Abstract
BackgroundMany 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.MethodsA 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.ResultsThe 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.ConclusionsDual 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.
Highlights
Dual practice, when health workers employed full time by the government take on additional jobs, is widespread in developing countries, those with growing private sectors
Dual practice has been rising in importance on the policy agenda due to media reports of adverse health service delivery outcomes [10,11], as well as suspected linkages to absenteeism and the wastage linked to it [12,13]
We explore how dual practice evolved in the Ugandan health system and how it is currently managed, in an urban environment – the city of Kampala, with an active private sector
Summary
Dual practice, when health workers employed full time by the government take on additional jobs, is widespread in developing countries, those with growing private sectors. Dual practice can be broader than private for-profit sector service delivery – including both research and NGO work. Researchers and policy-makers in developing countries display increasing interest in how dual practice affects the health system [6,7]. While estimates from public facilities do not exist, in general, health providers and policymakers perceive that almost all government-employed health workers have dual practice. A recent study aiming to establish policy-makers’ research priorities revealed that a principal concern was dual practice that was “reported to greatly affect the performance of the public sector. An in-depth understanding of dual practice can contribute to policy discussions on improving public sector performance
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