Dual Practice Research Articles

Surgery and trauma care providers' perception of the impact of dual-practice employment on quality of care provided in an Andean country.

Dual-practice, simultaneous employment by healthcare workers in the public and private sectors is pervasive worldwide. Although an estimated 30 per cent of the global burden of disease is surgical, the implications of dual practice on surgical care are not well understood. Anonymous in-depth individual interviews on trauma quality improvement practices were conducted with healthcare providers who participate in the care of the injured at ten large hospitals in Peru's capital city, Lima. A grounded theory approach to qualitative data analysis was employed to identify salient themes. Fifty interviews were conducted. A group of themes that emerged related to the perceived negative and positive impacts of dual practice on the quality of surgical care. Participants asserted that the majority of physicians in Lima working in the public sector also worked in the private sector. Dual practice has negative impacts on physicians' time, quality of care in the public sector, and surgical education. Dual practice positively affects patient care by allowing physicians to acquire management and quality improvement skills, and providing incentives for research and academic productivity. In addition, dual practice provides opportunities for clinical innovations and raises the economic status of the physician. Surgeons in Peru report that dual practice influences patient care negatively by creating time and human resource conflicts. Participants assert that these conflicts widen the gap in quality of care between rich and poor. This practice warrants redirection through national-level regulation of physician schedules and reorganization of public investment in health via physician remuneration.

Hospital physician payment mechanisms in Austria: do they provide gateways to institutional corruption?

Institutional corruption in the health care sector has gained considerable attention during recent years, as it acknowledges the fact that service providers who are acting in accordance with the institutional and environmental settings can nevertheless undermine a health care system’s purposes as a result of the (financial) conflicts of interest to which the service providers are exposed. The present analysis aims to contribute to the examination of institutional corruption in the health sector by analyzing whether the current payment mechanism of separately remunerating salaried hospital physicians for treating supplementary insured patients in public hospitals, in combination with the public hospital physician’s possibility of taking up dual practice as a self-employed physician with a private practice and/or as an attending physician in private hospitals, has the potential to undermine the primary purposes of the Austrian public health care system. Based on the analysis of the institutional design of the Austrian public hospital sector, legal provisions and directives have been identified, which have the potential to promote conduct on the part of the public hospital physician that systematically undermines the achievement of the Austrian public health system’s primary purposes.

To Ban or Not to Ban? Regulating Dual Practice in Palestine

—Dual practice, health professionals working simultaneously in the public and private sectors, is perceived to negatively impact quality of health care. Though a range of policy options exists to regulate dual practice, little is known about the impact of different options on quality of care. Successful policy is dependent on a country's health care system, health labor market, monitoring of private sector activity, and enforceability of regulations. This article provides evidence on the potential impact of banning dual practice in Palestine. We apply theoretical evidence and international experience, together with context-specific primary and secondary data, to assess the policy's enforceability, implications, and sustainability in the Palestinian context. In this setting, though the risk of losing health workers to the private sector is low, banning dual practice will most likely lead to the “brain drain” of rare specialists from the public sector. Moreover, though there is some evidence that dual practice is negatively impacting quality of care, poor quality in public facilities associated with shortages in supplies and equipment, poor organizational and management practices, low motivation, and absence of monitoring and accountability systems are unlikely to change by banning dual practice. Finally, the ban, as conceptualized, is fiscally unsustainable in a strained health budget and may be challenging to enforce due to a weak monitoring system. Overall, it was found that an outright ban on dual practice would not reduce the financial burden on patients and enhance their access to quality services in the public sector.

Dual Practice by Health Workers: Theory and Evidence from Indonesia

Using a simple theoretical model we conjecture that dual practice may increase the number of patients seen but reduce hours spent at public facilities, if public physicians lack motivation and/or if their opportunity costs are very large. Using data from Indonesia, we then test these theoretical conjectures. Our identification strategy relies on a 1997 legislation necessitating health professionals to apply for license for private practice only after three years of graduation. Results using a difference-in-difference regression discontinuity design provides support to our conjectures, identifying the role of weak work discipline, lack of motivation and opportunity costs of public service provision.

