(ALMOST?) BREAKING THE GLASS CEILING:
OPEN MERIT ADMISSIONS IN MEDICAL
EDUCATION IN PAKISTAN
Tahir Andrabi and Niharika Singh
Oct 30, 2015
AALIMS, Princeton University
2
Motivation
• In Pakistan (and other South Asian countries), two
narratives about women prevail:
• Gender gap in enrollment
• Low female labor market participation
• In comparison, in the US, the gender education discourse
is focused on:
• College major choice (STEM vs. Humanities, and rates of return)
• Stalled labor participation of women relative to other OECD
countries
3
Motivation
• How are educational choices determined at higher levels?
• How do these link to labor market opportunities?
• How do they interact with social and institutional norms?
4
This Study
• Examine the system-wide impacts of the introduction of
an open merit system in Pakistani medical colleges in
1991
• Educational choices of men and women in high school in Pakistan
• Labor market participation of male vs female doctors
• Mostly descriptive evidence
• Causal effect: rule out reverse causality
• Changing demand for higher education by women forced the open
merit system to be implemented
• Limitations
• Labor market participation of doctors
• Returns to medical education
5
Outline
I.
II.
III.
IV.
V.
VI.
Context – Pakistani medical education and introduction
of merit-based admissions
Open Merit: An exogenous Shift?
“First-Stage” Results – Enrollment and Doctor Supply
Upstream effects – Educational choices in high school
Downstream effects – Labor force participation and
feminization of the profession
Future Work
6
Context – Medical Education
• Medicine was and is an elite profession.
• MBBS is a bachelors degree and students enroll after
high school (Intermediate)
• Medical education is heavily regulated and number of
seats in medical colleges is determined by the regulatory
authority (and the government).
• Pakistan Medical and Dental Council (PMDC) is the
regulatory authority for practitioners and for medical
education
• Established in 1962
• Until recently, private medical colleges were fairly limited,
and they largely opened after 2000.
7
Context – Medical Education
• As of Dec 2014
Colleges by Province and Type
Type
Punjab
Sindh
KPK
Balochistan
AJ&K
Total
Private
28
14
9
1
1
53
Public
18
9
8
1
3
39
Total
46
23
17
2
4
92
• 7 public medical colleges in Punjab in 1985
• First private medical college in Pakistan: 1983
• First private medical college in Punjab: 1996
• Only 4 private colleges before 1996.
• Seats in public colleges over time have been between 250 to 350 per batch.
• Seats in private colleges roughly 100 per batch
• When we focus on Punjab, we are looking at roughly 50% of medical college
seats available in the country.
8
The Open Merit Timeline:
Expansion of
medical
college seats
(75-80)
Quality
concerns
(80-82)
Litigation starts
Punjab High court
Case 1987
Lower courts rule
seat reduction is
a policy decision
Reduction of
Seats
(83-86)
From 1776
to1440
annually
Ad hoc upwards
adjustment of
women seats
87-91
Legal debate
evolves into
Constitutional
debate
Women affected differentially
The score threshold for entry for
women in their seat quota was
820, whereas it was only 731 for
boys within their seat quota.
Supreme Court
decrees
Open Merit
1991
First Admissions
1992
9
Quota removal:
exogenous supply shift or demand driven?
• Seat reduction was entirely driven by concern over medical
standards and had nothing to with the gender composition of
medical schools
Both the learned Judges constituting the Division Bench,
wrote separate judgments but upheld the Government's decision to decrease the
number of the seats and agreed that the reduction was in the interest of the
medical profession, made to eliminate overcrowding in the medical Colleges, remove
difficulties arising out of lack of trained staff and inadequate facilities in the teaching
hospitals, resulting in deterioration in the standard of medical education
• Lahore High Court Judgment, 1987
• Seat reduction prompted the litigation that led to quota
removal!
• When the number of overall seats was stable, there was no
pressure on the system to add women.
10
Main Data Sources & Sample
• All secondary data
• Punjab Development Statistics Reports 1970-2014
• Information on enrollment at different educational levels
• PMDC database of doctor registrations from 1952-2014
• Individual-level doctor data; has information on sex, college, year of
graduation, specialty
• Almost the complete universe of doctors, more so from the 1980s onwards
• For first-stage and upstream effects, we have data from Punjab, the
largest province in the country and about 50% of medical colleges.
• For downstream trends, we have data from all of Pakistan through
PMDC.
11
First-stage Results - Enrollment
• What does introduction of the merit system do to medical college
enrollment?
12
Medical College Enrollment in Comparison, Fraction female
Medical colleges are now as feminized as professional education colleges.
