Dual practice in Uganda

SPEAKER: The complexity of health systems is mostly about people. People are hard to predict as individuals. How one person reacts in any situation might be quite different to how another person might respond. When hundreds, thousands, or millions of unpredictable, complex people interact with each other, individually and as groups, the result is unbelievable complexity. Making a health workforce more effective requires a deep understanding of the complex relationships between health professionals and between them and everyone and everything else in the health system. Researchers from Johns Hopkins University and Makerere University wanted to understand how the health workforce in Uganda responded to a particularly

tricky issue: dual practice. Dual practice is where a health professional employed by the government also takes on additional work, usually in the private sector. Dual practice is widespread in many countries and can have a big impact on the health system. It can bring benefits to health professionals. But if they have too many responsibilities, they may begin to neglect one job or provide poor-quality service. In Uganda before the 1970s, there was very little dual practice. Government jobs were well paid and prestigious. So there was little incentive to work in the private sector. In the 1970s and ’80s, Uganda experienced military rule and then civil war, along with chronic funding shortages due to a global recession and international sanctions.

Government salaries were now low. And many government health professionals began to take up dual practice as a way to add to their income. As dual practice became increasingly common, the government was suspicious that doctors, nurses, and other health professionals were neglecting their government duties in order to spend more time working in private facilities. They also perceived the rapidly growing private health sector as providing poor quality, unregulated services. To protect government health services, the government banned dual practice and even closed down private clinics. This had the opposite effect to what they intended.

Because government employees could no longer earn a reasonable income without dual practice, many health professionals resigned from their government jobs and went into full-time private practice or left Uganda. Emergent behaviour developed as protesting health professionals joined together and began lobbying the government to allow dual practice. The sudden loss of government health workers, along with the advocacy of health professional associations, pressured the government to allow some dual practice, setting up a balancing feedback loop. Whenever the government tried to introduce more restrictions on dual practice, this led to more resignations and protests, which in turn caused the government to relax their restrictions. This wasn’t entirely bad for the government.

Allowing dual practice meant that their staff felt able to continue in their government jobs but could still earn good incomes. In fact, even though the government remained suspicious that dual practice was causing some absenteeism and poor service quality, hospital managers became dependent on dual practice to keep their staff happy. And some formal and informal practices emerged, designed to control dual practice and maintain quality. In some facilities, managers tolerated dual practice but worked hard to set expectations that staff would be present for a minimum number of hours per day at their government job and meet informal performance standards.

Another facility got agreements from private research organisations that they would not actively recruit government staff, reducing local opportunities for dual practice and decreasing absenteeism from government jobs. A common approach to managing dual practice is to set up private services or a private wing within a public hospital. The hospital that tried this did not see it as very effective, partly because the facilities were poor quality. In some other contexts, this strategy has worked quite well. But because health systems are complex, a proven strategy may not always work if it’s not implemented in a way that suits the context. All of these constructive responses developed because the managers understood the feedback loops and emergent behaviour involved.

Destructive responses, like banning dual practice, arose when governments didn’t understand the complexity of the situation they were dealing with. Understanding complexity of systems is crucial. And often this starts with understanding the individuals within the system, their needs and motivations, something a good health systems manager or policy maker should always seek to do.