Confucius’ Zhong-Shu and Zhuangzi’s Qiwu: Zhang Taiyan’s Parallel Interpretation

To avoid the one-sidedness and abuse of the rule of xieju 絜矩 (principle of applying a measuring square), Zhang Taiyan 章太炎 redefines zhong-shu 忠恕, the Confucian golden rule, as two separate yet complementary principles, the idea of which is most manifestly drawn from Zhuangzi’s 莊子 “Qiwulun 齊物論” (“Discourse on Making All Things Equal”). Zhang’s association of zhong-shu and qiwu 齊物 is based upon his vision of equality premised on recognition of and respect for differences. In Zhang’s reading of the Zhuangzi in light of Yogācāra, the crucial “concept matching” (geyi 格義) is the explanation of cheng xin 成心 as seeds in the ālaya consciousness. Cheng xin in this sense not only refers to the natural pattern of things and so is the basis for inference and deduction, but also serves as the means to deal with the diversity of opinions. In moral practice, Zhang proposes the liang xing 兩行 approach of his qiwu philosophy: to recognize the equal worth of all beings on one hand, and to take the particular characteristics and desires of individuals into account on the other. Thus, it requires the dual practice of zhong and shu: to acquire firsthand observation through personal experience, and to imagine oneself in the position of the other.

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

ObjectiveDual 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.MethodsA 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.ResultsThe 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.ConclusionThis 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.

Strategies to Enhance Success Among Dual-Specialty Students in Advanced Practice Nursing Programs.

In attempts to simultaneously address the 2008 Consensus model and meet the growing need for advanced practice nurses with a robust scope of practice, some schools of nursing offer dual advanced practice nursing (APN) programs. Built on the successes of multiple dual programs at two universities, this article provides specific practice strategies to enhance academic success among students and faculty in dual-specialty APN programs. Faculty- and student-led strategies are outlined, addressing the academic and professional aspects of the dual APN role. With implementation of these strategies, graduation and subsequent dual certification rates in these programs remains extremely high. Adaptation of these strategies to support student and faculty efforts can potentiate additional opportunities for successful dual APN programs. [J Nurs Educ. 2016;55(8):463-466.

P2Y12 receptor inhibitors in patients with non-ST-elevation acute coronary syndrome in the real world: use, patient selection, and outcomes from contemporary European registries.

Non-ST-elevation acute coronary syndrome (NSTE-ACS) is present in about 60-70% of patients admitted with acute coronary syndromes in clinical practice. This study provides a 'real-life' overview of NSTE-ACS patient characteristics, dual antiplatelet therapy clinical practice, and outcomes at both the time of discharge from hospital and up to 1-year post-discharge. A total of 10 registries (documenting 84 054 NSTE-ACS patients) provided data in a systematic manner on patient characteristics and outcomes for NSTE-ACS in general, and 6 of these (with 52 173 NSTE-ACS patients) also provided more specific data according to P2Y12 receptor inhibitor used. Unadjusted analyses were performed at the study level, and no formal meta-analysis was performed due to large heterogeneity between studies in the settings, patient characteristics, and outcome definitions. All-cause death rates across registries ranged from 0.76 to 4.79% in-hospital, from 1.61 to 6.65% at 30 days, from 3.66 to 7.16% at 180 days, and from 3.14 to 9.73% at 1 year. Major bleeding events were reported in up to 2.77% of patients while in hospital (in seven registries), up to 1.08% at 30 days (data from one registry only), and 2.06% at 1 year (one registry). There were substantial differences in the use of and patient selection for clopidogrel, prasugrel, and ticagrelor, which were associated with differences in short- and long-term ischaemic and bleeding events. In future registries, data collection should be performed in a more standardized way with respect to endpoints, definitions, and time points.

“So as Not to Arrive”: The Object-Theater of Late Jamesian Consciousness

Henry James’s late style in the House of Fiction metaphor and The Golden Bowl elicits a dual reading practice demanding both formal analysis that traces the dematerialization of objects in the fictional world and a reifying attitude that permits these objects a material presence around which scenes are constructed. At key moments, consciousness is simultaneously metaphorized as an object and theatricalized as a scene in which the conscious character interacts with the original object-metaphor. If the materiality and even figurality of these objects are unstable, it is in this phenomenal instability that these moments’ affective intensity originates.

Implications of dual practice for universal health coverage.

Making progress towards universal health coverage (UHC) requires that health workers are adequate in numbers, prepared for their jobs and motivated to perform. In establishing the best ways to develop the health workforce, relatively little attention has been paid to the trends and implications of dual practice – concurrent employment in public and private sectors. We review recent research on dual practice for its potential to guide staffing policies in relation to UHC. Many studies describe the characteristics and correlates of dual practice and speculate about impacts, but there is very little evidence that is directly relevant to policy-makers. No studies have evaluated the impact of policies on the characteristics of dual practice or implications for UHC. We address this lack and call for case studies of policy interventions on dual practice in different contexts. Such research requires investment in better data collection and greater determination on the part of researchers, research funding bodies and national research councils to overcome the difficulties of researching sensitive topics of health systems functions.

