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[e-drug] Moonlighting physicians

E-drug: Moonlighting physicians

Dear E-druggers, 

I subscribe to the newsletter "Health Economics & Financing
Exchange", prepared by the Health Economics & Financing
Programme of the London School of Hygiene and Tropical Medicines,
with DFID funding. This newsletter aims at making accessible jargon-
free research reports available. It is free!

The most recent issue deals with "Moonlighting physicians: public
sector doctors with second jobs", something the authors call Dual
Practice (DP). Given our recent discussion on reasons for the brain
drain of pharmacists, I reproduce some of the contents below 
copied as fair use). Should you be interested in more detailed results
of these studies, please contact Stephen Jan, Health Economics &
Financing Programme LSHTM, e-mail: stephen.jan@lshtm.ac.uk

Anyone who would like to regularly receive this Newsletter, please
contact HEFP, Health Policy Unit, London School of Hygiene & Tro-
pical Medicine, Kewppel Street, London, WC1E 7HT, UK, tel: +44-20-
7927.2176, fax: +44-20-7637.5391, e-mail: nicola.lord@lshtm.ac.uk

Hilbrand Haak
Consultants for Health and Development
Sleedoorntuin 7                       tel: +31-71-523.2052
2317 MV  Leiden          fax: +31-71-523.3592
The Netherlands   e-mail: haakh@chd-consultants.nl

Visit CHD's website at www.chd-consultants.nl

Dual Practice Among Public Medical Doctors in Thailand

In Thailand, as in other countries, the government allows public
medical doctors to undertake private practice. Low salaries in the
public sector is a significant motivation. Furthermore, there is a strong
preference for private services in Thailand and therefore good
opportunities in terms of both income generation and prestige
associated with it. Previous evidence, however, has shown that dual
practice (DP) may lead to negative impacts on public health services.
Therefore, knowledge of the impact, patterns, behaviour, motivation
and regulatory issues around dual practice may provide guidance on
forming appropriate policies for solving problems that may result from

The study was conducted in five provinces of Thailand (Bangkok,
Konkaen, Lopburi, Payao, Songkla) in 2001.Three methodologies
were employed, namely, comprehensive document reviews, a survey
of 1,808 public medical doctors using anonymous self-administered
questionnaires, and in-depth interviews of key informants.

The response rate of the survey was 36% or 659 completed
questionnaires. Results revealed that 69% of public doctors had dual
practices. The main reason for having dual practice was "income from
public service is inadequate". A logistic regression analysis showed
that factors influencing dual practice engagement were being male
medical doctors and medical specialists. The ratio of total monthly
income between fully public and dual practice medical doctors was
2.2. In-depth interviews illustrated that implications of dual practice
range from public-time corruption, neglecting public patients, poor
performance in the public sector due to exhaustion from private work
and related to this, differences in the quality of care between public
and private. Existing regulations regarding dual practice tend to be
indirect with poor enforcement. Responsible organizations such as
the Ministry of Public Health and Thai Medical Councils have neither
any policy in this area nor intention to regulate it.

As private provision still plays significant roles in the Thai health care
system, dual practice performs two useful functions: compensating
for the low salary of public medical doctors and increasing access to
health care. However, the negative impacts of dual practice require
regulations and measures to minimize these consequences. The
strengthening of regulatory measures and administrative capabilities,
the introduction of new methods for public medical doctor's payment
which reflect performance and quality of care, and a reform of
employment patterns into part-time and full-time may be options for
policy recommendations. Moreover, indirect measures such as good
dual practice guidelines, Quality Assurance (QA), and Hospital
Accreditation (HA) should be introduced. This will control the adverse
consequences of dual practice, and improve consumer choice and
patient access to health care.

