A theoretical approach to dual practice regulations in the health sector

González, Paula; Macho‐Stadler, Inés

doi:10.1016/j.jhealeco.2012.08.005

Cited by 49 publications

(86 citation statements)

References 32 publications

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“…Such steps have been exercised in several countries, but bans in the form of exclusive public sector contracts have rarely been successful [2,5,17,33-37]. Intermediate steps have been taken, for example, in the UK and France, where public specialists are allowed to earn 10% (UK) or 30% (France) of their total income from private fees [17,38].…”

Section: Discussionmentioning

confidence: 99%

Physicians’ engagement in dual practices and the effects on labor supply in public hospitals: results from a register-based study

Johannessen¹,

Hagen

2014

BMC Health Serv Res

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BackgroundPhysician dual practice, a combination of public and private practice, has attracted attention due to fear of reduced work supply and a lack of key personnel in the public system, increase in low priority treatments, and conflicts of interest for physicians who may be competing for their own patients when working for private suppliers. In this article, we analyze both choice of dual practice among hospital physicians and the dual practices’ effect on work supply in public hospitals.MethodsThe sample consisted of 12,399 Norwegian hospital physicians working in public hospitals between 2001 and 2009. We linked hospital registry data on salaries and hospital working hours with data from national income and other registries covering non-hospital income, including income from dual work, cohabiting status, childbirths and socioeconomic characteristics. Our dataset also included hospital variables describing i.e. workload. We estimated odds ratio for choosing dual practice and the effects of dual practice on public working hours using different versions of mixed models.ResultsThe percentage of physicians engaged in dual practice fell from 35.1% for men and 17.6% for women in 2001 to 25.0% and 14.2%, respectively, in 2009. For both genders, financial debt and interest payments were positively correlated and having a newborn baby was negatively correlated with engaging in dual practice. Larger family size and being cohabitating increased the odds ratio of dual practice among men but reduced it for women. The most significant internal hospital factor for choosing dual practice was high wages for extended working hours, which significantly reduced the odds ratio for dual practice. The total working hours in public hospitals were similar for both those who did and did not engage in dual practice; however, dual practice reduced public working hours in some specialties.ConclusionEconomic factors followed by family variables are significant elements influencing dual practice. Although our findings indicate that engagement in dual practice by public hospital physicians in a well-regulated market may increase the total labor supply, this may vary significantly between medical specialties.

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Section: Discussionmentioning

confidence: 99%

Physicians’ engagement in dual practices and the effects on labor supply in public hospitals: results from a register-based study

Johannessen¹,

Hagen

2014

BMC Health Serv Res

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“…Indeed, it is increasingly uncommon to find full–time health workers who are civil servants exclusively working in the public sector [4–7]. For instance, in Austria approximately 100% of senior health specialists work in both sectors, in the United Kingdom 60% of public physicians work in both sectors [8]. In Ireland, more than 90% of physicians employed in public hospitals also have privileges to practice in the private sector [8].…”

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confidence: 99%

“…The pervasive practice of dual practice and the shift of doctors from the public sector to the private sector suggests a need to reassess the traditional models of physician education, placement and compensation, and the functioning of labor markets for highly skilled health workers [1]. There is limited evidence on the policies and regulatory mechanisms for promoting physician retention in the public sector [8,9]. …”

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confidence: 99%

Factors influencing physicians’ choice of workplace: systematic review of drivers of attrition and policy interventions to address them

Koussa¹,

Atun²,

Bowser³

et al. 2016

Journal of Global Health

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ObjectivesThe movement of skilled physicians from the public to the private sector is a key constraint to achieving universal health coverage and is currently affecting health systems worldwide. This systematic review aims to assess factors influencing physicians’ choice of workplace, and policy interventions for retaining physicians in the public sector.MethodsFive literature databases were searched. Studies were included in the review if they focused on at least one of the following criteria: (i) incentives or motivators for retaining physicians in the public sector, (ii) pull factors that encouraged physicians to move to the private sector, (iii) push factors that forced physicians to leave the public sector, (iv) policy interventions or case studies that addressed physician retention in the public sector, and (v) qualitative reviews of policy interventions that were implemented in different health system settings.ResultsNineteen articles met the inclusion criteria. Six major themes that affected physicians’ choice of workplace were identified including: financial incentives, career development, infrastructure and staffing, professional work environment, workload and autonomy. The majority of the studies suggested that the use of financial incentives was a motivator in retaining physicians in the public sector. The review also identified policy interventions including: regulatory controls, incentives and management reforms. Regulatory controls and incentives were the two most frequently reported policy interventions.ConclusionWhile factors affecting physicians’ choice of workplace are country specific, financial incentives and professional development are core factors. Other factors are highly influenced by context, and thus, it would be useful for future cross–country research to use standardized data collection tools, allowing comparison of contextual factors as well as the examination of how context affects physician retention in the public sector.

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“…Studying the dynamic aspects of dual practice and related interactions both within and outside the boundaries of a health system requires a departure from the linear, theoretical models found in the literature [2,17-20]. A more appropriate model acknowledges the holistic, complex, and adaptive nature of health systems and their broader environment.…”

Section: Introductionmentioning

confidence: 99%

Advancing the application of systems thinking in health: exploring dual practice and its management in Kampala, Uganda

Paina

Bennett

Ssengooba

et al. 2014

Health Res Policy Sys

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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.

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A theoretical approach to dual practice regulations in the health sector

Cited by 49 publications

References 32 publications

Physicians’ engagement in dual practices and the effects on labor supply in public hospitals: results from a register-based study

Physicians’ engagement in dual practices and the effects on labor supply in public hospitals: results from a register-based study

Factors influencing physicians’ choice of workplace: systematic review of drivers of attrition and policy interventions to address them

Advancing the application of systems thinking in health: exploring dual practice and its management in Kampala, Uganda

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