COMPARATIVE PERFORMANCE OF PUBLIC AND PRIVATE SECTOR HEALTH EDUCATION IN PAKISTAN: PARENT’S PERSPECTIVE

Shazia Nawabi, Ayesha Maqsood and Muhammad Qasim Javed. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 06 September 2018 Final Accepted: 08 October 2018 Published: November 2018

Participants were interviewed in both English and Urdu languages according to their comfort level. Interviews were done in confidentiality and field notes were also maintained to increase credibility of data. Afterwards the data in Urdu was transcripted in English language by us, having command on both languages. Data collection procedure took three months and included interviews followed by transcription of each interview.
Grounded theory approach 5 was used for thematic content analysis, so data collection and analysis occurred simultaneously. Initially data analysis was done manually using open, axial and selective codes. Data was reduced further by creating internal coherence, strong distinction between sub-themes and finally themes were refined.
After getting basic idea about categories and themes, data was entered in Computer Aided Qualitative Data Analysis Software NVIVO for data management and analysis.
Presentation and visualization of results was ensured using NVIVO data tables, flow charts, models and group queries (figures 1, 2, 3). Qualitative summaries were generated to help interpret the data according to issues and themes analyzed.

Results:-
There were 18 survey participants. Age of participants varied from 33 to 52 years and belonged to middle and high socioeconomic status. All of the men surveyed were employed and generally belonged to professions including army, law, education and business. Whereas 40% of women surveyed were employed and associated with teaching profession (Table 1). All participants were Muslims by religion and they were not asked to specify their nationality/caste etc.
A total of 108codes were created from data. Six categoriesand twenty subcategorieswere identified initially as a result of open coding (Table 2). Categories were further interlinked in the process of axial and selective coding andfinally led to the emergence of four themes based on the shared views from the participants (Table 3). Themes were affordability, standard, academic excellence and patient exposure( figure 4) Most frequently discussed theme was affordability. A representative statement from one of the interviews is as follows: "I will like government setup, because if my child is capable he will get admission in government medical college, otherwise medical profession is so expensive that it should be managed at government level and personally I think very few private colleges are good in Pakistan but in my opinion there is no such option in front of me "(Participant 2) The second most important theme was standard of medical and dental colleges and sub-themes were infra-structure, reputation/recognition and faculty. Representative statementsfor each sub-theme from different interviews are as follows: "I will again emphasize that standard of medical education in government medical colleges is still better than private medical colleges and we are satisfied with them"(Participant 1) "Secondly there recognition is more. And private sectors medical colleges are not still able to establish their repute locally and internationally as compared to established government colleges and they are far behind as compared to government colleges" (Participant 3) Other representative statements are "I will go for government sector medical colleges, reason being EXACT case is in front of us and we don't know to rely on whom. You have full confidence and reliance on government sector medical colleges" (Participant 5) "I definitely want my daughter to study in government college and its main reason is faculty is much stable in private sector as turnover rate is less due to so many reasons"(Participant 18) The third commonly found theme was academic excellence and competition. A representative statement from one of the interviews is as follows: "If we compare government and private medical colleges, students of government colleges are better than private sector colleges" (participant 4) The fourth and final theme emerged was patient exposure. Almost 70% of the participants considered it as an important factor to be a good physician and dentist. They believed that government medical colleges have increased flow of patients and students can well practice and enhance their clinical skills there. A representative statement from one of the interviews is as follows.