Phusit Prakongsai
International Health Policy Programme, Thailand

Positive and negative consequences of dual practice in Peru

In Peru, medical practice has had private and public dimensions for a
long time. Such arrangements have been regulated more by social
consensus than by written rules. The traditional combination of public
and private practices has produced a complex framework of
interactions. Little is known about these interactions and little has
been done to regulate them in Peru.

To explore the extent, characteristics, incentives, effects and possible
regulation of private medical practice in public facilities (dual practice
or DP), the London School of Hygiene and Tropical Medicine with
support of the Peruvian College of Physicians have done a cross
sectional quantitative-qualitative analysis. A closed end questionnaire
was randomly administered to 1173 doctors working at the Ministry of
Health, the Peruvian Social Security (ESSALUD) and private health
facilities placed in five departments of Peru (Lima, Huancavelica,
Loreto, Piura and Tacna). Furthermore 26 in depth-interviews were
made with doctors and key informants from Lima.

Results from the survey and focus groups reveal that DP is mainly a
strategy to obtain better incomes in the face of low public salaries.
Furthermore this situation is influenced by the Peruvian
macroeconomic environment characterised by an oversupply of
doctors caused by the deregulation of medical practice and
education. DP is common in all types of health facilities and working
institutions, and is closely associated with clinical practices. DP has
both negative and positive effects on public health: channelling
patients to private clinics, long queues of patients and downgrading
the quality of care have been reported as negative aspects; better
income for hospitals, better managerial procedures, and quick health
care were reported as positive aspects.

Interviews suggested that the negative effects must be regulated by
developing full public health jobs as well as improving career
opportunities and doctors' income. Other suggestions to regulate DP
were regulation of medical education as well as formalisation of fair
medical practice and reinforcement of the legal framework. Some of
these measures are being developed by the Peruvian Ministry of
Health, though they need to be reinforced and accelerated. There
needs also to be recognition of DP as a real problem and
development of monitoring structures and mechanisms of
supervision. These structures must incorporate representatives of all
stakeholders (state, professional bodies, hospital boards, consumer
organizations, and ombudsman), and involve Ministry of Health
headquarters as well as its decentralised offices

Manuel Jumpa 
Public Health and Management Faculty 
Cayetano Heredia Peruvian University 

Dual Practice in Zimbabwe: a policy and regulatory dilemma

A study of dual practice in Zimbabwe was carried out between June
2001 and June 2002 - a period during which a lot of macro-economic
changes, affecting health care delivery were taking place. The
specific purpose of the study was to investigate the behaviour of
public health care providers vis-a-vis private practice, the possible
effect of such behaviour and to analyse the effectiveness of the policy
and regulatory framework under which this took place, in order to
recommend appropriate measures.

Information was collected through interviews and six focus group
discussions, with 15 I key stakeholders in the health system. In
addition, desk research to analyze all policy and regulatory
documents was carried out. Radio programmes to elicit consumer
views about dual practice were also run on national radio stations.

>From the results obtained, it would appear that dual practice was
indeed a problem, which required a suitable intervention in the form of
appropriate policies and regulations. Every health care profession in
Zimbabwe was found to be involved in some form of dual practice.
The nature, magnitude and effects of engagement differed,
depending on the form of dual practice, the profession, availability of
opportunity and consumer demand. There was a policy and
regulatory framework in place, which was not very effective. Policies
were formulated and implemented in an uncoordinated manner.
There also appeared to be an institutionalised non-compliance by all
structures involved in the monitoring of the framework, that regarded
dual practice as an informal mechanism for addressing issues of
working conditions of health care providers. From the results and
those obtained from other countries it would appear that the issue of
regulating dual practice is universal.

General recommendations that came from the key stakeholders who
took part in the study included the acceptance and institutionalization
of dual practice in order to maximise its possible benefits and
minimize its possible detrimental effects on quality and cost of care. It
was also suggested that the formulation, implementation and
monitoring of the policies and regulations should be done in a
coordinated way.

Norman Nyazema & Felix Marondeze 
Institute of Continuing Health Education

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