While Pakistan struggles with grim health metrics—including a national infant mortality rate of ~54 per 1,000 live births, 40% child stunting, and maternal mortality near 186 per 100,000—Punjab only looks good by comparison. It still suffers from a high infant mortality rate (~49–50 per 1,000), and nearly a third of its children under five remain stunted.
Punjab’s population grows at 2.5% annually, adding over 3 million people every year. To simply cover population growth, the province needs an additional 3,000 active doctors every year. Out of Punjab's ~8,000 annual medical graduates, around half abandon clinical practice immediately. Among those who remain, nearly a quarter emigrate within five years, and another 10 to 15 per cent of established specialists leave mid-career.
Punjab’s public health infrastructure experiences a chronic deficit, with approximately 3,000 out of 6,000 sanctioned medical officer and specialist posts sitting vacant across Rural Health Centres (RHCs), Basic Health Units (BHUs), Tehsil Headquarter (THQ) hospitals, and District Headquarter (DHQ) hospitals. The deficit increases as we move away from major cities (Lahore, Multan, Rawalpindi).
Punjab does not have a production problem—producing ~8,000 MBBS graduates annually from public and private colleges is mathematically sufficient for a population of 127 million if retention is 80%. Instead, Punjab suffers from a replacement trap: because the health department loses over half the cohort of medical graduates to non-practice and emigration, it constantly demands more medical college seats to fill the void.
Misdirection of Public Intent
This slow-burning crisis is rooted in a fundamental misdirection of public intent: we treat medical education as an unencumbered personal subsidy for high-performing test-takers rather than a public investment in clinical care. Through a rigid, rote-memorisation "merit" formula, we fill medical college lecture halls with students who excel at standardised exams, yet frequently lack any genuine commitment to clinical practice, much less public service. The MBBS degree functions primarily as a middle-class status trophy, a stepping stone for civil service exams, or an exit visa to the greener pastures of the affluent West.
Consequently, over half our public investment vanishes almost immediately as graduates abandon clinical medicine or emigrate, leaving thousands of public hospital posts vacant across the province. The same drain was used to justify the mushrooming of poorly regulated private medical colleges that now cumulatively produce more MBBS graduates in the province than the public sector.
And yet 3,000 posts for doctors in the provincial health department sit vacant. Working out the real annual need proves that halving the attrition rate through retention reform does more for healthcare delivery than doubling medical school admissions. Retention reform entails reform at two levels: fixing the pipeline (MBBS admissions) and fixing the bucket (overhauling healthcare delivery and service structures). Here we consider the former.
Failure of the Current Admission Criteria
We have forever perpetuated the myth that MBBS students are the “cream of the nation” without ever concerning ourselves with assessing the processes and structures through which this cream rises to the top. Admittedly, MBBS is one of the toughest fields of education and training a young person can undertake. But “academic excellence”, even if we accept the currently implemented standards that certify it, cannot by itself guarantee that the student intends to become a doctor who will, at the very least, (a) practise medicine and (b) do it in this country. Because these are the criteria against which all candidates vying for an MBBS seat should be assessed.
The current system does not fail by accident; it fails by design because it was built to manufacture and perpetuate social status for the middle class, not healthcare for the public
The current “standardised” admission criteria that takes into account nothing more than Matric, FSc, and MDCAT scores is obviously failing at this. A discussion of the failings of our secondary school and high school education is beyond our scope here. Suffice it to say that these do not, in general, inculcate the knowledge, skills, and personality traits needed to make the best thinker and problem solver or the best service provider.
We limit ourselves here to a brief consideration of the standardised MDCAT exam, which is an 180 single-best-type MCQ exam with questions on Biology (81), Physics (36), Chemistry (45), English (9), and “logical reasoning” (9), and which measures very little beyond test-prep endurance. A high score on the exam proves that a 17-year-old can memorise textbook lines and optimise MDCAT test techniques at an expensive coaching academy. It tells you nothing about their actual desire to treat sick people. And since an MBBS seat—especially a KEMU or AIMC seat—is the ultimate family status symbol, the system rewards students who yield to immense parental and societal pressure to score 95%+ to win the "trophy," even if they secretly hate biology and plan to sit for the CSS exam the second they graduate.
True "merit", especially for a public-funded institution, would mean selecting candidates who have a high probability of actually serving the public health system. A candidate with an 88% aggregate who genuinely wants to practise medicine in a rural tehsil hospital delivers far more value to society than a 95% scorer who leaves for bureaucracy, a corporate job, or a foreign licensing exam on day one.