13
First-stage Results: Doctor Supply in Pakistan
-
We move the bands to 1992 to 1997 since those are the years where the graduates
from the cohorts affected by policy changes would appear in the data.
Registration happens after completion of MBBS degree.
Females overtake males in 1999, i.e. cohort of 1994, which maps to the enrollment
results previously.
14
Medical Education Trajectory
Upstream
Matric Results
(Grade 10)
Intermediate
Results
(Grade 12)
Entrance Exam*
(Grade 12)
*Since early 2000s
Downstream
MBBS from
Medical
College (5
Years)
House job
(1 year)
Postgraduation
entrance
exams
Postgraduate
study
Medical
specialist
Takes at least 6 years to become a specialist after MBBS degree
15
High School Educational Context
• Streaming in high school
• Choose Arts or Science in Grades 9 and 10
• Then, for grades 11 & 12, choose Pre-Medical, Pre-Engineering,
Humanities, Computer Science or others.
• General perceptions and behavior are if you are relatively
high ability, you will choose Science in Matric, and Premedical or Pre-engineering in Intermediate
• Choices early on will preclude future choices
16
Upstream Effects – Intermediate
• Changes incentives for high school students in general, but
particularly for high achieving males and females
• We will focus on intermediate grades (11 & 12) only.
• Why not matric?
• Matric Science is too broad a category.
• Data from two different sources, one of which we have more confidence
than in the other.
• Data: Punjab Development Statistics reports and covers period 1985-
2013. Currently trying to get student-level data from the gov’t.
17
Upstream Effects - Hypotheses
• Effects of open merit admission
• With expanded opportunities, increased enrollment in STEM fields
• Sex-specific effects on choices within STEM
• As opportunity opens up in medical schools, females enter in large
numbers into pre-medical
• Males switch from pre-medical to pre-engineering since previously lower
merit men who were able to earn admissions now face stiffer
competition
• Alternative explanations
• General changes in rate of return to STEM fields
• Should observe secular increases for both sexes
• Differential preference shocks by sex
• This would imply that medical profession now seen as more accepting
of women. Unlikely considering recent backlash.
18
Female educational choice
Number
Fraction
- Overall numbers increasing across fields
- As a fraction of all girls in a given year, over time, fewer are choosing
humanities, and shift is mostly into STEM fields (pre-engineering, premedicine, and computer science (starting in 2000))
*Other is commerce, home economics, etc.
19
Male educational choice
Number
Fraction
- Overall numbers stable for humanities but increasing in Stem and other fields
- As a fraction of all boys in a given year, over time, fewer are choosing
humanities, and the larger shift is into STEM fields
20
Comparing within Stem choice by sex, Number
Pre-medical
Pre-engineering
- We look at pre-medical and pre-engineering since these are typically seen as
“high-ability” fields.
- Existence of sex-specific patterns.
- In pre-medical, while male numbers are increasing slowly over time, female
numbers experience a dramatic increase.
- Women now make up the majority of pre-medical students in Intermediate
grades.
21
Stem fields, fraction female
Pre-medical is predominantly female, and pre-engineering is
predominantly male.
22
Downstream Effects: Leaky Pipeline?
• Under open merit regime, female presence dominates in
the medical colleges.
• What does this mean for labor market outcomes? How
leaky is the pipeline?
• Prevalent narrative is that most women dropout after
getting their MBBS degrees.
• They are not interested in specialization, but are using the MBBS
degree to find a better marriage match.
• Policy backlash to female enrollment and achievement:
Re-instatement of a 50:50 quota issued September 2014
by the regulatory authority, but struck down by
government in Punjab. Uncertainty remains.
23
Policy Backlash
Notification Text sent on
Sep 18, 2014
“The Council in its 137th
Session held on 4th February,
2014, has considered the
growing trend of females in
Medical Education and their
decreasing sustainability in
the medical field and had
decided as under:
“Number of seats for the
male and female medical
students should be 50% each.”
The seats may be filled as
per above percentage on open
merit. This decision shall be
implemented on all
undergraduate public and
private sector medical/dental
colleges for the new admission
from year 2014-2015. This
decision does not apply on the
colleges for female only.”
Text from Lahore High Court
Judgment on Argument by Regulator
24
Downstream Effects
• Hard to ascertain labor market outcomes since limited
data exists
• Very elite population, and representatives surveys (e.g.
Labor Force Surveys) are not suitable to understand this
market
• We have data on an even more elite subpopulation of
doctors, namely post-grad enrollment, specialists and
teaching professionals.
