Policy and regulatory responses to dual practice in the health sector

Navigating delayed diagnoses, self-neglect, and lost livelihoods: a qualitative exploration of fisherfolk's health perspectives and management of non-communicable diseases in Kerala, India

INTRODUCTION

Non-Communicable Diseases (NCDs) place a significant burden on India's healthcare system, accounting for approximately 62% of all deaths in the country in 2017. The southern Indian state - Kerala - has some of the highest rates of NCDs. Within the state, the fisherfolk community has a high prevalence of risk factors such as tobacco use and alcohol consumption. Working in the fisheries industry demands physical exertion, night shifts alongside extended periods of time at sea (for seafaring fisherfolk). Evidence is scant on how these conditions relate to the health-seeking experiences of fisherfolk, particularly in the context of NCDs. We conducted a qualitative study in two districts of Kerala to fill this gap.

METHODS

In-depth individual and small group interviews- as per participant preference -  with male and female fishing community members living with NCDs were conducted between October 2022 and February 2023 in two districts of Kerala. Interviews were conducted to explore community members' experiences with health-seeking for NCDs. Transliterated English transcripts were coded using ATLAS.ti software and analysed using thematic analysis with inductive generation of codes, with indexing against Levesque, Harris, and Russell's 2013 access to healthcare framework.

RESULTS

Thirty-three interviews with 42 participants were conducted. We found that NCDs were usually diagnosed late- either when admitted/consulted for other illnesses or when the symptoms became unbearable. Health-seeking patterns differed between seafaring and inland fishing subgroups, who were sampled from two districts in the state. Seafaring fisherfolk preferred public facilities for regular checkups and medicines while in-land fisherfolk relied on private facilities, although it was considered expensive. Ability to seek care was impacted by the working hours of the health centre which did not suit their working hours. Health constaints and related expenses also impacted their financial status and occupation, with some opting for less strenuous jobs.

CONCLUSION

This study highlights the NCD-related health-seeking experiences of the fisherfolk community in Kerala, India. Fisherfolk reported self neglect, delayed diagnosis, cost and livelihood constraints owing to the onset of NCDs, even as dual practice and medicine access in the public sector were appreciated. Overall, larger studies and policymaking processes should consider in depth the experiences faced by particular economic groups like fisherfolk, who may face unique health and care-seeking challenges.

Hepatitis Delta Virus Surveillance Practice among Clinicians in Nigeria: A Cross-Sectional Survey

BACKGROUND

The near total absence of routine Hepatitis Delta Virus (HDV) screening in many countries in sub-Saharan Africa is a major challenge to understanding the burden of HDV in the region.

AIM

To evaluate Hepatitis Delta Virus screening practices and associated factors among clinicians in Nigeria.

METHODS

A cross-sectional study was conducted in June-July 2022, in which a self-administered questionnaire that inquired about HDV awareness, screening practices, and treatment options was shared electronically with consenting clinicians practicing in Nigeria. At the end of the survey, data was analyzed using descriptive and inferential statistics. The level of significance was set at 0.05.

RESULTS

At the end of the survey, 210 of the 213 responses retrieved from respondents were analyzed. The respondent's mean age was 38.60 ± 7.27 years with a male-to-female ratio of 1:2.5. They comprised 13.8% gastroenterologists and 86.2% respondents in other areas of clinical medicine. The study showed that 89.5% of the respondents knew that HDV infection occurs only in hepatitis B virus (HBV)-infected individuals. Most (91.4%) respondents do not screen for HDV in chronic HBV patients, mainly due to the non-availability of screening tools and lack of awareness of any screening test for HDV. Research interest was reported as the reason for screening among clinicians who had ever screened for HDV. Pegylated interferon was the main regimen used for treatment by 87.5% of respondents. About 2% did not know treatment options for HDV. A significant association between knowledge of HDV infection and area of specialty, as well as the nature of medical practice was noted (P = 0.008 and 0.013, respectively).

CONCLUSION

The study showed a high level of awareness of HDV dependency on HBV, for natural infection to occur. However, it documented very minimal HDV screening in clinical settings and factors affecting screening among clinicians.

Heterogeneity in physician's job preferences in a dual practice context - Evidence from a DCE

Many countries are facing challenges in recruiting and retaining physicians, particularly in regions where the public and private sectors compete for doctors. Understanding the factors influencing physicians' job choices can help inform policies aimed at attracting and retaining this valuable workforce. This study aims to elicit the strength of physicians' preferences regarding various job-related aspects, including earnings, time flexibility, discussion of clinical cases, frequency of facilities and equipment updates, training opportunities and autonomy in decision making. To achieve this, a Discrete Choice Experiment (DCE) was administered to 697 physicians. Each participant completed a series of eight choice tasks, where they had to choose between two hypothetical jobs differing in these attributes with levels mirroring positions in the public and private sectors in Portugal. The resulting choices were analysed using mixed logit, generalized multinomial logit and latent classes models to account for diverse unobserved variations in physicians' preferences and to explore preference heterogeneity across different observable characteristics. Jobs that offered more autonomy and training opportunities were strongly preferred, as physicians would require additional compensation to work with reduced autonomy (equivalent to 28.62% of gross income) or less frequent training (equivalent to 22.75%). This study also shows that the ranking of the job characteristics is similar between physicians working exclusively in the public sector and those engaged in dual practice. Nevertheless, public sector physicians place more emphasis on the availability of frequent training possibilities and frequent updates of facilities and equipment compared to their counterparts in dual practice. These findings contribute to existing knowledge by highlighting the significance of non-monetary attributes and shedding light on the preferences of physicians across various employment scenarios. They offer valuable insights for policy development aimed at influencing physicians' allocation of time between sectors.

Examining the extent, forms and factors influencing multiple job holding among medical doctors, professional nurses and rehabilitation therapists in two South African provinces: a cross-sectional study

OBJECTIVE

Multiple job holding (MJH), or working in more than one paid job simultaneously, is a common characteristic of health labour markets. The study examined the extent (prevalence), forms and factors influencing MJH among public sector medical doctors, professional nurses and rehabilitation therapists in two South African provinces.

