SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
August, 2016 - SUPPORT Summary of a systematic review | print this article |
Dual practice in the healthcare setting refers to the holding of more than one job, in unrelated health facilities, by a health professional. In many low-income countries, low pay and difficult working conditions lead many health professionals in the public sector to add to their income by taking on private patients who pay for the services that they receive. Dual practice has both negative and positive consequences and there are concerns that its negative impacts may exceed the positive ones. By allowing public sector workers to supplement their income, it may be easier for the public health sector to keep their skilled workers. However, dual practice may also lead health professionals to spend less time in their public sector job; take time off without permission to work in their private positions; lower the quality of their services in the public sector in order to drive patients to their private practice; or take resources from their public sector workplace to use in their private sector jobs.
Various interventions have been implemented to manage dual practice e.g. banning dual practice, regulating the number of hours that public sector workers are allowed to do private practice, regulating how much public sector workers are allowed to earn from private practice, salary increases and promotions for workers who agree to only work in the public sector, and allowing limited private practice within public facilities.
Key messages
► No studies met the inclusion criteria for the review, as no rig-
orous studies have evaluated the effects of interventions to
manage dual practice.
►There is a need for well-designed studies to evaluate the im-
pact of interventions that attempt to regulate health worker
dual practice in low-income countries.
People making decisions concerning the management of dual practice in health care settings.
Kiwanuka SN, Rutebemberwa E, Nalwadda C, et al. Interventions to manage dual practice among health workers. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD008405.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Dual practice in the healthcare setting is a common practice in high-income and low- and middle-income countries. It refers to the holding of more than one job, in unrelated health facilities, by a health professional. In most low-income countries, dual practice mostly refers to health professionals engaging in both public and private practice.
Dual practice has both negative and positive consequences and its impact varies from country to country. Some of the positive consequences include its ability to generate additional income for health workers and increased contribution of the private health sector in the provision of health services. However, the negative impacts of dual practice may exceed the positive ones and include: the perpetuation of self-gain by health workers through generating demand for their own services in the private sector by over prescribing treatment; conflict of interest, whereby health workers lower the quality of services they provide in the public sector in order to drive patients to the private sector; and brain drain, whereby the existence of the private sector makes it increasingly hard to attract and retain health workers in the public sector.
Interventions that have been implemented to manage dual practice include: complete prohibition; restrictions on private sector earnings; providing incentives for exclusive public service; raising health worker salaries in the public sector; allowing private practice in public facilities; self-regulation; and regulation of the private sector.
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About the systematic review underlying this summary |
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Review objectives: To assess the effects of interventions implemented to manage dual practice |
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| Type of | What the review authors searched for | What the review authors found |
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Study designs & interventions |
Randomized trials, non-ran- domized trials, controlled be- fore-after studies, interrupted time series studies |
No studies were found eligible for in- clusion in the review |
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Participants |
All health professionals
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No studies were found eligible for in- clusion in the review |
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Settings |
Not specified
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No studies were found eligible for in- clusion in the review |
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Outcomes |
Increased working hours by health workers in public facili- ties, reduced patient waiting times, reduced absenteeism, reduction in number of pri- vate sector licenses issued, re- duction in private earning, re- duced job satisfaction |
No studies were found eligible for in- clusion in the review |
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Date of most recent search: May 2011
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Limitations: This is a well-conducted systematic review with minor limitations, but no studies were found that met the inclusion criteria.
Kiwanuka SN, Rutebemberwa E, Nalwadda C, et al. Interventions to manage dual practice among health workers. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD008405. |
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Kiwanuka SN, Rutebemberwa E, Nalwadda C, et al. Interventions to manage dual practice among health workers. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD008405.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
No studies met the inclusion criteria for the review.
The impacts of interventions to manage dual practice are uncertain. Potential impacts could include:
• Reduction in the migration of health workers
• Reduction in absenteeism at public health facilities, and
• Reduction in tardiness
Potential interventions to manage dual practice include:
• Complete prohibition, also referred to as banning, of dual practice
• Restrictions on private sector earnings: e.g. imposing a ceiling on income which can be earned as a result of the additional jobs
• Providing incentives for exclusive public service: e.g. financial (allowances, bonuses) and non-financial incentives (promotions)
• Raising health worker salaries: e.g. measures to make public sector salaries more competitive
• Allowing private practice in public facilities: e.g. allowing private sections to be established within public hospitals or for physicians to admit their private patients to public facilities
• Self-regulation: e.g. promotion of professional and ethical conduct among health workers, under the oversight of professional bodies and civil society
• Regulation of the private sector: e.g. imposing ceilings on private sector prices, limiting access of the private sector to social insurance, and limiting the types of services that can be offered in the private sector
Very low certainty evidence, from experiences in some countries, suggests that:
• The banning of dual practice might not be successful;
• Increasing salaries of public sector health workers might not reduce dual practice;
• Licensure restriction might be promising in controlling dual practice; and
• Regulating private sector activities and earnings might help in reducing dual practice.
| Findings | Interpretation* |
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APPLICABILITY
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►No studies met the inclusion criteria for the review. |
►Dual practice may be more of a problem in low- income countries, due to low wages in the public sector, and interventions to manage it may have different effects e.g. the risk of health professionals migrating is likely to be greater in low-income countries compared to high-income countries. |
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EQUITY
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►The review did not provide data on differential effects of the interventions for disadvantaged populations. |
►Interventions that restrict dual practice may adversely affect poor populations that are dependent on public services, if health professionals stop working in the public sector as a consequence. |
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ECONOMIC CONSIDERATIONS
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►The review did not provide data on the cost of any of the interventions aimed at managing dual practice. |
►The balance between the benefits of implementing interventions such as increased wages or financial incentives is uncertain. ►Although implementing restrictions on dual practice may cost less than financial incentives, the costs of health professionals electing not to work in the public sector are uncertain.
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MONITORING & EVALUATION
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No reliable evidence of the impacts or costs of interventions to manage dual practice was found. |
►There is a need for careful monitoring of impacts and costs of interventions to manage dual practice. ►Consideration should be given to undertaking evaluations prior to scaling up interventions using randomized trials, or using interrupted time series studies when randomized trials are not practical. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
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Related literature
Socha KZ, Bech M. Physician dual practice: A review of literature. Health Policy 2011;102:1-7.
García-Prado A, González P. Policy and regulatory responses to dual practice in the health sector. Health Policy 2007;84:142-52.
García-Prado A, González P. Whom do physicians work for? An analysis of dual practice in the health sector. J Health Polit Policy Law 2011;36:265-94.
Ferrinho P, Van Lerberghe W, Fronteira I, Hipólito F, Biscaia A. Dual practice in the health sector: review of the evidence. Hum Resour Health 2004;2:14.
This summary was prepared by
Charles I. Okwundu, Centre for Evidence-based Health Care, Stellenbosch Univer-sity, South Africa and Charles Shey Wiysonge, Centre for Evidence-based Health Care, Stellenbosch University, & Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
Conflict of interest
None declared. For details, see: www.supportsummaries.org/coi
Acknowledgements
This summary has been peer reviewed by: Suzanne Kiwanuka and Peter Okebukola.
This review should be cited as
Kiwanuka SN, Rutebemberwa E, Nalwadda C, et al. Interventions to manage dual practice among health workers. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD008405.
The summary should be cited as
Okwundu CI, Wiysonge CS. Which interventions improve the management of dual practice? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org
Keywords
Management of dual practice, public health sector, private health facilities, evi-dence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care