The complex remuneration of human resources for health in low-income settings: policy implications and a research agenda for designing effective financial incentives.

BackgroundHuman resources for health represent an essential component of health systems and play a key role to accelerate progress towards universal health coverage. Many countries in sub-Saharan Africa face challenges regarding the availability, distribution and performance of health workers, which could be in part addressed by providing effective financial incentives.MethodsBased on an overview of the existing literature, the paper highlights the gaps in the existing research in low-income countries exploring the different components of health workers’ incomes. It then proposes a novel approach to the analysis of financial incentives and delineates a research agenda, which could contribute to shed light on this topic.FindingsThe article finds that, while there is ample research that investigates separately each of the incomes health workers may earn (for example, salary, fee-for-service payments, informal incomes, “top-ups” and per diems, dual practice and non-health activities), there is a dearth of studies which look at the health workers’ “complex remuneration”, that is, the whole of the financial incentives available. Little research exists which analyses simultaneously all revenues of health workers, quantifies the overall remuneration and explores its complexity, its multiple components and their features, as well as the possible interaction between income components. However, such a comprehensive approach is essential to fully comprehend health workers’ incentives, by investigating the causes (at individual and system level) of the fragmentation in the income structure and the variability in income levels, as well as the consequences of the “complex remuneration” on motivation and performance. This proposition has important policy implications in terms of devising effective incentive packages as it calls for an active consideration of the role that “complex remuneration” plays in determining recruitment, retention and motivation patterns, as well as, more broadly, the performance of health systems.ConclusionsThis paper argues that research focusing on the health workers’ “complex remuneration” is critical to address some of the most challenging issues affecting human resources for health. An empirical research agenda is proposed to fill the gap in our understanding.

A Two-Tier Health Care System: The New Zealand Story

The Canadian health care system is at a crossroads. Litigation building on the Supreme Court of Canada’s decision in Chaoulli that could lead to the establishment of a parallel private tier is underway in several provinces. For example, in a challenge set to proceed to trial this fall, Dr. Brian Day and six patient plaintiffs are challenging several British Columbia laws that restrict parallel private care. Provincial governments across Canada employ various laws to protect public Medicare, including bans on private insurance for publicly insured services, limits on dual practice by physicians (i.e. prohibiting those who are paid through the public insurance plan from also being paid from the public purse), and bans on extra-billing for insured services (i.e. preventing physicians from topping up public payments by charging patients more). Plaintiffs in the upcoming cases allege that the combination of long wait times in the public system and limits on private care infringe their Charter rights to life and security of the person. As judges evaluate these claims, a key consideration will be whether restrictions on private care are essential to preserving quality, efficiency, and accessibility within Canada’s public health care system. In assessing the impact of liberalizing these laws, courts will rely on the comparative experience of countries that also have universal public health insurance, but that allow parallel private care. However, too often, the subtleties of foreign countries’ experiences with two-tier care and contextual differences between health care systems are downplayed or ignored, in favour of simplistic conclusions. For example, in Chaoulli, Chief Justice McLachlin accepted a “common sense” argument that prohibiting private health insurance was not related to the provision of quality public health care, given the experiences of several western democracies with “medical services that are superior to and more affordable than the services that are presently available in Canada,” without addressing the differences that exist between Canada and these countries. This paper draws lessons for Canada from New Zealand’s health care system, which permits two-tier health care. After briefly comparing the two systems, we address the claim that New Zealand’s shorter wait lists coupled with its permissive approach to a parallel private system suggest that Canada should loosen its own restrictions on privatization. We argue that not only are there concerns with the reliability of New Zealand’s wait list data, but that its method of organizing wait lists and its permissiveness of dual practice raise serious concerns with equitable access, quality of care, and physician conflicts of interest. We conclude by arguing that the uncertainty inherent in adapting comparative health policy literature to the Canadian context necessitates judicial deference to policy-makers in the upcoming constitutional challenges.

Doctors as the governing body of the Kurdish health system: exploring upward and downward accountability among physicians and its influence on the adoption of coping behaviours.