DESIGN

A cross-sectional, analytical study.

SETTING

29 public sector hospitals in the Gauteng and Mpumalanga provinces of South Africa.

PARTICIPANTS

Full-time public sector medical doctors, professional nurses and rehabilitation therapists.

RESULTS

We obtained an overall response rate of 84.3%, with 486 medical doctors, 571 professional nurses and 340 rehabilitation therapists completing the survey. The mean age was 39.9±9.7 years for medical doctors, 43.7±10.4 years for professional nurses and 32.3±8.7 years for rehabilitation therapists. In the preceding 12 months, the prevalence of MJH was 33.7% (95% CI 25.8% to 42.6%) among medical doctors, 8.6% (95% CI 6.3% to 11.7%) among professional nurses and 38.7% (95% CI 31.5% to 46.5%) among rehabilitation therapists. Medical doctors worked a median of 20 (10-40) hours per month in their additional jobs, professional nurses worked 24 (12-34) hours per month and rehabilitation therapists worked 16 (8-28) hours per month. Private practice was the most prevalent form of MJH among medical doctors and rehabilitation therapists, compared with nursing agencies for professional nurses. MJH was significantly more likely among medical specialists (OR 4.3, p<0.001), married professional nurses (OR 2.4, p=0.022) and male rehabilitation therapists (OR 2.4, p=0.005).

CONCLUSION

The high prevalence of MJH could adversely affect the care of public sector patients. The study findings should inform the review and revision of existing MJH policies.

An overview and visual analysis of research on government regulation in healthcare

Objective

During the period of COVID-19, government regulation (GR) played an important role in healthcare. This study examines the current research situation of GR in healthcare, discusses the research hotspots, the most productive authors and countries, and the most common journals, and analyzes the changes in GR in healthcare before and after the outbreak of COVID-19.

Methods

This study followed PRISMA guidelines to collect literature on GR in healthcare. And the VOSviewer software was used to perform a quantitative analysis of these documents to obtain a visual map, including year, country, institution, journal, author, and research topic.

Results

A total of 1,830 papers that involved 976 academic journals, 3,178 institutions, and 133 countries were identified from 1985 to 2023. The United States was the country with the highest production (n = 613), followed by the United Kingdom (n = 289). The institution with the largest number of publications was the University of London in the UK (n = 103); In the author collaboration network, the biggest cluster is Bomhoff M, Bouwman R, Friele R, et al. The top five journals in terms of the number of articles were BMC Health Services Research (n = 70), Plos One (n = 35), Health Policy (n = 33), Social Science & Medicine (n = 29), Health Policy and Planning (n = 29), and Frontiers in Public Health (n = 27). The existing literature mainly focused on "health policy," "public health," "China," "mental health," "India," "qualitative research," "legislation," and "governance," et al. Since 2020, research on "COVID-19" has also become a priority in the domain of healthcare.

Conclusion

This study reveals the overall performance of the literature on GR published in healthcare. Healthcare needs GR, especially in response to the COVID-19 epidemic, which has played an irreplaceable role. The outbreak of COVID-19 not only tested the health systems of various countries, but also changed GR in healthcare. With the end of COVID-19, whether these changes will end remains to be further studied.

Should developing countries ban dual practice by physicians? Analysis under mixed hospital competition

Dual practice, where physicians work both in public and private hospitals, is a widely observed phenomenon, particularly in developing countries. This paper studies a multi-stage game where hospitals compete for physicians as well as patients and, the service provided by physicians endogenously depends on the competitive setting in which hospitals operate. Specifically, we examine the impact of allowing dual practice on hospital payoffs, physician's service and societal welfare. We find that dual practice is socially desirable, since it softens the competition for physician's exclusive service while also increasing the amount of their service. However, if the degree of competition between the hospitals is significant, dual practice may not yield the highest payoffs for both public and private hospitals.

Does voluntary health insurance reduce the use of and the willingness to finance public health care in Sweden?

Voluntary private health insurance (VHI) has generally been of limited importance in national health service-type health care systems, especially in the Nordic countries. During the last decades however, an increase in VHI uptake has taken place in the region. Critics of this development argue that voluntary health insurance can undermine support for public health care, while proponents contend that increased private funding for health services could relieve strained public health care systems. Using data from Sweden, this study investigates empirically how voluntary health insurance affects the public health care system. The results of the study indicate that the public Swedish health care system is fairly resilient to the impact of voluntary health insurance with regards to support for the tax-based funding. No difference between insurance holders and non-holders was found in willingness to finance public health care through taxes. A slight unburdening effect on public health care use was observed as VHI holders appeared to use public health care to a lesser extent than those without an insurance. However, a majority of the insurance holders continued to use the public health care system, indicating only a modest substitution effect.

Understanding Online Dual Practice of Public Hospital Doctors in China: A Mixed-Methods Study

Telemedicine and telehealth hold promise for reducing access barriers, improving quality, and containing medical costs. As Internet companies enter the healthcare market, a rising number of online healthcare platforms have emerged worldwide. In some countries like China, public hospital doctors are providing direct-to-consumer telemedicine services on these commercial platforms as independent providers. Such online service provision creates a new form of dual practice, which we refer to as “online dual practice” in this study. Using a mixed-methods design, this study aims to investigate the prevalence of online dual practice, doctors’ time allocation and motivations for engaging in it, and its potential impacts on the health system in China. We use the web-crawled data from four leading online health platforms to examine the prevalence of online dual practice in China. Then we conduct in-depth interviews with 38 active doctors on these platforms to investigate their time allocation, motivations, and perception regarding online service provision. We find that the nationwide prevalence of online dual practice in China reaches at least 16.5% in 2020, and that it is more common among senior public hospital doctors. Public hospital doctors mainly use small pockets of time during working hours and after-hours to render services on the platforms. The five most commonly cited motivations for their engagement in online dual practice are efficiency improvement, personal control, career development, financial rewards, and serving the patients. Interviewed doctors believe that their online service provision is conducive to increasing healthcare access and improving efficiency, but some also express their concerns about the quality of care. Further analysis shows that the impact of online dual practice on health system performance remains an open question and regulatory policies on it should be health-system specific.