"No of patients for their practical experience is also less in private setup, so I would like my child to go for government sector" (Participant 15)
Almost 90% of the participants considered government health institutes more reliable and gold standard for medical education. Only two participants perceived private medical colleges better or at par with public colleges as far as infra-structure and experienced faculty were concerned. Majority of participants were satisfied with knowledge and skills of Pakistani doctors and dentists bull almost all of participants exhibited reservations regarding attitude of Pakistani doctors. They compared their attitude with foreign doctors and found them having empathy, better attitude and values. There was no significant difference between the views and opinions of male and female participants in the study although slight differences were found between perceptions of participants demographically. Parents living in Mirpur (a small city in peripheral Pakistan) perceived private medical and dental colleges at par with Government colleges and they quoted examples of Agha Khan, Riphah University and shifa college of medicine as good medical colleges, while parents living in Rawalpindi and Islamabad (major cities) perceived private medical colleges inferior to public ones in all abovementioned respects.
Results of group querry further confirmed categories and themes embeded in data( Figure 2).

Discussion:-
Since past two decades, there has been rapid proliferation/mushrooming of private medical and dental colleges in Pakistan. Current number of PMDC registered medical and dental colleges is 141, out of which 50 are public sector and 91 private sector colleges ( Table 4), which means private sector medical colleges have actually outgrew Government institutes. Admission criteria to public medical schools are based on qualifying entry test (NTS) examination after a tough competition with high achievers, while admission into private institutions is dependent not only on relative academic merit, but also very much on the ability of the student to afford the education. 1 In the present study most frequently discussed theme was also affordability of medical and dental education in private medical institutes. Since education at private medical colleges is four to five times more expensive, so 90% of parents preferred Government institutes for their children. This finding is in accordance with international trends in medical education where private schools are times more expensive then government ones and most of parents there also prefer public medical colleges for their children. 6 Second most important theme according to interviewees' was standard of medical colleges and sub-themes were infra-structure, faculty (number, qualification and experience), recognition and affiliation of medical and dental colleges. Majority of parents perceived government medical colleges better in all four sub areas than private colleges. They found government institutes more trust worthy as far as degree recognition is concerned and perceived faculty as more experienced and qualified with low turnover rate which positively effects educational process of students. This finding is in contrast to other parts of the world. Some of the best medical colleges in the world are in USA and from among those the top medical colleges are in the private sector, like Harvard, John Hopkins, Stanford, Yale etc. Whereas some studies concluded that public colleges appear to be more efficient in satisfying public demand in terms of quality of provision. 7 Another important concern while choosing any educational institute and especially medical is academic excellence and professionalism of its graduates. In our study it was found as third important theme while comparing both public and private medical setups. Different studies have explored this factor. 8 The present study also found this factor an important constituent of college choice decision and found parents generally agreed upon the fact that brilliant students of country join government medical colleges. Participants of the study also highlighted the fact that wen their children study with high achievers, they also become hardworking and focused towards high academic achievements.
Final theme emerged from the study was patient exposure in medical colleges for enhancement of clinical skills .Another majority of parents emphasized on importance of this factor in increasing competencies of medical and dental graduates. There is plenty of literature available on importance of clinical exposure and patient interaction as a key educational strategy 9, 10 but we could not find any literature internationally on difference in patient exposure of medical and dental graduates in public and private sectors. Pakistani parents are well aware of this fact and they prefer government colleges as they know that treatment is either free or cheaper in government hospitals, so more patients are available to students for practice. They emphasized the fact that a competent doctor needs a lot of undergraduate patient exposure in his medical school.
Constant comparison and interlinking of themes resulted in thematic representation of parental perceptions regarding comparison of government and private medical colleges (Figure 3).
The results of this study cannot be generalized due to its contextual and qualitative nature. Further quantitative studies are required in this research area to increase validity of present results.

Conclusion:-
It is concluded from the present research that parents perceived government sector medical colleges as their first option for their children reasons being low fee structures, studying with high merit peers, better infra-structure, experienced and stable faculty, and lot of patient exposure during clinical years. They further perceived Pakistani medical and dental graduates as brilliant in knowledge and skills, but majority of them put a question mark on their attitudes, values and empathy levels. Parents generally compared and found foreign doctors better than Pakistani doctors. Further quantitative studies needs to be done based on themes generated from the present study to increase generalizability of the study.