It is common for doctors working in the public sector to hold second jobs in private practice. Dual medical practice occurs in virtually all countries regardless of income.

Dual medical practice is potentially a serious problem in low and middle-income countries because such activity can create inappropriate incentives for behaviour:

• It can encourage the misappropriation of scarce public sector resources into the private sector by doctors engaging in this activity.
• It can also lead to doctors diverting patients from public facilities into higher cost private services. This could then make it difficult for the poorest and most vulnerable sections of the population to afford healthcare.

The Health Economics and Financing Programme at the London School of Hygiene and Tropical Medicine is currently involved in studies of dual medical practice in four countries, China, Thailand, Peru and Zimbabwe. These studies focus on the motivation for dual medical practice, the regulations that govern it (or indeed, in some settings, the lack of such regulations) and the impact it has on public sector services. The evidence was gathered mainly through interviews with doctors, hospital managers and policy-makers.

Research findings so far include:

• Dual job holding is widely practiced and acknowledged. This occurs even in settings where there are major regulatory restrictions in places such as China. In China regulations are often not followed because changes in economic and political conditions, such as economic liberalisation and entry into the World Trade Organisation, have caused them to become outdated. These changes have encouraged private (largely foreign) investment in medical facilities, which have opened up important income generating opportunities for medical practitioners. This has increased their bargaining power and income expectations, and has made it virtually impossible for hospital managers to restrict such activity.
• Dual practice is an important source of income for many doctors although in some cases, non-financial rewards such as training opportunities are also important. For example, in China, private hospitals are often equipped with the latest medical technology not available in the public sector.
• The reason why doctors maintain their public sector jobs despite good income opportunities in private practice is that it provides stable income, training opportunities and sometimes other benefits such as a pension.
• Dual practice allows the public sector to maintain skilled staff and to minimise its financial burden. This is because it allows public sector doctors to generate income through private work without drawing on the limited funds in the public sector.
• Dual practice allows doctors to provide services outside normal working hours and possibly in areas where public services are difficult to access such as rural districts. This is because, as a private practitioner, a doctor has the financial incentive to provide services where there is obvious demand.

Key policy implications are that:

• dual practice can be seen as a possible policy solution to the problem of maintaining medical staff and inadequate public sector resources. It can minimise the financial burden on the public sector to pay doctors the incomes they might normally expect.
• in encouraging dual practice, there is a need to enforce clear guidelines and mechanisms that will prevent misuse of public sector resources.
• it is possible that dual practice can increase rather than reduce access to services for the poorest groups. In some cases services provided this way may be cheaper and are provided outside the hours and the areas that public services are normally available.

id21 Research Highlight: 26 March 2003

Further Information:
Stephen Jan
Health Economics & Financing Programme
Health Policy Unit
London School of Hygiene & Tropical Medicine
Keppel St
London
WC1E 7HT
UK

Tel: + 44 (0) 20 7927 2262
Fax: +44 (0) 20 7637 5391
Contact the contributor: stephen.jan@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

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