Growth and welfare in mixed health system financing with physician dual practice in a developing economy: a case of Indonesia

Based on Indonesia's hybrid BPJS Kesehatan health system, we analyze for welfare-optimal government financing strategy in an economy with a mixed health system using an endogenous growth framework with physician dual practice. We find the model solution to produce two vastly different regimes in terms of policy implications: a "high" public-sector congestion regime as in the benchmark case of Indonesia, and a "low" public-sector congestion, high capacity regime. In the former, welfare-optimal health financing strategy appears to be promoting private health service. In contrast, in the low-congestion, high capacity regime, a welfare-optimal strategy is to do the opposite of increasing government physician wage at the expense of private health subsidy. These results highlight the importance of developing a benchmarking system that measures the actual degree of congestion faced by the public health service in a developing economy, as it ultimately would influence the optimal health financing strategy to be pursued.

Social Support Mediates the Effect of Burnout on Health in Health Care Professionals

Burnout is characterized by emotional exhaustion and caused by exposure to excessive and prolonged stress related to job conditions. Moreover, burnout is highly prevalent among health care professionals. The aim of this study is, first, to examine the mediating role of social support over the effect of burnout in health care professionals and, second, to explore potential gender differences. A convenience sample of 1,035 health professionals from Ecuador, including 608 physicians and 427 nurses (68% women, with and age M = 40 + 9 years old), was surveyed using the Maslach Burnout Inventory (MBI), Social Support Survey (MOS), and General Health Questionnaire (GHQ-28) as measures of burnout, social support, and general health, respectively. Social support was found to mediate the negative effects of burnout on health regardless of gender. Differences across the three dimensions of burnout and health are further discussed, along with their implications for designing effective burnout interventions for health care professionals in Ecuador.

Assessment of dual practice among physicians in Cambodia

BACKGROUND

Dual practice and multiple job holding are widespread among health workers throughout the world. Although dual practice can help the financially strained public sector retain skilled workers, there are also potential negative consequences if it is not regulated. In Cambodia, there is substantial anecdotal evidence of dual practice among physicians but there is very little data on the extent and prevalence of the practice. This study was conducted by the University of Health Sciences (UHS) to gain insight in to the employment practices of UHS alumni. Results from this survey may help to inform policymakers in rational planning for future health system development related to capacity building and regulation of human resources for health.

METHODS

Data were collected from a self-administered survey of UHS graduates who graduated between 1999 and 2012. A total of 162 medical graduates were randomly sampled from a total of 1867 medical graduates between 1999 and 2012. Contacted individuals were asked to complete a written structured questionnaire regarding demographic characteristics, current employment and types of employment, compensation, and job satisfaction. The response rate of graduates sampled was 49% (79 completed questionnaires). The low response rate was primarily due to the difficulty in locating individuals.

RESULTS

Of 79 respondents, 96% were currently employed at the time of the survey. However, only 63 of the respondents (80%) were working in the healthcare sector. The 16 respondents (20%) not working in healthcare were excluded from further analyses since they are not relevant to dual practice analysis. The vast majority (87%) of respondents are public sector employees (61.9% in public sector only and 25.4% in both public and private sector). 12.7% of respondents only work in the private sector. Almost half (47.6%) of respondents hold more than one job. For income satisfaction, physicians employed in both sectors have higher satisfaction than physicians employed in the public sector only.

CONCLUSIONS

As policymakers in Cambodia consider new approaches to regulation of the practice, it is important to know the context of the practice, the benefits to the healthcare system, and the costs. Recognizing the high prevalence of multiple job holding in Cambodia, as evidenced in our survey of UHS medical graduates, contributes to the discussion as important information that can be used toward meaningful reform.

Dual practice and multiple job holding among Iranian general practitioners: Rate and effective factors

BACKGROUND

Physician's dual practice is a common phenomenon in both developing and developed countries. This study aimed to investigate the rate and factors affecting the dual practice of general practitioners (GPs) as the most important primary care providers in Iran.

METHODS

This cross-sectional study was conducted on the data of 666 Iranian GPs, derived from a national survey. In this work, a researcher-made checklist was used to collect the required information. Multinomial logistic regression was used to examine the factors affecting concurrent employment in both public and private sectors and the factors affecting employment in more than one place (either public or private).

RESULTS

About 23.51% of the GPs were only working in the public sector, and 57.84% only in the private sectors. Also, 18.65% were working in both the private and public sectors. Results also indicated that 26.17% of the GPs were working in two or more places (whether public or private). Male GPs (p < .1) as well as the GPs with higher earnings expectations (p < .01) were more likely to have dual practice. Besides, the GPs working in small towns and villages (compared with Tehran, as capital of Iran; p < .05) were less likely to have dual practice. Gender (male) and earnings expectations had a significant effect on working in more than one place (p < .01).

CONCLUSION

The most important and significant factor affecting GPs' dual practice in Iran was their financial expectations. Thus, appropriate policies to modify physicians' income expectations and reforms such as improving tariffs setting should be adopted in the health systems.

Using the theory of planned behaviour to predict nurse's intention to undertake dual practice in China: A multicentre survey

AIMS AND OBJECTIVES

To identify the intention of nurses to dual practice (DP) and inform policymaking in centralised government settings.

BACKGROUND

DP is pervasive worldwide but was not permitted in China until 2009, with a primary goal of encouraging nurses from over-staffed health services to work additional shifts in understaffed settings.

DESIGN

A descriptive cross-sectional survey.

METHODS

A DP questionnaire based on the theory of planned behaviour was developed and issued to nurses from three comprehensive public hospitals in 24 units selected by stratified random cluster sampling (n = 526). This study was reported based on STROBE checklist.

