Dual practice in the health sector: review of the evidence

Abstract

This paper reports on income generation practices among civil servants in the health sector, with a particular emphasis on dual practice. It first approaches the subject of public–private overlap. Thereafter it focuses on coping strategies in general and then on dual practice in particular.To compensate for unrealistically low salaries, health workers rely on individual coping strategies. Many clinicians combine salaried, public-sector clinical work with a fee-for-service private clientele. This dual practice is often a means by which health workers try to meet their survival needs, reflecting the inability of health ministries to ensure adequate salaries and working conditions.Dual practice may be considered present in most countries, if not all. Nevertheless, there is surprisingly little hard evidence about the extent to which health workers resort to dual practice, about the balance of economic and other motives for doing so, or about the consequences for the proper use of the scarce public resources dedicated to health.In this paper dual practice is approached from six different perspectives: (1) conceptual, regarding what is meant by dual practice; (2) descriptive, trying to develop a typology of dual practices; (3) quantitative, trying to determine its prevalence; (4) impact on personal income, the health care system and health status; (5) qualitative, looking at the reasons why practitioners so frequently remain in public practice while also working in the private sector and at contextual, personal life, institutional and professional factors that make it easier or more difficult to have dual practices; and (6) possible interventions to deal with dual practice.

To Ban or Not to Ban? Regulating Dual Practice in Palestine

“…7 Dual practice is emerging as an important challenge to health policy makers in developing countries because it may have direct implications for health workers' labor supply, and for the quantity and quality of care provided. 5,8,9 Its opponents argue that it induces undesirable behavior in health workers, such as supplier-induced demand and cream skimming. 10 Increased absenteeism of physicians from public hospitals to focus their time and attention in private practice, from which they generate more income, is featured widely in the literature.…”

“…10 Increased absenteeism of physicians from public hospitals to focus their time and attention in private practice, from which they generate more income, is featured widely in the literature. 5 Other cited unethical behaviors to promote private practice at the cost of public services include physicians giving their best performance at their private practice while keeping a minimal level of effort at the public hospitals, 8 referring public facility patients to their private practice, and intentionally altering the quality of treatment, increasing waiting times, and reducing communication with patients in the public hospitals to divert patients to their private practice. Without mechanisms to control such behavior, the cost of dual practice can surpass the benefits.…”

“…Among physicians, it is as high as 80% in Bangladesh and Indonesia, 1,2 50% in Chad, 47% in Jamaica, 42% in Sri Lanka, 41% in Zimbabwe, 29% in Cote d'Ivoire, and 21% in Mozambique 3 and is common in Mexico, Egypt, 2 Australia, New Zealand, Japan, and Vietnam. 4 Whereas in low-income countries it is often reported as a coping mechanism to compensate for low wages in the public sector, 5 in high-income countries practitioners tend to view dual practice as an opportunity to achieve clinical autonomy and realize professional aspirations. 6 Dual practice may furthermore be motivated by opportunity to have better contact with patients in the private sector, to treat fewer patients with more time and attention, to offer services unavailable in the public sector, and to gain experience more quickly relative to exclusive public practice.…”

Ready to deliver maternal and newborn care? Health providers’ perceptions of their work context in rural Mozambique

“…Such high levels of statement disagreement raise the concern that a social desirability bias may have been operating here. The high agreement mean score on the Commitment to work dimension was also surprising as it has been previously reported that health workers in Mozambique combine their salaried work in the public sector with clinical practice with a fee-for-service private clientele [47,48]. …”

International health policy and stagnating maternal mortality: is there a causal link?

“…In order to compensate, many have been forced to pick and choose patients who come to the public health service and transfer the most profitable ones to their private clinics. [28][29][30] Such actions have reinforced the privatisation of health care, while paradoxically securing the existence of public services, which benefit from the political support of doctors' professional associations.…”