Dual Practice Research Articles

Saving the public from the private? Incentives and outcomes in dual practice

AbstractWe consider a monopoly physician offering free public treatment and, if allowed, a private treatment for which patients have to pay out of pocket. While patients differ in the propensity to benefit from private treatment it always yields better health outcomes than public treatment but is also more costly in terms of money and time. We study the physician's supply of private care and allocation of time costs across public and private patients and contrast these with the first‐best allocation. To increase the willingness‐to‐pay for private treatment the physician shifts time costs to public patients. While this turns out to be socially optimal, the resulting positive network effect leads to an over‐provision of private care if time costs are sufficiently high. A second‐best allocation arises when the health authority sets public reimbursement but has no control over private provision. Depending on the welfare weight the health authority attaches to physician profits, a ban of dual practice may improve on the second‐best allocation. Notably, a ban benefits not only public patients but also private patients with a moderate propensity to benefit from private care.

Dual Practice of Health Workers: Evidence from Indonesia

This paper assesses the causal impact of dual practice on health services provided by public health professionals. Using health-facility (known as puskesmas) level panel data from Indonesia, we exploit the exogenous variation in the initiation of private practice among puskesmas heads after a 1997 health regulation. This regulation requires health professionals to apply for a license for private practice at least three years after their graduation. Using a difference-in-differences regression discontinuity design, our estimates suggest that dual practice of health professionals (relative to those engaged only in public service provision) is associated with about 18 working hours less per week on average at public facilities. Dual practice is also associated with about 7 additional patients seen per week by health professionals in their public duties. We also find a higher likelihood of dual practitioners to refer public patients to private clinics. These findings are consistent with weak monitoring and low motivation of health workers in the presence of growing private practice opportunities and pose serious challenges for the human resource management of universal health care provisions.

Beyond wages: Why dual practice physicians discriminate care quality towards private patients in Ghana

ABSTRACT There is sparse implicit evidence that Dual Practitioners (DPs), physicians holding public and private jobs concurrently discriminate care quality toward private patients to attract better wages. We examined this phenomenon drawing on literature to construct and test the hypotheses that beyond wages, differences in leadership and management, working conditions and psychological ownership between the private and public healthcare sectors influence DPs discriminatory care quality efforts. The study surveyed 121 DPs in four cities across Ghana. Data were collected using a structured questionnaire modelled on the three constructs and two outcome measures of care quality: patient-centeredness and patient satisfaction. Repeated t-measures and logistic regression models were used to analyse data. DPs rated private facilities higher than public facilities in all the domains of the three constructs. DPs patient-centeredness and commitment to patient satisfaction was highly influenced by effective leadership and management and good working conditions in the private than public facilities. Psychological ownership had statistically significant influence on DPs patient-centeredness in the private facilities but not the public. These findings provide explicit evidence toward understanding the causalities of DPs service quality fragmentation across practice settings and contribute to policy regulation of the medical labor market in Ghana and other countries.

Assessment of dual practice among physicians in Cambodia

BackgroundDual 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.MethodsData 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.ResultsOf 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.ConclusionsAs 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.

Несбалансированность закона как фактор противодействия его реализации

Introduction. The article analyzes a particular manifestation of a defective state of legal matter that occurs in the content of acts of the highest legal force, leading to imbalance of the law and imbalance of legal regulation. The main task is to show the consequences of an unbalanced law, which are expressed in situations of counteraction to its implementation, and difficulties in achieving legally significant goals by various subjects of relations. Theoretical analysis. To solve this problem, the author has studied special literature on the issue of balance and imbalance of the legal sphere; on establishing opportunities to use categories that reflect the processes in larger legal entities; determining the grounds and reasons for the imbalance of the law, leading to the emergence of dual and incomprehensible practice of implementing the law, unequal reflection of rights and obligations, as well as the interests of contractors, and so on. A number of laws that are defective in their content, but do not give grounds for initiating procedures for declaring them invalid, unconstitutional, and so on, are subjected to empirical analysis. They only form conditions for opposing their implementation, as well as judicial practice for applying unbalanced laws. Results. The author comes to the conclusion that there are no grounds for inadmissibility of analyzing a normative legal act as unbalanced. The reasons for the imbalance of the law may be significant errors in the formulation of the content, violation of the principle of unity of rights and obligations, inconsistency of the legal status of the addressees of the law, discretion and limits of powers, powers and responsibilities.

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

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. 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). 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). 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.

Factors Associated with Dual Practice in Surgery Specialists: Application of Multi-Level Analysis on National Registry Data

Dual practice by surgery specialists is a widespread issue across health systems. This study aimed to determine the level of dual practice engagement and its related factors among Iran's surgery specialists. A pre-structured form was developed to collect the data about surgery 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. Multilevel logistic regression was used to assessing the association between dual practice with study variables. Overall, 14931 surgeons were participated (93% response rate) and 6405 (57% of) engaged in DP on total. Urinary tract & genital and neurosurgery specialties had the highest rank with 69%. DP was more frequent in specialists with higher age and experience, populated provinces, higher deprivation, and share of private hospitals. Faculty physicians (OR=0.69), full-time geographic physicians (OR=0.17), specialists with more than 25 years' experience (OR=2.59) and age more than 40 yr (OR=1.3) had significant association with dual practice. Multi-approach strategy is needed to control dual practice through tax regulations, income cap, and limitations in work hours and number of visits in private sector.