RESULTS

The mean for intention was 3.47 with strongly disagree as one point, neutral as three point and strongly agree as five point in scaling. Nurses with any of these characteristics: female, aged between 40 and 49, married, working more than 15 years, and managers were significantly reluctant to undertake DP. The structural equation model showed that the level of positive attitude, subjective norm and perceived behavioural control could positively predict intention, and attitude had highest effect value. Perceived behavioural control and attitude acted as sequential mediators between subjective norm and intention. Nurses preferred large or private hospitals if conducting DP without restriction from the government.

CONCLUSIONS

Nurses' intention to undertake DP was not strong, which was impacted by attitude, subjective norm, time and energy. Nurses preferred large or private hospitals; therefore, the goal of improving equity by DP in developing countries might be undermined.

RELEVANCE TO CLINICAL PRACTICE

To encourage DP, attitude and subjective norm are important paths, the latter being the initial step. Reasonable incentives or restrictions, such as specifying regulations on practice place and time limitation, qualifications and legal liability and remuneration are recommended to ensure successful DP implementation from over-staffed health services to understaffed settings.

Dual practice of public hospital physicians in Vietnam

Although many public hospital physicians in Vietnam offer private service on the side, little is known about the magnitude and nature of the phenomenon so-called dual practice, let alone the dynamics between the public and private health sectors. This study investigates how and to what degree public hospital physicians engage in private practice. It also examines the commitment of dual practitioners to the public sector. The analysis is based on a hospital-based survey of 483 physicians at 10 public hospitals in four provinces of Vietnam. Nearly half of the participants in the study sample reported themselves as dual practitioners. Various types of private practice were mentioned. Private practice at health facilities owned by the private sector was the most prevalent, followed by private practice delivered at health facilities owned by the dual practitioners themselves. Private practice inside public hospitals was also noted. Dual practitioners were likely to be senior and hold management positions inside their public hospitals. Substantial income differences were found between dual practitioners and those physicians practicing exclusively in the public sector. The majority of dual practitioners, however, reported the willingness to give up private practice if certain conditions were met, such as a basic salary increase or non-pecuniary benefits. The main reasons dual practitioners gave for not leaving the public sector included a sense of public responsibility and opportunities to gain a broader professional network and more training. This study reiterates the significant challenges associated with dual practice, including its financial implications and possible effects on health care quality and access. The need for a high-quality workforce committed to the public sector is particularly critical, given the possibility of universal insurance coverage. Future research should address the need to improve data collection on physicians' dual practice and incorporate the topic in policy debates on health reform.

Extent and nature of dual practice engagement among Iran medical specialists

BACKGROUND

Dual practice (DP) by medical specialists is a widespread issue across health systems. This study aims to determine the level of DP engagement among Iran's specialists.

METHODS

A pre-structured form was developed to collect the data about medical specialists worked in all 925 Iran hospitals in 2016. The forms were sent to the hospitals via medical universities in each province. The data were merged at the national level and matched using medical council ID codes, national ID codes, and eventually a combination of the first name, surname, and father's name.

RESULTS

A total of 48 345 records were collected for 30 273 specialists from 858 (93%) hospitals out of total 925 hospitals. Sixteen thousand eight hundred forty-nine (69% of) specialists were non-faculty members and 6317 (26% of) specialists were employed on a contract basis. Eleven thousand six hundred and thirty-eight (47.7% of) specialists were engaged in DP on total. Female specialists had 0.78 times less DP chance; faculties compared to non-faculties had 0.65 times more DP chance and full-time geographic specialists compared to non-full-time specialists had 0.15 times more DP chance. DP was more frequent in specialists with higher age and more job experience and in provinces with more population, deprivation, and higher number of specialists per facility (P < 0.05).

CONCLUSIONS

The level of DP is relatively high among Iran medical specialists, especially in geographic full-time specialists. However, they are totally banned and they receive extra payment for being full-time; restrictive regulations and financial incentives without considering other factors might not eliminate DP in specialists and it should be addressed based on conditions of each country and regions inside the country.

Prohibiting physicians' dual practice in Iran: Policy options for implementation

BACKGROUND

In Iran, based on the recent national policy documents, physician dual practice (PDP) has been prohibited. This study aimed to develop policy options (POs) to implement physicians' dual practice prohibition law in Iran.

METHODS

International evidence published in English and local documents published in Persian about PDP analyzed and results (advantages, disadvantages, challenges and requirements to ban PDP, and applied policies to limit the dual practice) were extracted. Results discussed among the research team in 5 rounds of meetings. In each meeting, any possible PO to limit PDP in Iran was proposed based on brainstorming technique and 12 POs were developed. These 12 POs and their advantages and disadvantages were discussed in a focus group discussion attended by 14 informed policy makers, and 3 additional POs were added.

RESULTS

Fifteen POs were developed. Each PO has its own advantages and disadvantages. It is worth to highlight that not only are the proposed POs not mutually exclusive but they are also mutually reinforcing; that is, each of these POs can be applied alone or they can be implemented alongside each other simultaneously.

CONCLUSION

No single optimal PO exists for dealing with the dual practice in Iranian health system. Implementing a mix of POs could reduce possible complications of each PO and increase the chance of successful implementation of the law. It is advisable to follow a conservative and incremental approach and start with POs that will cause less resistance and political challenges.

Understanding nurses' dual practice: a scoping review of what we know and what we still need to ask on nurses holding multiple jobs

BACKGROUND

Mounting evidence suggests that holding multiple concurrent jobs in public and private (dual practice) is common among health workers in low- as well as high-income countries. Nurses are world's largest health professional workforce and a critical resource for achieving Universal Health Coverage. Nonetheless, little is known about nurses' engagement with dual practice.

METHODS

We conducted a scoping review of the literature on nurses' dual practice with the objective of generating hypotheses on its nature and consequences, and define a research agenda on the phenomenon. The Arksey and O'Malley's methodological steps were followed to develop the research questions, identify relevant studies, include/exclude studies, extract the data, and report the findings. PRISMA guidelines were additionally used to conduct the review and report on results.

