Behind the scenes of dual practice: understanding physicians’ engagement in private services in low-income settings
By Giuliano Russo and Barbara McPake
Physicians’ engagement with dual practice and private sector activities has always been frowned-upon by patients and regulators alike, on ethical grounds, but also on the suspicion that it diverts scarce resources and effort from public services, particularly in low-income countries. However, little evidence exists about the prevalence of dual employment and on its determinants. A new series of papers from Portuguese-speaking African countries offers a fresh insight into this practice, showing that physician personal characteristics, local health system governance and health markets play a critical role on the form physicians engage with the private sector and the time they allocate to public and private activities.
A recent paper published in Social Science and Medicine finds an association between the probability of being a dual practitioner and variables like private sector hourly rates, length of time as a physicians and holding a specialisation. However, how much money they make from their public and private jobs does not seem to explain the time physicians devote to the private sector, which appears to be more related to their personal characteristics like age, number of dependents and type of specialisation.
In another paper published in 2013 in Health Policy and Planning, unexpected forms of dual practice are found to exist in the three study locations, with public sector doctors engaging creatively with the private practice by offering ‘special’ on-payment services also inside and beside public hospitals. The study links forms and prevalence of physician dual practice with supply and demand factors, as well as with health system governance features and with how clearly separated public and private medical services are in the three locations.
As for those physicians who leave the public to work exclusively for the private sector, a third paper from Human Resources for Health shows that only a limited proportion of the medical workforce opts to do so, with members of this group being older than their public and dual practice peers. These ‘private only physicians’ are shown to work fewer hours per week, and earn more than public sector doctors, but not necessarily more than dual practitioners. Rather, a preference for a more independent and flexible work modality seems to be at the heart of their decision to focus exclusively on the private.
This new evidence suggests that physicians’ decisions on when, how and how much to work for the private sector are still poorly understood, and cannot be explained exclusively by financial arguments. More research is underway to explore the complexities of physician dual practice by the authors of the papers above, so do watch this space and feel free to comment below!