Barriers to implementation of emergency obstetric and neonatal care in rural Pakistan.

BackgroundRecognizing the need for improving maternal and newborn care, the Punjab public health department (Pakistan) launched emergency obstetric neonatal care (EmONC) services under WHO guideline. Unfortunately, the program implementation is facing some serious problems. The purpose of this study was to identify barriers to implementation of EmONC in district Bahawalnagar (Pakistan).MethodsThis study used sequential exploratory design. Specifically, a qualitative study was conducted to identify barriers to EmONC. Subsequently, the relative importance of these barriers was determined in a quantitative study. Participants were health service providers involved in 24-hours basic EmONC services in the basic health units of district Bahawalnagar (Pakistan). Qualitative data were gathered by interviewing the participants using key informant guide. Quantitative data were collected in a rank order survey of the same participants. The methodological quality was assessed using mixed methods appraisal tool (MMAT) version 2011.ResultsThe results indicate that lack of teamwork, conflict management, communication, and improper power distribution are important interpersonal barriers. The significant organizational-level barriers include job insecurity, lack of organizational culture, human resource deployment issues, and lack of role clarity. Lack of target management, lack of resource availability, house job requirement, and dual practice issues were identified as major system-level barriers.ConclusionBarriers to EmONC implementation must be addressed for improving maternal and neonatal care in district Bahawalnagar.

The ‘long and winding road’ of faith: learning about the Christian life and discipleship from two Methodist congregations

ABSTRACT The popular understanding and practice of discipleship has often assumed a particular shape of the life of faith, one which is more ‘heroic’ and active. This paper explores how the understanding and experience of learning and growing as Christians in two Methodist congregations challenges and nuances this understanding of discipleship. Focusing on the themes of non-heroic faith and participative faith which arose in the data, it compares the understanding of the Christian life within these congregations with the discipleship material in the book Holy Habits, by Andrew Roberts. Through engaging with Vygotskii’s Zone of Proximal Development an alternative pedagogy from that presented in the discipleship material is suggested of the dual practice of deep conversation and risk-taking. Far from retreating from a participative faith, the paper shows how it can provide a theological basis for such faith to grow and mature.

Cengiz Çekil’s Dual Practice: Conceptual Installations and Authoritarian Monuments, 1983–91

Cengiz Cekil, Arrangement No. 2 (Duzenleme No. 2), 1986 installation view, included in an unpublished compendium of the artist’s work. SALT Research, Cengiz Cekil Archive, Istanbul (photograph prov...

Interventions to reduce the impact of dual practice in the public health sector.

Dual practice (i.e. workers who work in the public and private sector) has an impact on health services in terms of quality and costs. However, the effectiveness of regulatory policies has not been proven. We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. We identified three systematic reviews that included 23 primary studies overall, of which all correspond to observational studies. We concluded it is not clear whether the interventions to reduce the negative consequences of dual practice in the health system are effective because the certainty of the available evidence is very low.

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

To identify the intention of nurses to dual practice (DP) and inform policymaking in centralised government settings. 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. A descriptive cross-sectional survey. 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. 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 15years, 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. 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. 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.

The Dynamics of Health Care and Growth: A Model with Physician in Dual Practice

We present a growth model with micro-foundations of a mixed health care system and physician dual-practice, to analyze for welfare-optimal government financing strategy for a mixed health system in developing countries. Calibrating the model for Indonesia, we find that a government subsidy to private health care is both growth- and welfare-enhancing, whereas it is more effective for the government to invest in health infrastructure instead of a public-sector rewarding policy in raising government physicians’ wage if its goal is to improve physician effort in public practice. Indeed, for the rewarding policy, a dynamic trade-off in growth is found, which is not previously documented in the literature. We also find the model to produce two regimes with different welfare-optimal health financing (a “normal” regime and a low public-sector congestion regime). In the former, welfare-optimal health financing strategy appears to be promoting private health subsidy at the expense of public-sector physician wages. In the latter, the opposite is welfare-optimal.

Dual Practice on Health Service- Should it be Promoted in Qatar?

Dual Practice on Health Service- Should it be Promoted in Qatar?

Extent and nature of dual practice engagement among Iran medical specialists

BackgroundDual 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.MethodsA 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.ResultsA 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).ConclusionsThe 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.

Job satisfaction, dual practice and intention to work abroad in the Serbian public healthcare sector

Job satisfaction, dual practice and intention to work abroad in the Serbian public healthcare sector

Job satisfaction, dual practice and intention to work abroad in the Serbian public healthcare sector

Job satisfaction, dual practice and intention to work abroad in the Serbian public healthcare sector

A Comparison of Electronic Medical Record Data to Paper Records in Antiretroviral Therapy Clinic in Ethiopia: What is affecting the Quality of the Data?