RESULTS

Of the initial 194 records identified, a total of 35 met the inclusion criteria for nurses' dual practice; the vast majority (65%) were peer-reviewed publications, followed by nursing magazine publications (19%), reports, and doctoral dissertations. Twenty publications focused on high-income countries, 16 on low- or middle-income ones, and two had a multi country perspective. Although holding multiple jobs not always amounted to dual practice, several ways were found for public-sector nurses to engage concomitantly in public and private employments, in regulated as well as in informal, casual fashions. Some of these forms were reported as particularly prevalent, from over 50% in Australia, Canada, and the UK, to 28% in South Africa. The opportunity to increase a meagre salary, but also a dissatisfaction with the main job and the flexibility offered by multiple job-holding arrangements, were among the reported reasons for engaging in these practices.

DISCUSSION AND CONCLUSIONS

Limited and mostly circumstantial evidence exists on nurses' dual practice, with the few existing studies suggesting that the phenomenon is likely to be very common and carry  implications for health systems and nurses' welfare worldwide. We offer an agenda for future research to consolidate the existing evidence and to further explore nurses' motivation; without a better understanding of nurse dual practice, this will continue to be a largely 'hidden' element in nursing workforce policy and practice, with an unclear impact on the delivery of care.

Public-on-private dual practice among physicians in public hospitals of Tigray National Regional State, North Ethiopia: perspectives of physicians, patients and managers

Background

Physicians who work in the private sector while also holding a salaried job in a public hospital, known as “dual practice,” is one of the main retention strategies adopted by the government of Ethiopia. Dual practice was legally endorsed in Tigray National Regional State, Ethiopia in 2010. Therefore, the aim of this study was to explore the extent of dual practice, reasons why physicians engage in it, and its effects on public hospital services in this state in northern Ethiopia.

Methods

A cross-sectional study using mixed methods was conducted from February to March 2011 in six geographically representative public hospitals of Tigray National Regional State. A semi-structured, self-administered questionnaire was distributed to all physicians working in the study hospitals, and an interviewer-administered, structured questionnaire was used to collect data from admitted patients. Focus group discussions were conducted with hospital governing boards. Quantitative and qualitative data were used in the analysis.

Results

Data were collected from 31 physicians and 449 patients in the six study hospitals. Six focus group discussions were conducted. Twenty-eight (90.3%) of the physicians were engaged in dual practice to some extent: 16 (51.6%) owned private clinics outside the public hospital, 5 (16.1%) worked part-time in outside private clinics, and 7 (22.6%) worked in the private wing of public hospitals. Income supplementation was the primary reason for engaging in dual practice, as reported by 100% of the physicians. The positive effects of dual practice from both managers’ and physicians’ perspectives were physician retention in the public sector. Ninety-one patients (20.3%) had been referred from a private clinic immediately prior to their current admission-a circular diversion pattern. Eighteen (19.8%) of the diverted patients reported that health workers in the public hospitals diverted them.

Conclusions

Circular diversion pattern of referral system is the key negative consequence of dual practice. Physicians and hospital managers agreed that health worker retention was the main positive consequence of dual practice upon the public sector, and banning dual practice would result in a major loss of senior physicians. The motive behind the circular diversion pattern described by patients should be studied further.

Factors influencing physicians' choice of workplace: systematic review of drivers of attrition and policy interventions to address them

Objectives

The movement of skilled physicians from the public to the private sector is a key constraint to achieving universal health coverage and is currently affecting health systems worldwide. This systematic review aims to assess factors influencing physicians’ choice of workplace, and policy interventions for retaining physicians in the public sector.

Methods

Five literature databases were searched. Studies were included in the review if they focused on at least one of the following criteria: (i) incentives or motivators for retaining physicians in the public sector, (ii) pull factors that encouraged physicians to move to the private sector, (iii) push factors that forced physicians to leave the public sector, (iv) policy interventions or case studies that addressed physician retention in the public sector, and (v) qualitative reviews of policy interventions that were implemented in different health system settings.

Results

Nineteen articles met the inclusion criteria. Six major themes that affected physicians’ choice of workplace were identified including: financial incentives, career development, infrastructure and staffing, professional work environment, workload and autonomy. The majority of the studies suggested that the use of financial incentives was a motivator in retaining physicians in the public sector. The review also identified policy interventions including: regulatory controls, incentives and management reforms. Regulatory controls and incentives were the two most frequently reported policy interventions.

Conclusion

While factors affecting physicians’ choice of workplace are country specific, financial incentives and professional development are core factors. Other factors are highly influenced by context, and thus, it would be useful for future cross–country research to use standardized data collection tools, allowing comparison of contextual factors as well as the examination of how context affects physician retention in the public sector.

Are health workers motivated by income? Job motivation of Cambodian primary health workers implementing performance-based financing

BACKGROUND

Financial incentives are widely used in performance-based financing (PBF) schemes, but their contribution to health workers' incomes and job motivation is poorly understood. Cambodia undertook health sector reform from the middle of 2009 and PBF was employed as a part of the reform process.

OBJECTIVE

This study examines job motivation for primary health workers (PHWs) under PBF reform in Cambodia and assesses the relationship between job motivation and income.

DESIGN

A cross-sectional self-administered survey was conducted on 266 PHWs, from 54 health centers in the 15 districts involved in the reform. The health workers were asked to report all sources of income from public sector jobs and provide answers to 20 items related to job motivation. Factor analysis was conducted to identify the latent variables of job motivation. Factors associated with motivation were identified through multivariable regression.

RESULTS

PHWs reported multiple sources of income and an average total income of US$190 per month. Financial incentives under the PBF scheme account for 42% of the average total income. PHWs had an index motivation score of 4.9 (on a scale from one to six), suggesting they had generally high job motivation that was related to a sense of community service, respect, and job benefits. Regression analysis indicated that income and the perception of a fair distribution of incentives were both statistically significant in association with higher job motivation scores.

CONCLUSIONS

Financial incentives used in the reform formed a significant part of health workers' income and influenced their job motivation. Improving job motivation requires fixing payment mechanisms and increasing the size of incentives. PBF is more likely to succeed when income, training needs, and the desire for a sense of community service are addressed and institutionalized within the health system.

