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

Giuliano Russo,Paulo Ferrinho,Inês Fronteira,Barbara Mcpake

doi:10.1093/heapol/czt071

Giuliano Russo, Paulo Ferrinho + Show 2 more

Open Access

https://doi.org/10.1093/heapol/czt071

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Abstract

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.

Highlights

Physicians’ simultaneous engagement in multiple clinical professions is very common worldwide
Qualitative interviews We individually interviewed a purposive sample of 48 public and private sector physicians, as well as key health policymakers identified with the help of local Ministry of Health (MoH) and Medical Councils (Table S1 in supplementary data)
A substantial proportion of public sector physicians reported engaging with four types of private clinical activities, involving different levels of public resource use, regulation, quality and prices: (a) Private practice ‘outside’ public practice: medical practitioners operate or work in distinct private facilities, unconnected physically or institutionally to public sector facilities

Summary

Introduction

Physicians’ simultaneous engagement in multiple clinical professions is very common worldwide Those who combine a mix of public and private sector work are most often referred to as ‘engaging in dual practice’ (Eggleston and Bir 2006; GarcıaPrado and Gonzalez 2011; Socha and Bech 2011), as ‘multiple or dual job-holders’ (Berman and Cuizon 2004; Jan et al 2005), or as undertaking ‘multiple income-generating activities’ (Jumpa et al 2007). In Europe, Humphrey and Russell (2004) find that in the UK, 63% of public hospital consultants and specialists maintain a private practice alongside their job in the National Health Service, while Dolado and Felgueroso (2007) found that 20% of Spanish public sector physicians have a second job. Private health practice was legalized in 1986, but no regulation exists of

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