BackgroundThe health system of Iraqi Kurdistan is severely understudied, particularly with regard to patient-physician interactions and their effects. We examine patterns of behaviour among physicians in Kurdistan, the justifications given and possible enabling factors, with a view to understanding accountability both from above and below.MethodsAn ethnographic study was conducted in the Sulaimaniyah Teaching Hospital in the Kurdistan Region of Iraq. Data was collected through negotiated interactive observation, and interviews were conducted with 10 participants, 5 physicians and 5 patients. Data collected was analysed using thematic analysis.ResultsCommon patterns of practice among physicians in Kurdistan include displays of discontent, reluctance to negotiate decisions with patients and unfavourable behaviours including dual practice and predatory behaviours towards patients. These behaviours are justified as a mechanism of dealing with negative aspects of their work, including overcrowding, low salaries and social pressure to live up to socially conceived ideas of a physician’s identity.ConclusionsMichael Lipsky’s theory of street-level bureaucrats and their coping behaviours is a useful way to analyse the Kurdish health system. Physician behaviours are enabled by a number of factors that work to enhance physician discretion through lowering of upward and downward accountability. Physicians are under very little pressure to change their behaviour, and as a result, they effectively become the street-level governing body of the Kurdish health system.

From Informal Exchanges to Dual Practices. The Shadows of the Romanian Health Care Reform

Abstract The current frailties of the Romanian health care system are often explained by resorting to the previous regime’s institutional framework, rarely accepting that they are also the product of post-1990 reforms and the neoliberal means of system reconfiguration. This paper provides an ethnographic account of the ways in which two “products” of these reforms actively contribute to the augmentation of private medical services and to the diminishing access to quality care in the public system: the bureaucratization of primary medicine and the “dual medical practice”. More specifically, I use the concept of “informal exchanges” in order to explore the variety of transactions that occur between patients and the health care staff and to document the means through which its main social actors understand, reproduce, legitimize or blame the very existence of these practices. Then, I analyze how referrals to private medical units increasingly replace informal payments, simultaneously laying even harder obstacles in the access to health care for those in need.

"Doctor, Why Didn't You Adopt My Baby?" Observant Participation, Care, and the Simultaneous Practice of Medicine and Anthropology.

Medical anthropology has long appreciated the clinical encounter as a rich source of data and a key site for critical inquiry. It is no surprise, then, that a number of physician-anthropologists have used their clinical insights to make important contributions to the field. How does this duality challenge and enhance the moral practice and ethics of care inherent both to ethnography and to medicine? How do bureaucratic and professional obligations of HIPAA and the IRB intersect with aspirations of anthropology to understand human experience and of medicine to heal with compassion? In this paper, I describe my simultaneous fieldwork and clinical practice at an urban women's jail in the United States. In this setting, being a physician facilitates privileged access to people and spaces within, garners easy trust, and enables an insider perspective more akin to observant participation than participant observation. Through experiences of delivering the infants of incarcerated pregnant women and of being with the mothers as they navigate drug addiction, child custody battles, and re-incarceration, the roles of doctor and anthropologist become mutually constitutive and transformative. Moreover, the dual practice reveals congruities and cracks in each discipline's ethics of care. Being an anthropologist among informants who may have been patients reworks expectations of care and necessitates ethical practice informed by the dual roles.

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.MethodsThis 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.ResultsFindings 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.ConclusionsThe 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.Electronic supplementary materialThe online version of this article (doi:10.1186/1478-4491-13-3) contains supplementary material, which is available to authorized users.

High rate of teenage pregnancy and sexually transmitted infections in Fort Beaufort, Eastern Cape Province, South Africa

There is increased in teenage pregnancy despite the presence of dual protection practice and health care awareness programmes related to health and sexuality education in South Africa. The present study explores the underlying causes of high teenage pregnancy and sexually transmitted diseases rates, including HIV and AIDS in Fort Beaufort. The sample comprised of 70 conviently selected pregnant teenagers aged 15-19 years. Data were collected through self-administered questionnaire. About 56.9% participants knew nothing about family planning, 27.5% concieved family planning as prevention of pregnancy, and regard injection as a method of family planning, while 11% described family planning as planning for future babies. Those who knew about family planning mentioned friends, clinics, schools, family and neighbours as the source of information about family planning. Concerning condom use, majority (96.1%) heard about condoms, 66.7% once used the condoms and 72.5% were knowledgeable about condom use and 27.5% did not know how to use the condoms. About 34% knew that condoms protect against pregnancy and STIs, pregnancy (20.0%), STIs (37.1%) and 9% did not know anything about condoms. Regarding knowledge about STIs, 47% knew that one gets STIs through sex with an infected partner, though infectious, can be treated, 45% had no knowledge about STIs, 7.8% knew that one gets STIs when he/she sleeps with a partner without using condoms. Only 3.0% admitted having been treated for STIs. Teenagers are not well informed about family planning methods. Those who used condoms are not consistent and had limited knowledge about their use. The teenagers had knowledge about HIV and AIDS as well as STIs, but they did not use condoms during sexual intercourse which indicate negligence. There is need to reinforce health education on family planning and counseling to clients for better choices of methods including dual protection in order to prevent pregnancy and STIs, including HIV and AIDS. Keywords : Teenage pregnancy, condom use, sexually transmitted infections, Eastern Cape.