Factors influencing the perception of medical staff and outpatients of dual practice in Shanghai, People's Republic of China

OBJECTIVE

Dual practice is defined as a physician's performance of medical activities in different health care institutions (two or more) simultaneously. This study aimed to examine the perception and acceptance of medical staff and outpatients of dual practice and explore the possible factors affecting people's perception.

METHODS

A cross-sectional study was conducted in 13 public hospitals in Shanghai. Participants included medical staff and outpatients. We distributed 1,000 questionnaires to each participant group, and the response rates were 66.7% and 69.4%, respectively. Statistical differences in variables were tested, and multinomial logistic regression methods were employed for statistical analysis.

RESULTS

The study included two parts: medical staff survey and outpatient survey. The results of medical staff survey showed that 63.0% of the respondents supported dual practice. Medical staff who belonged to the surgical department or held positive belief of dual practice were more willing to participate in dual practice. Moreover, the publicity activities of dual practice and hospitals' human resource management system were important factors affecting the willingness of the medical staff. The results of outpatient survey showed that 44.5% of respondents believed that dual practice could reduce difficulty in consulting a doctor. Regarding the perceived benefits of dual practice, the proportion of outpatients who believed that dual practice could meet the demand for health convenience, minor illness, and chronic disease were 45.4%, 42.4%, and 53.7%, respectively. Additionally, demographic characteristics significantly influenced the perception of outpatients.

CONCLUSION

This study confirmed that both medical staff and outpatients generally held positive attitudes toward dual practice. Medical staff who belonged to the surgical department or held positive belief of dual practice were more willing to participate in dual practice. Moreover, the existence of publicity activities and more flexible management system of hospitals' human resource would promote physicians' willingness to participate in dual practice. In addition, perception of outpatients of dual practice was affected by demographic characteristics.

Conceptualizing the impacts of dual practice on the retention of public sector specialists - evidence from South Africa

BACKGROUND

'Dual practice', or multiple job holding, generally involves public sector-based health workers taking additional work in the private sector. This form of the practice is purported to help retain public health care workers in low and middle-income countries' public sectors through additional wage incentives. There has been little conceptual or empirical development of the relationship between dual practice and retention.

METHODS

This article helps begin to fill this gap, drawing on empirical evidence from a qualitative study focusing on South African specialists. Fifty-one repeat, in-depth interviews were carried out with 28 doctors (predominantly specialists) with more than one job, in one public and one private urban hospital.

RESULTS

Findings suggest dual practice can impact both positively and negatively on specialists' intention to stay in the public sector. This is through multiple conceptual channels including those previously identified in the literature such as dual practice acting as a 'stepping stone' to private practice by reducing migration costs. Dual practice can also lead specialists to re-evaluate how they compare public and private jobs, and to overworking which can expedite decisions on whether to stay in the public sector or leave. Numerous respondents undertook dual practice without official permission.

CONCLUSIONS

The idea that dual practice helps retain public specialists in South Africa may be overstated. Yet banning the practice may be ineffective, given many undertake it without permission in any case. Regulation should be better enforced to ensure dual practice is not abused. The conceptual framework developed in this article could form a basis for further qualitative and quantitative inquiry.

Advancing the application of systems thinking in health: exploring dual practice and its management in Kampala, Uganda

BACKGROUND

Many full-time Ugandan government health providers take on additional jobs - a phenomenon called dual practice. We describe the complex patterns that characterize the evolution of dual practice in Uganda, and the local management practices that emerged in response, in five government facilities. An in-depth understanding of dual practice can contribute to policy discussions on improving public sector performance.

METHODS

A multiple case study design with embedded units of analysis was supplemented by interviews with policy stakeholders and a review of historical and policy documents. Five facility case studies captured the perspective of doctors, nurses, and health managers through semi-structured in-depth interviews. A causal loop diagram illustrated interactions and feedback between old and new actors, as well as emerging roles and relationships.

RESULTS

The causal loop diagram illustrated how feedback related to dual practice policy developed in Uganda. As opportunities for dual practice grew and the public health system declined over time, government providers increasingly coped through dual practice. Over time, government restrictions to dual practice triggered policy resistance and protest from government providers. Resulting feedback contributed to compromising the supply of government providers and, potentially, of service delivery outcomes. Informal government policies and restrictions replaced the formal restrictions identified in the early phases. In some instances, government health managers, particularly those in hospitals, developed their own practices to cope with dual practice and to maintain public sector performance. Management practices varied according to the health manager's attitude towards dual practice and personal experience with dual practice. These practices were distinct in hospitals. Hospitals faced challenges managing internal dual practice opportunities, such as those created by externally-funded research projects based within the hospital. Private wings' inefficiencies and strict fee schedule made them undesirable work locations for providers.

CONCLUSIONS

Dual practice prevails because public and private sector incentives, non-financial and financial, are complementary. Local management practices for dual practice have not been previously documented and provide learning opportunities to inform policy discussions. Understanding how dual practice evolves and how it is managed locally is essential for health workforce policy, planning, and performance discussions in Uganda and similar settings.

Physicians' engagement in dual practices and the effects on labor supply in public hospitals: results from a register-based study

Background

Physician dual practice, a combination of public and private practice, has attracted attention due to fear of reduced work supply and a lack of key personnel in the public system, increase in low priority treatments, and conflicts of interest for physicians who may be competing for their own patients when working for private suppliers. In this article, we analyze both choice of dual practice among hospital physicians and the dual practices’ effect on work supply in public hospitals.

Methods

The sample consisted of 12,399 Norwegian hospital physicians working in public hospitals between 2001 and 2009. We linked hospital registry data on salaries and hospital working hours with data from national income and other registries covering non-hospital income, including income from dual work, cohabiting status, childbirths and socioeconomic characteristics. Our dataset also included hospital variables describing i.e. workload. We estimated odds ratio for choosing dual practice and the effects of dual practice on public working hours using different versions of mixed models.