Thus the current system does not fail by accident; it fails by design because it was built to manufacture and perpetuate social status for the middle class, not healthcare for the public. Until we align medical training with actual health delivery rather than personal social and career scaffolding, we will continue to spend billions funding degrees for a workforce that has no intention of staying in the system. As a first step towards that alignment, the MBBS admission criteria need to be redefined as a response to the question already stated: how do we induct candidates into the MBBS degree programme who are most likely to serve the public health service in the province?
A New Framework for Selection
The “merit” formula (10% Matric, 40% FSc, 50% MDCAT score) should only be used to longlist candidates who meet minimum criteria. The longlisted candidates should then be required to undertake a series of subsequent testing that establishes not “merit” but their suitability to serve as a physician or surgeon in Pakistan. These can include at the very least the following:
- Situational Judgement Tests (SJTs): Scenario-based testing designed to evaluate ethics, empathy, resilience under stress, and most importantly, commitment to medicine and to public service rather than textbook memorisation, the last of these being the failure standard. Any candidate who cannot satisfy the examiners of their commitment to practise medicine and to public service should be outrightly rejected.
- Structured Interviews: Standardised, panel-based interviews that probe a candidate’s motivation for choosing medicine. A 17-year-old who explicitly states, "I just want a degree so I can attempt the CSS exam or do PLAB/USMLE," shouldn't be awarded a heavily subsidised seat intended for public healthcare delivery.
Once the candidates prove their suitability to the satisfaction of a board of examiners (how that might be constituted is a topic for another discussion), the public sector medical colleges and universities can invite them to apply to individual colleges who can then make their “merit” lists that might be based on the original (FSc, Matric, and MDCAT) “merit”.
The “private sector”, which benefits from the current public-funded selection procedures (MDCAT), should be asked to contribute to the funding and organisation of this new intensive recruitment protocol, as it will require much higher funding than the procedures currently in place.
Rethinking Subsidies and Licensing
Then there is the question of which students should be fully or partly subsidised and how the system of subsidies can be used to buttress the public healthcare delivery system in the province. 100% of tuition fee coverage (and stipends) should be offered only to lower-income or middle-class students who genuinely need public funding. Low-income graduates who gain upward social mobility through a doctor's salary are significantly less likely to immediately abandon practice compared to candidates from affluent backgrounds.
There can also be a system of deferred subsidies offered to students in the form of loan forgiveness or cash-back rebates for every year they serve in a public hospital post-graduation. If they choose to leave early, they simply pay off the remaining tuition balance without any extra legal battle over "penalties."
These changes take the admission process from blind selection to intentional recruitment. By screening for genuine clinical aptitude, psychological resilience, and most importantly, a commitment to medical practice and public service, it evaluates whether a candidate actually wants to be a working physician, rather than rewarding someone who simply mastered exam-drilling to secure a personal trophy. By making the transition from unconditional free passes to purpose-driven support, the state refuses to hand over an unencumbered free ticket for individual career building and switches to an investment explicitly tied to serving the public health aims of the province.
Perhaps we need additional gatekeeping at the exit as well, as we now have multiple independent institutions, both public and private, who are issuing MBBS degrees based on their own criteria. This can be in the form of a province-wide or national exit and licensing exam which all MBBS graduates are required to pass before they are granted a full licence to practise, including public sector postings and postgraduate training posts.
The licensing exam cannot be set, invigilated, or graded by domestic medical university faculties or local licensing bodies who have conflicts of interest. The exam bank, invigilation, and computer-based evaluation must be outsourced to an independent, foreign-audited international body (or a secure, automated digital testing architecture with psychometric security), similar to how international clinical boards operate. When local inspectors cannot touch the exam bank or paper grading, the pass rates reflect reality.
The raw, unedited licensing exam pass rates and postgraduate induction rates for every single medical college must be published by legal mandate on a public, searchable web portal every year. When (desperate) middle-class and affluent families see that College X charges PKR 15 million for the MBBS degree but 80% of its graduates fail the basic licensing exam and cannot secure jobs, the commercial model collapses under its own weight. The market for degree-buying dies when the degree becomes publicly certified as worthless. The state doesn't need to forcibly shut down every substandard private college; it just needs to destroy the customer base.
Having said all that, the state must fully fund, facilitate, and protect the lives and careers of all doctors who commit to practising in the public healthcare system, and more so those who serve in the primary and secondary healthcare facilities in the underserved areas of the province. The state must back them with a dignified living wage, a clear postgraduate career path, operational hospital infrastructure, and physical workplace security. Fixing who enters the lecture hall and the clinic is only half the battle. Drop a committed graduate into a broken hospital, and they will still leave sooner or later—which brings us to the disaster at the bedside and the urgently needed reform of healthcare delivery and service infrastructure in the province.