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Managing dual practice

How can dual practice be managed and how can we even know if it worse than the alternative? This article considers these questions.
The image shows a blurred hospital background with a patient on a bed
© Nossal Institute for Global Health at the University of Melbourne

We’ve seen that health workers have complex motivations, incentives and disincentives which shape their behaviour; this complexity is very obvious among health workers who engage in dual practice.

Dual practice – holding both public and private clinical jobs at the same time – is very common across the world.

The following table provides some data from every region about dual practice:

Country or region Data on dual practice
UK Over 60% of public hospital doctors conduct private practice alongside their public hospital work
Spain 20% of public sector doctors have a second job
Norway 25% of public hospital doctors hold a private sector job. Dual practice very common among specialised nurses
Portugal Public sector physicians and nurses can choose exclusive, better paid contracts, or ones with reduced pay that permit private sector work
Latin America Dual practice widespread
Bangladesh Most doctors, particularly specialists, earn more than half their income in private practice
Egypt, Indonesia, Kenya and Mexico Over 80% of public sector physicians engage in private activities
South Africa About 40% of nurses working in a sample of public hospitals reported working for the private sector

It is important to think about dual practice at the level of the whole system, in terms of the role it plays in supporting or undermining universal health coverage (UHC). For example, an analysis at the service level might suggest that dual practice is ‘bad’ because it encourages absenteeism from public sector jobs, or poorer quality care in the public sector. However, a system level analysis might suggest that without dual practice, a large number of health professionals would be lost to the system as a whole through migration or opting out of the health sector. Perhaps the only thing keeping them in the health system is the freedom to work two jobs! Looking at this level, allowing dual practice may be important for keeping the health system functioning. However, it’s difficult to predict the effects would be of making dual practice easier or more difficult to engage in.

McPake et al. (2016) say it is important to recognise a number of ‘types’ of dual practice, as described in the following table:

Type of dual practice Description of where a second job is held or private sector activity undertaken
Outside A completely separate private environment
Beside In a private ward or clinic physically associated with a public facility but run as a separate business
Within Private services are offered inside a public facility but outside service operating hours or space
Integrated Additional fees are charged for services offered alongside standard public ones, often informally, on the understanding of a faster or higher quality of services

While many discussions of dual practice focus only on the first ‘outside’ category, where a private service is offered may matter little to either patients or staff, or to what kinds of incentives and outcomes arise.

Evidence of the importance of economic factors in shaping dual practice behaviours or outcomes is mixed, implying that increasing public sector pay may not be sufficient to manage the problems that often arise with dual practice. There are clearly other factors involved. Consequently, a range of regulatory strategies is needed, targeted to different types of dual practice and the contexts where they have emerged.

Table 1. (Dual practice typology: examples of local conditions, consequences for UHC goals and policy options) in Implications of dual practice for universal health coverage – see page 144 – summarises the article’s conclusions in relation to these relationships.

Look at the ‘local conditions’ and identify which scenario characterises your health system context, then look at the regulatory options.

Do you think these options would be effective? Have any been tried? Are there other approaches you think would be needed alongside these to ensure good quality services across the health system (public and private sectors)?

References
McPake, B, Russo, G, Hipgrave, D, Hort, K & Campbell, J, 2016, ‘Implications of dual practice for universal health coverage’, Bulletin of the World Health Organization, vol. 94, no. 2, p. 142.
© Nossal Institute for Global Health at the University of Melbourne
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