Results

The percentage of physicians engaged in dual practice fell from 35.1% for men and 17.6% for women in 2001 to 25.0% and 14.2%, respectively, in 2009. For both genders, financial debt and interest payments were positively correlated and having a newborn baby was negatively correlated with engaging in dual practice. Larger family size and being cohabitating increased the odds ratio of dual practice among men but reduced it for women. The most significant internal hospital factor for choosing dual practice was high wages for extended working hours, which significantly reduced the odds ratio for dual practice. The total working hours in public hospitals were similar for both those who did and did not engage in dual practice; however, dual practice reduced public working hours in some specialties.

Conclusion

Economic factors followed by family variables are significant elements influencing dual practice. Although our findings indicate that engagement in dual practice by public hospital physicians in a well-regulated market may increase the total labor supply, this may vary significantly between medical specialties.

Adoption, implementation and prioritization of specialist outreach policy in Australia: a national perspective

The World Health Organization has endorsed the use of outreach to promote: efficient redeployment of the health-care workforce; continuity of care at the local level; and professional support for local, rural, health-care workers. Australia is the only country that has had, since 2000, a sustained national policy on outreach for subsidizing medical specialist outreach to rural areas. This paper describes the adoption, implementation and prioritization of a national specialist outreach policy in Australia. Adoption of the national policy followed a long history of successful outreach, largely driven by the professional interest and personal commitment of the workforce. Initially the policy supported only new outreach services but concerns about the sustainability of existing services resulted in eligibility for funding being extended to all specialist services. The costs of travel, travel time, accommodation, professional support, staff relief at specialists' primary practices and equipment hire were subsidized. Over time, a national political commitment to the equitable treatment of indigenous people resulted in more targeted support for outreach in remote areas. Current priorities are: (i) establishing team-based outreach services; (ii) improving local staff's skills; (iii) achieving local coordination; and (iv) conducting a nationally consistent needs assessment. The absence of subsidies for specialists' clinical work can discourage private specialists from providing services in remote areas where clinical throughput is low. To be successful, outreach policy must harmonize with the interests of the workforce and support professional autonomy. Internationally, the development of outreach policy must take account of the local pay and practice conditions of health workers.

Building social currency with foreskin cuts: a coping mechanism of Papua New Guinea health workers and the implications for new programmes

BACKGROUND

Recent research as part of a multi-disciplinary investigation on the acceptability and impact of male circumcision for HIV prevention in Papua New Guinea (PNG) has shown that health workers (HWs) undertake unauthorized forms of penile cutting practices in public health facilities or in community settings, at times within a traditional context. Participation in these activities shares common features with coping mechanisms, strategies used by HWs to alleviate the burden of unsatisfactory living and working conditions. Coping mechanisms, however, are typically described as motivated by economic advantage, but in PNG evidence exists that the behaviours of HWs are also influenced by opportunities for social capital.

METHODS

Twenty-five in-depth interviews (IDIs) were completed with a variety of HWs from 2009 until 2011 and were triangulated with findings from 45 focus group discussions and 82 IDIs completed with community members as part of a wider qualitative study. Thematic analysis examined HW participation in unauthorized penile cutting services.

RESULTS

The emergence of unauthorized practices as a coping mechanism in PNG is compelled by mutual obligations and social capital arising from community recognition and satisfaction of moral, professional and cultural obligations. Using the example of unauthorized penile cutting practices amongst HWs in PNG, the research shows that although economic gains are not explicitly derived, evidence exists that they meet other community and socio cultural responsibilities forming a social currency within local traditional economies.

CONCLUSIONS

Coping mechanisms create an opportunity to extend the boundaries of a health system at the discretion of the HW. Fragile health systems create opportunities for coping mechanisms to become institutionalized, pre-empting appropriate policy development or regulation in the introduction of new programmes. In order to ensure the success of new programmes, the existence of such practices and their potential implications must be addressed within programme design, and in implementation and regulation.

Negotiating markets for health: an exploration of physicians' engagement in dual practice in three African capital cities

Scarce evidence exists on the features, determinants and implications of physicians’ dual practice, especially in resource-poor settings. This study considered dual practice patterns in three African cities and the respective markets for physician services, with the objective of understanding the influence of local determinants on the practice. Forty-eight semi-structured qualitative interviews were conducted in the three cities to understand features of the practice and the respective markets. A survey was carried out in a sample of 331 physicians to explore their characteristics and decisions to work in public and private sectors. Descriptive analysis and inferential statistics were employed to explore differences in physicians’ engagement in dual practice across the three locations. Different forms of dual practice were found to exist in the three cities, with public physicians engaging in private practice outside but also inside public facilities, in regulated as well as unregulated ways. Thirty-four per cent of the respondents indicated that they worked in public practice only, and 11% that they engaged exclusively in private practice. The remaining 55% indicated that they engaged in some form of dual practice, 31% ‘outside’ public facilities, 8% ‘inside’ and 16% both ‘outside’ and ‘inside’. Local health system governance and the structure of the markets for physician services were linked to the forms of dual practice found in each location, and to their prevalence. Our analysis suggests that physicians’ decisions to engage in dual practice are influenced by supply and demand factors, but also by how clearly separated public and private markets are. Where it is possible to provide little-regulated services within public infrastructure, less incentive seems to exist to engage in the formal private sector, with equity and efficiency implications for service provision. The study shows the value of analysing health markets to understand physicians’ engagement in professional activities, and contributes to an evidence base for its regulation.

An empirical analysis of public and private medical practice in Australia

The combination of public and private medical practice is widespread in many health systems and has important consequences for health care cost and quality. However, its forms and prevalence vary widely and are poorly understood. This paper examines factors associated with public and private sector work by medical specialists using a nationally representative sample of Australian doctors. We find considerable variations in the practice patterns, remuneration contracts and professional arrangements across doctors in different work sectors. Both specialists in mixed practice and private practice differ from public sector specialists with regard to their annual earnings, sources of income, maternity and other leave taken and number of practice locations. Public sector specialists are likely to be younger, to be international medical graduates, devote a higher percentage of time to education and research, and are more likely to do after hours and on-call work compared with private sector specialists. Gender and total hours worked do not differ between doctors across the different practice types.

