(ALMOST?) BREAKING THE GLASS CEILING: OPEN MERIT ADMISSIONS IN MEDICAL EDUCATION IN PAKISTAN

Tahir Andrabi and Niharika Singh

Oct 30, 2015

AALIMS, Princeton University

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

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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?

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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

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Outline

I. Context – Pakistani medical education and introduction of merit-based admissions

II. Open Merit: An exogenous Shift?

III. “First-Stage” Results – Enrollment and Doctor Supply

IV. Upstream effects – Educational choices in high school

V. Downstream effects – Labor force participation and feminization of the profession

VI. Future Work

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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.

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Context – Medical Education

• As of Dec 2014

• 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.

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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

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The Open Merit Timeline:

Ad hoc upwards adjustment of women seats

87-91

Legal debate evolves into

Constitutional debate

Supreme Court decrees

Open Merit

1991

First Admissions 1992

Litigation starts

Punjab High court Case 1987

Lower courts rule seat reduction is a policy decision

Expansion of medical

college seats

(75-80)

Quality concerns

(80-82)

Reduction of Seats

(83-86)

From 1776 to1440

annually

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.

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 inade quate 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.

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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.

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First-stage Results - Enrollment• What does introduction of the merit system do to medical college

enrollment?

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Medical College Enrollment in Comparison, Fraction female

Medical colleges are now as feminized as professional education colleges.

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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.

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Medical Education Trajectory

Matric Results

(Grade 10)

Intermediate Results

(Grade 12)

Entrance Exam* (Grade 12)

MBBS from Medical

College (5 Years)

House job (1 year)

Post-graduation entrance exams

Post-graduate

study

Medical specialist

Upstream

Downstream

*Since early 2000s

Takes at least 6 years to become a specialist after MBBS degree

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 Pre-medical or Pre-engineering in Intermediate

• Choices early on will preclude future choices

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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.

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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.

Female educational choice

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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, pre-medicine, and computer science (starting in 2000))

*Other is commerce, home economics, etc.

Male educational choice

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FractionNumber

- 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

Comparing within Stem choice by sex, Number

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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.

Stem fields, fraction female

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Pre-medical is predominantly female, and pre-engineering is predominantly male.

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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.

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Policy Backlash

“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.”

Notification Text sent on Sep 18, 2014

Text from Lahore High Court Judgment on Argument by Regulator

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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

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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.

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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.

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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.

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Downstream Effects – Post-grad enrollment, Number

• Why are the rates not similar?• Limited number of

seats and penalty for failing post-graduate entrance exams more severe for women than men

• When seats increased in 2012, more women enter.

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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

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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.

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Downstream Effects - Medical Teaching Profession, by Rank

- Relative to earlier cohorts, the 2001-present 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.

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Downstream Effects - Medical Teaching Profession, by Rank

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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.

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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.

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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.

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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?

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Downstream Effects – Other Specialties

Rising trend across specialties.

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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