend who, following marriage, “misses clinics and does not even attend normal classes.” She suspected that this was because “her religious type husband does not let her” and that “she makes excuses for him.” A female participant expressed that “most men do not want equal life partners and do not let their wives work” whereas a male participant added that while “every man wants his daughter to be a doctor, most men do not let their wives [practice].”

Women also spoke about the consequences, including the possibility of a divorce in case of non-conformity with expected duties as wives and daughters-in-law, “What if the marriage falls apart? Phir log kya kaheinge [what will people say then]? People may say that it was because she [the wife] was working.”

Several women pointed to the barriers which women encounter if they wish to practice medicine in Pakistan. Issues mentioned explicitly included long working hours within medicine and poor and unstructured training programs. As expressed by one female participant, “This is not a nine-to-five job. And you have to be there all the time, especially in the case of emergencies.”

Once women have children, the issue becomes magnified. One participant explained, “No woman would want to leave a one-month-old baby at home. If there were day-care centres, then they could take one to one-and-a-half hours off from their duties to spend time with the kid and still be able to work. This would allow women to balance their personal and professional lives.”

Women spoke of a “shift in priorities” following marriage and the internal conflicts women experience “if they are missing their kid’s friend’s birthday party because they were on call.” Lack of basic facilities, particularly in public sector hospitals, was also pointed out by a female participant: “When you are on night duty, there is no proper place to sleep.

So how can women work in such an environment?”

In the face of these structural barriers, women often choose to forego their careers not because they “want” to but because they “have” to, as captured compellingly by a participant, “Should I listen to my heart or them [my husband and in-laws]?”

Our study also uncovered the voices of dissent from women who wished to pursue a medical career and who shared their frustrations and anger with the prevailing sociocultural norms. One woman stated that she would continue to work, “even if my husband is earning 10 lakhs to 15 lakhs.” Another woman, the eldest among all daughters, expressed her determination to pursue a professional career because “I have to ensure that my younger brothers and sisters reach universities and get ahead in life.”

We heard a striking story of a quiet female participant belonging to a conservative tribal region who had gone against all odds to pursue her education by agreeing to get married to a less educated cousin in accordance to her parents’ wishes in exchange for their permission to continue her education. One female participant, planning to pursue a career after graduation, spoke of familial influences which place marriage as the utmost goal for women: “When a girl child is born, the first thought of a mother is, I want to get her married to a very rich and nice family, and this is what they [girls who do not practice] dream of since childhood.”

An important finding of our study was that a majority of men we interviewed were planning to head abroad for better career prospects following graduation due to the various issues plaguing the postgraduate training system in Pakistan which are disorganised, poorly structured, few in number and difficult to get into. Male participants also spoke at length about corruption in the system which led to “people with good grades not getting ahead, and not getting seats.”

Another significant reason attributed to this trend was the poor salary structures which was problematic because “when you study so much, and when you work hard day and night, you want to be rewarded,” and therefore, “salaries should be raised for doctors [if the government wants men to stay here]”

Many male participants also spoke about the insufficient and inadequate postgraduate training system in Pakistan, which led them to prefer programmes abroad. One respondant put it this way: “There is better technology over there, the systems are better over there, and if I practice here, it will take me a long time to reach that level of expertise [as found abroad].”

The violence against physicians was also a source of trouble for young to-be doctors who believed, “once you get fame and prestige, you also get famous among criminal circles, and then they target you.” Due to all these issues, a large majority of men in our study were already studying for international licensing exams.

The long years to becoming a well-trained physician making adequate money to support a family was considered one of the primary reasons for increasingly fewer men applying for admission into medical colleges. Once young men realise that “medicine does not pay well, even if they have an interest in the field, they end up joining other fields.” Male participants reported friends who had opted to go into fields such as computer engineering and accounting and were making good money immediately following graduation.

One male participant recounted: “I have a friend who has done BBA. And he is picking up salaries like 80,000 rupees per month following graduation, and that is amazing especially since many of his peers [in medical colleges] are still studying … Had I gone to any another field, I would be making my own money instead of using my dad’s money. It’s really frustrating.”

In light of the findings of the study, we believe that it is quite simplistic and reductive to attribute physician shortages in Pakistan to merely a matter of “doctor brides” who do not wish to pursue careers in medicine rather than recognising it as a complex social phenomenon that encompasses both female and male graduates.

Various sociocultural factors both encourage women to enter medical colleges while paradoxically also restricting them from careers in medicine. On the other hand, large numbers of males, choosing to either forego medicine or aiming to leave Pakistan for better training programs also compound the physician shortage. The PMDC in its recommendation to a return to quota system for women fails to take this into account.

The solution lies in resolving the structural barriers within medicine for both women and men by improving the quality of training programs, increasing salaries for trainee physicians and providing facilities for women, such as flexible working hours and day-care centres, practical steps which have been taken by other countries.

Moreover, considering the embedded social norms of gender roles within the Pakistani society, it would seem to us that the Chief Justice’s suggestion to women to convince their families to work is unlikely to lead to practical results. Allowances and social changes must evolve from within the system with the hope that the society will evolve gradually, and thus break down strict gender roles that entrap men and women both.

However, in the short run, addressing some of the immediate issues the study highlights including poor and unstructured postgraduate training systems, and lack of basic facilities would pave the way in resolving the issue of physician shortages.

The writers are associated with the Centre of Biomedical Ethics and Culture, SIUT. Farhat Moazam is the chairperson of the centre while Sualeha Sheikhani is a lecturer.

Published in Dawn, EOS, January 27th, 2019