• We do not observe those women and men who just get an
MBBS and do not continue further medical education in
Pakistan.
• Outside options: foreign degrees, private practice, civil service,
marriage
25
Downstream Effects
• Hypotheses:
• Post-grad enrollment: We should observe fraction of females rising.
Pass through from medical college.
• Teaching profession: We should observe more females in lower
level positions at fractions similar to those observed in college
enrollment.
• Specialties: Fraction of specialists who are female should be rising.
26
Data
• Post-graduate medical enrollment from PDS reports
• PMDC Database of doctor registrations from 1952-2014
• Focus on 1980-2010 period where registration seems to have become the
norm.
• Registration first occurs when MBBS is completed, and is updated with
further qualifications.
• PMDC Faculty files 2014
• Individual data on rank and department.
• Available for 87 out of 92 colleges.
27
Downstream Effects – Post-grad enrollment, Fraction
-
-
-
Entry into post-graduate
study happens at least 6
years after entry into
medical college.
The grey band is where
the group affected by
policy change would
appear in the data, i.e.
between 1993 and 1998.
Rising female share in
post-grad medical
enrollment.
28
Downstream Effects – Post-grad enrollment, Number
• Why are the rates not
similar?
• Limited number of
seats and penalty
for failing postgraduate entrance
exams more severe
for women than men
• When seats
increased in 2012,
more women enter.
29
Downstream Effects - Medical Teaching Profession
• Faculty data from 87 out of 92 medical colleges as of 2014,
including rank, specialization, graduation year
• Being associated with a teaching hospital is the top of the
profession
• Faculty hierarchy
• Professor
• Associate Professor
• Assistant Professor
• Registrar
• Demonstrator, Lecturer
30
Downstream Effects - Medical Teaching Profession
• We match about 98% of data to PMDC doctor database to
understand when faculty graduated from college, and look at
sex ratio by pass decade.
• We will only be able to say something about the lower level
positions, since not enough time will have passed to see
changes in the higher echelons of the profession.
31
Downstream Effects - Medical Teaching Profession, by Rank
Rank 6: Lecturer by Pass Year
Pass Year
Before 1980
1980-1989
1990-1999
2001-present
Total
Male
45
131
125
388
689
Female
6
73
137
539
755
Total
51
204
262
927
1,444
Female share
0.12
0.36
0.52
0.58
0.41
Rank 5: Demonstrator by Pass Year
Pass Year
Before 1980
1980-1989
1990-1999
2001-present
Total
Male
16
155
159
581
911
Female
4
53
208
734
999
Total
20
208
367
1,315
1,910
Female share
0.2
0.25
0.57
0.56
0.41
Rank 4: Registrar by Pass Year
Pass Year
Before 1980
1980-1989
1990-1999
2001-present
Total
Male
32
94
232
209
567
Female
4
27
153
208
392
Total
36
121
385
417
959
Female share
0.11
0.22
0.40
0.50
0.41
- Relative to earlier
cohorts, the 2001present cohort sees
higher female share for
lower-ranking
positions.
- A lot of other things
could be happening,
but this is suggestive of
some females at least
looking to move
forward in the
profession.
32
Downstream Effects - Medical Teaching Profession, by Rank
33
Downstream Effects – Specialists
• Data records MBBS as a minimal qualification and any
additional qualifications
• The specialization period after getting an MBBS degree is
at least 6 years (house job + 5 years of specialization).
• The next set of graphs will present results by registration
year at the PMDC, which first occurs after completing the
MBBS degree.
34
Downstream Effects – MBBS vs Specialists
- If we only look at the first degree, women overtake men.
- In higher qualification, we start to see women overcoming the gap.
35
Downstream Effects –Specialists
- Number of male and female specialists over time starts to equalize.
- But almost male specialists declining over time.
- At least these women, who spend additional years, are more likely to be working.
36
Downstream Effects – Specialists, Major Categories
-
-
-
Fraction female rising
across medicine and
pediatrics & related.
OB-Gyn is already
female dominated.
Surgery is moving as
well.
Feminization is
occurring within these
higher echelons.
Q: What are its
effects?
37
Downstream Effects – Other Specialties
Rising trend across specialties.
38
Summary & Future Work
• Descriptive changes in the educational system and the
medical profession in Pakistan
• STEM enrollment is increasing, but choices within STEM are
different for men and women
• Medical college enrollment dominated by women
• Medicine appears to be an increasingly feminized occupation
• Could be a causal effect of the open merit policy
• Future Work:
• Focus more on identification
• Obtain individual-data on high school exam results
• Cohort surveys to understand labor force participation
• Understanding the effects of feminization