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Dual practice regulatory mechanisms in the health sector: a systematic review of approaches and implementation

What do we want to know?

Dual job holding, also referred to as dual practice in the health care setting, has been documented as a common practice in both developed and developing countries. The practice refers to the holding of more than one job by a health professional. In other settings however, it may encompass health professionals working within different aspects of health such as allopathic medicine combined with traditional medicine or combining health related activities such as clinical practice with research. In most Low and Middle Income Countries (LMICs), dual practice refers to health professionals engaged in both public and private (health or non health) related work. However, dual practice regulation remains debatable for many governments.

While the impact of dual practice varies from country to country, based on its extent and the presence or absence of regulatory policies, regulation remains debateable for many governments in LMICs.  The International Centre for Systematic Reviews on Human Resources for Health, Makerere University School of Public Health, working with the EPPI Centre in London, therefore, conducted a systematic review to assess the different regulatory mechanisms employed to deal with dual practice and the effect of these mechanisms on health worker performance.

The review aimed at synthesizing the dual practice regulatory mechanisms proposed and implemented worldwide and to document factors key to their implementation, either barriers or facilitators and some of their reported outcomes.

Who wants to know?

Policy-makers by providing evidence on what mechanisms are working and the conditions under which the mechanisms are working and what consequences they might expect as a result of adopting some of these approaches.

Health planners and managers- the review provides evidence on the importance of recognizing that dual practice exists and the available by which dual practice can be reduced at health service delivery level.

What did we find?

We found out that there are mainly three categories of dual practice mechanisms that have been employed: 1) total banning of dual practice; 2) allow dual practice with restrictions; 3) allow dual practice without restrictions. 
Specifically, evidence indicated that:

  • Banning dual practice totally, is not generally enforceable,
  • Raising public sector salaries to compete with private sector earnings (in a bid to discourage public sector health workers from working in the private sector) is not realistic in many LMICs with resource constraints 
  • Restricting private practice to services not offered by the public sector, restricting private sector charges, insurance and access to public funds can reduce private practice in the presence of universal insurance coverage and well established financial monitoring systems
  • In many LMICs that are already suffering consequences of health worker shortages, unrestricted dual practice, is not feasible.

What are the implications?

The findings of this review imply that in countries where the shortage of health workers is an area of major concern, allowing dual practice without restrictions may hurt the situation further, while total ban may be challenging to implement in settings where public sector workers earn low salaries. It may therefore be feasible to design mechanisms that take into critical consideration the specific conditions pertaining in individual countries, especially the different ways in which dual practice manifests itself. The most effective mechanisms therefore, may be multi-dimensional.       

How did we get these results?

The three review questions that enabled us collect the evidence were;
1. What mechanisms have been used to regulate or manage dual practice among health workers?
2. What challenges arise or may be anticipated to emerge from existing or proposed mechanisms to regulate dual practice?
3. What factors may enhance existing or proposed mechanisms to regulate practice?

The review considered literature describing a range of strategies on dual practice regulatory mechanisms as well as identifying and describing factors influencing (barriers or facilitators) the implementation of these mechanisms.

The EPPI Centre reference number for this report is 1903.

This report should be cited as:
Kiwanuka SN, Kinengyere AA, Rutebemberwa E, Nalwadda C, Ssengooba F, Olico-Okui, Pariyo GW (2011) Dual practice regulatory mechanisms in the health sector: a systematic review of approaches and implementation. London: EPPI Centre, Social Science Research Unit, Institute of Education, University of London.
ISBN: 978-1-907345-08-1

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