Narratives of Detachment: Meister Eckhart and Buddhaghosa on Personal Transformation

Meister Eckhart has many Buddhist admirers, not least the Japanese Zen teacher, Daisetz Suzuki, and one of his most celebrated translators, Maurice Walshe. As an exercise in what has come to be called Comparative Theology, this paper brings Eckhart into dialogue with the fifth century Theravadin commentator, Buddhaghosa. The main teachings of Buddhaghosa’s celebrated Visuddhimagga, the ‘Path of Purification’, focus on the dual practice of ethics and concentration, building stages of meditative consciousness, most notably upekkha, often translated as ‘equanimity’ or ‘detachment’, that lead to Nirvana. It is this last quality, the state of calm and open mindfulness, that most suggests a correlation with Eckhart and what he speaks of as Abgescheidenheit. Despite the many differences between their cultural backgrounds and metaphysical presuppositions, certain resonances between Eckhart and Buddhaghosa, particularly with regard to the virtues that underpin the religious life, open up a dialectical path between the already and the not-yet, transcendence and immanence, sameness and otherness.

How do dual practitioners divide their time? The cases of three African capital cities

Health professionals dual practice has received increasing attention, particularly in the context of the universal health coverage movement. This paper explores the determinants of doctors' choices to become a dual practitioner and of dual practitioners' choices to allocate time to the private sector in the capital cities of Mozambique, Guinea Bissau and Cape Verde. The data are drawn from a survey conducted in 2012 among 329 physicians. We use a two-part model to analyse the decision of both public and private practitioners to become dual practitioners, and to allocate time between public and private sectors. We impute potential earnings in public and private practice by using nearest-neighbour propensity score matching.Our results show that hourly wage in the private sector, number of dependents, length of time as a physician, work outside city, and being a specialist with or without technology all have a positive association with the probability of being a dual physician, while number of dependents displays a negative sign. Level of salaries in the public sector are not associated with dual practice engagement, with important implications for attempts aimed at retaining professionals in the public sector through wage increases. As predicted by theory that recognises doctors' role in price setting, earnings rates are not significant predictors of private sector time allocation; personal characteristics of physicians appear more important, such as age, number of dependents, specialist without technology, specialist with technology, and three reasons for not working more hours in the private sector. Answers to questions about the factors that limit working hours in the private sector have significant predictive power, suggesting that type of employment in the private sector may be an underlying determinant of both dual practice engagement and time allocation decisions.

Why do some physicians in Portuguese-speaking African countries work exclusively for the private sector? Findings from a mixed-methods study.

BackgroundDespite the growing interest in the private health sector in low- and middle-income countries, little is known about physicians working outside the public sector. The present work adopts a mixed-methods approach to explore characteristics, working patterns, choices, and motivations of the physicians working exclusively for the private sector in the capital cities of Cape Verde, Guinea Bissau, and Mozambique. The paper’s objective is to contribute to the understanding of such physicians, ultimately informing the policies regulating the medical profession in low- and middle-income countries.MethodsThe qualitative part of the study involved 48 interviews with physicians and health policy-makers and aimed at understanding the practice in the three locations. The quantitative study included a survey of 329 physicians, and multivariate analysis was conducted to analyse characteristics, time allocation, earnings, and motivations of those physicians working only for the private sector, in comparison to their public sector-only and dual practice peers.ResultsOur findings showed that only a limited proportion of physicians in the three locations work exclusively for the private sector (11.2%), with members of this group being older than those practicing only in the public or in both sectors. They were found to work fewer hours per week (49 hours) than their public (56 hours) and dual practice peers (62 hours) (P <0.001 and P = 0.011, respectively). Their median earnings were USD 4,405 per month, with substantial variations across the three locations. Statistically significant differences were found with the earnings of public-only physicians (P <0.001), but not with those of the dual practice group (P = 0.340). The qualitative data from the interviews showed private-only physicians’ preference for an independent and more flexible work modality, and this was quoted as a determining factor for their choice of sector. This group appears to include those working in the more informal sector, and those who decided to leave the civil service following a disagreement with the public employer.ConclusionsThe study shows the importance of understanding the relation between health professionals’ characteristics, motivations, and their engagement with the private sector to develop effective policies to regulate the profession. This may ultimately contribute to achieving universal access to medical services in low- and middle-income countries.Electronic supplementary materialThe online version of this article (doi:10.1186/1478-4491-12-51) contains supplementary material, which is available to authorized users.