BackgroundAnti-Retroviral Therapy (ART) care is a lifelong treatment, which needs accurate and reliable data collected for long period of time. Poor quality of medical records data remains a challenge and is directly related to the quality of care of patients. To improve this, there is an increasing trend to implement electronic medical record (EMR) in hospitals. However, there is little evidence on the impact of EMR on the quality of health data in low- resource setting hospitals like Ethiopia. This comparative study aims to fill this evidence gap by assessing the completeness and reliability of paper-based and electronic medical records and explore the challenges of ensuring data quality at the Anti-Retroviral Therapy (ART) clinic at the University of Gondar Referral Hospital in Northwest Ethiopia.MethodsAn institution-based comparative cross-sectional study, supplemented with a qualitative approach was conducted from February 1 to March 30, 2017 at the ART clinic of the University of Gondar Hospital. A total of 250 medical records having both electronic and paper-based versions were collected and assessed. A national ART registration form which consists of 40 ART data elements was used as a checklist to assess completeness and reliability dimensions of data quality on medical records of patients on HIV care. Kappa statistics were computed to describe the level of data agreement between paper-based and electronic records across patient characteristics. In-depth interviews were conducted using semi-structured questionnaires with ten key informants to explore the challenges related with the quality of medical records. Responses of the key informant interviews were analyzed using thematic analysis.ResultsThe overall completeness of medical records was 78% with 95% CI (70.8% - 85.1%) in paper-based and 76% with 95%CI (67.8% - 83.2%) EMR. The data reliability measured in Kappa statistics shows strong agreements on the socio-demographic data such as educational status 0.93 (0.891, 0.963), WHO staging 0.86 (0.808, 0.906); general appearance 0.83 (0.755, 0.892) and patient referral record 0.87 (0.795, 0.932). The major challenges hindering good data quality was the current side by side dual data documentation practice (the need to document both on the paper and the EMR for a single record), patient overload and low data documentation practice of health workers.ConclusionThe overall completeness of ART medical records was still slightly better in paper-based records than EMR. The main reason affecting the EMR data quality was the current dual documentation practice both on the paper and electronic for each patient in the hospital and the high load of patients in the clinic. The hospital management need to decide to use either the paper or the electronic system and build the capacity of health workers to improve data quality in the hospital.

The relationship between dual practice, intention to work abroad and job satisfaction: A population-based study in the Serbian public healthcare sector

Increasing dual practice and emigration of health workers threatens the effectiveness of the healthcare system. Insufficient information exists about these phenomena in the transitional countries of South-East Europe. Serbia, a European Union candidate, permits dual practice and there is a high intention to work abroad among its prospective healthcare professionals. A population-based, cross-sectional study was conducted to determine the prevalence and predictors of job satisfaction, dual practice, and intention to work abroad of all workers in the Serbian public healthcare sector (73,940 employees, a response rate of 83.8%). This study observed that 22.6% of the respondents were dissatisfied with their jobs, 11.7% reported dual practice, and 14.3% had an intention to work abroad. Physicians and nurses younger than 55 years of age employed in a tertiary healthcare institution, and males were more likely to be dissatisfied than other workers. Poor management and working conditions increased job dissatisfaction, with a subsequent increased odds for dual practice and intention to work abroad by 1.5 and 3.6 times, respectively. The national and institutional framework for health workforce policy and management must be powerful and efficient when taking advantage of the positive effects and managing the negative aspects of dual practice and the intention to work abroad.

Effect of dual practice on service delivery time by surgeons in the Islamic Republic of Iran: multi-level analysis of a national survey, 2016.

One of the work patterns which affects the supply of specialists is the phenomenon of dual practice (DP), i.e., working simultaneously in the public and private sectors. Uncontrolled DP in the surgery health workforce can have adverse effects on access to surgeons, efficiency, effectiveness and quality of surgery services. The aim of this article is to examine the impact of DP on service delivery time by surgeons. We used a prestructured form to collect data on surgery specialists in all 925 Iranian hospitals. National medical ID codes, council ID codes, first name, surname and father's name were used for data matching. Multilevel linear regression was used to assess the association between DP and study variables, which were recruitment type, faculty status, experience, sex and age. The 4642 surgery specialists in this study, representing 31.08% of the total number of surgeons identified, spent mean 1.09 (standard deviation 0.33) hours full-time equivalent (FTE) on health care service delivery. Specialists with DP had long service delivery time (β = 0.427). Female specialists (β = -0.049) and full-time specialists (β = -0.082) spent less time on health care service delivery. Permanent specialists had higher FTE (P < 0.001) and as the population increases, FTE increases (P < 0.05). Although DP had a direct impact on surgeons' working hours, it seems that a greater share of the difference in working time was used in the private sector services, leading to poor access to surgery services in the public sector. Therefore, it is necessary to develop a systems approach to regulate DP.