A theoretical approach to dual practice regulations in the health sector

Internationally, there is wide cross-country heterogeneity in government responses to dual practice in the health sector. This paper provides a uniform theoretical framework to analyze and compare some of the most common regulations. We focus on three interventions: banning dual practice, offering rewarding contracts to public physicians, and limiting dual practice (including both limits to private earnings of dual providers and limits to involvement in private activities). An ancillary objective of the paper is to investigate whether regulations that are optimal for developed countries are adequate for developing countries as well. Our results offer theoretical support for the desirability of different regulations in different economic environments.

Interventions to manage dual practice among health workers

BACKGROUND

Dual practice, whereby health workers hold two or more jobs, is a common phenomenon globally. In resource constrained low- and middle-income countries dual practice poses an ongoing threat to the efficiency, quality and equity of health services, especially in the public sector. Identifying effective interventions to manage dual practice is important.

OBJECTIVES

To assess the effects of regulations implemented to manage dual practice.

SEARCH STRATEGY

Databases searched included: The Cochrane Central Register of Controlled Trials (CENTRAL) 2011, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 26 May 2011); MEDLINE In-Process & Other Non-Indexed Citations May 24, 2011 (searched 26 May 2011); MEDLINE, Ovid (1948 to May week 2 2011) (searched 26 May 2011); EMBASE, Ovid (1980 to 2011 week 20) (searched 26 May 2011); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 04 December 2009); LILACS (searched January 2010); and AIM (December 2009) (searched 18 December 2009).

SELECTION CRITERIA

Randomized controlled trials, non-randomized controlled trials, controlled before-and-after studies and interrupted-time-series studies. Dual practice was defined as holding more than one job. Studies for inclusion were those focusing on interventions to manage dual practice among health professionals employed in the public health sector.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the criteria for inclusion and exclusion of studies when scanning the identified titles and abstracts. The same two review authors independently screened full reports of selected citations. At each stage, results were compared and discrepancies settled through discussion.

MAIN RESULTS

No studies were found which were eligible for inclusion in this review.

AUTHORS' CONCLUSIONS

There is a need to rigorously evaluate the effects of interventions implemented to manage dual practice among health workers. However, there is still much that is unknown about dual practice itself. The designing of studies to evaluate the effects of interventions to manage dual practice could benefit from prior studies to assess the various manifestations of dual practice, their prevalence and their likely impacts on health services delivery. These findings would then inform the design of studies to evaluate interventions to manage dual practice.

Whom do physicians work for? An analysis of dual practice in the health sector

This article presents a thorough analysis of dual practice among physicians who work in both the public and private sectors. A conceptual framework is presented to help the reader understand dual practice and the contexts where it takes place. The article reviews the existing theoretical and empirical literature on this form of dual practice among physicians. It analyzes the extent of this phenomenon, the underlying factors that motivate physicians to engage in dual practice, and the main implications of their decision to do so. It also examines and discusses current policies that address dual practice. In this regard, the article provides some qualified support for the use of "rewarding" policies to retain physicians in the public sectors of more developed countries, while "limiting" policies are recommended for developing countries - with the caveat that the policies should be accompanied by the strengthening of institutional and contracting environments. The article highlights the lack of quality evaluative evidence regarding the consequences of dual practice on the delivery of health care services. It concludes that the overall impact of dual practice remains an open question that warrants more attention from researchers and policy makers alike.

"We noticed that suddenly the country has become full of MRI". Policy makers' views on diffusion and use of health technologies in Iran

Objective

Uncontrolled proliferation of health technologies (HT) is one contributor to the increasing pressure on health systems to adopt new technologies. With limited resources, policy-makers encounter difficulties in fulfilling their responsibility to meet the healthcare needs of the population. The aim of this study is to explore how policy-makers' reason about the diffusion and utilization of health technologies in Iran using magnetic resonance imaging (MRI) and interferon beta as tracers.

Method

This qualitative exploration complements quantitative data generated in a research project investigating the diffusion and utilization of MRI and interferon beta in Iran. Qualitative semi-structured interviews were conducted with 13 informants in different positions and levels of authority in the Ministry of Health (MOH), University of Medical Sciences, Health Insurance Organizations, and Parliament. The data was analysed using the framework approach.

Findings

Although policy-makers appeared to be positive to health technology assessment (HTA), the processes of policy-making described by the interviewees did not seem to be based on a full understanding of this (discipline). Several obstacles to applying knowledge about HT and HTA were described. The current official plan for MRI adoption and diffusion in the country was said not to be followed, and no such plan was described for interferon beta. Instead, market forces such as advertising, and physician and consumer demand, appear to have strong influence on HT diffusion and use. Dual practice may have increased the induced demand and also reduced the supervision of the private sector by the MOH.

Conclusion

Management instability and lack of coordination in the MOH were found to be important obstacles to accumulation of knowledge and experience which, in turn, could have led to suboptimal managerial and policy-making processes. Furthermore marketing should be controlled in order to avoid creating unnecessary patient demands and negative influences on physicians' behavior.

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

This paper examines why progress towards Millennium Development Goal 5 on maternal health appears to have stagnated in much of the global south. We contend that besides the widely recognised existence of weak health systems, including weak services, low staffing levels, managerial weaknesses, and lack of infrastructure and information, this stagnation relates to the inability of most countries to meet two essential conditions: to develop access to publicly funded, comprehensive health care, and to provide the not-for-profit sector with needed political, technical and financial support. This paper offers a critical perspective on the past 15 years of international health policies as a possible cofactor of high maternal mortality, because of their emphasis on disease control in public health services at the expense of access to comprehensive health care, and failures of contracting out and public-private partnerships in health care. Health care delivery cannot be an issue both of trade and of right. Without policies to make health systems in the global south more publicly-oriented and accountable, the current standards of maternal and child health care are likely to remain poor, and maternal deaths will continue to affect women and their families at an intolerably high level.