Dual practice, factors and solutions for healthcare professionals

Dual practice is a phenomenon found in most countries, but it is noticeably more frequent in low-income countries, such as ours. It has been gaining more and more importance lately due to the fact that it may contribute to reducing the already insufficient number of professional health workers in healthcare systems. The reasons that lead to dual practice have not been sufficiently studied. Research results mainly point to economic factors as predictors, but apart from these factors, it is necessary to investigate the prevalence, real consequences, managing this phenomenon, as well as the assessment of the impact of policy measures implemented in this area. Although dual practice is seen as a possible systemic solution to issues such as limited resources (and revenues) in the public sector, low regulatory capacity and the interaction between market forces and human resources, if poorly regulated, it can lead to a conflict of interest as well as resource drain from the public to the private sector. An optimal regulation of the situation and the mobility of health workforce depends on the exceptional circumstances of the country, government capabilities, and the improvement of the health system. At the international level, governments react differently to the phenomenon of dual practice. To recognize the role of dual practice and mobility in the health workforce market, experts advocate more data on dual practice of healthcare workers and the need to integrate these data into national health workforce accounts. The need to develop a national health policy for monitoring dual practice in our country and to develop strategies for mitigating negative effects was highlighted. This paper analyzes the available literature on dual practice, the factors that influence the emergence of this phenomenon, and possible solutions for health workers.

INTRODUCTION

Dual practice is present in most countries (if not in all), where its prevalence and forms vary considerably. For example, working overtime can be considered a form of dual employment. Literature describes dual practice in various ways. It may refer to physicians with multiple specialties as is the case in Egypt, where the most popular areas of multispecialty are cardiology and internal medicine [1]. Apart from this, dual practice may include healthcare professionals who are involved in different disciplines (e.g., osteopathy, homeopathy, allopathy, in combination with traditional medicine – Chinese, African, etc.) [2]. Dual practice means combining different forms of healthcare practice – it may be clinical practice combined with research, teaching or management, or even professional healthcare practice combined with an economic activity unrelated to health (e.g., agriculture) [2]. When researching dual practice, it is particularly interesting to investigate employees who simultaneously work in the public health sector and in private practice. The reasons that lead to dual practice have not been sufficiently studied. The available results mainly indicate that employees who work in public institutions are dissatisfied with their income and working conditions, and that they also show professional dissatisfaction, insufficient motivation, etc. Some studies indicate that the results are related to context, that they differ depending on the professional group and place of employment [3],[4],[5], and that dual practice is more common among specialist doctors who work in hospitals than in other professional groups or among doctors who work in health centers. According to Ferrinho et al. [2], dual practice can also be expected as a result of health care reform like in Canada [6], where restructuring of the surgical service resulted in 3.5 times more surgeons working in more environments than before the reform. Literature does not provide enough facts on to what extent healthcare professionals use dual practice, the balance between economic and other motives for using this practice, or the consequences concerning the proper use of scarce public resources intended for health care [2]. Although dual practice is considered a possible systemic solution to issues such as limited resources (and revenues) in the public sector, low regulatory capacity and interaction between market forces and human resources [7], if poorly regulated (i.e., there is a lack of regulations or they are insufficiently applied), it may lead to a conflict of interest, predatory behavior of healthcare workers, limitations in accessing services, poor quality of services provided to the users in the public sector, as well as resource drain from the public sector to the private sector [2].

Apart from economic factors as predictors of dual practice [3],[7],[8], it is also necessary to research its prevalence, real consequences, managing this phenomenon, as well as the assessment of the impact of policy measures implemented in this field.

DUAL PRACTICE IN SERBIA AND WORLDWIDE

Dual practice is a phenomenon found in most countries, but it is significantly more frequent in low-income countries, such as ours [9],[10],[11],[12],[13] and it has been gaining more and more importance lately due to the fact that it may contribute to reducing the already insufficient number of professional health workers in healthcare systems [14]. It has been noted in literature that healthcare professionals with low salaries, as is the case in Serbia [10],[11], do multiple jobs to make the ends meet [12],[13],[15],[16]. When it comes to the public healthcare network in Serbia [17], healthcare professionals are generally dissatisfied with salaries, benefits, equipment and workload [18] as their salaries have been below the national average income for several years now [10],[11],[12], so dual practice is a survival strategy like in multiple countries worldwide [7]. An optimal regulation of the situation and the mobility of health workforce depends on the exceptional circumstances of the country, government capabilities, and the improvement of the health system [8],[19]. In the Republic of Serbia, the current Law on Health Care (Article 199) and the Employment Act (Article 202) [21] enable fulltime employees (both in the public and the private sector) to have an additional job up to 30% of the total working time in addition to their primary job. Recent data from a survey of employee satisfaction in public institutions of the Republic of Serbia conducted in 2018 [22] indicate that since 2014 the number of those who are planning to go to the private healthcare sector has been on the rise, and that almost half of all doctors and one-third of nurses use some form of dual practice [22] (318). Various studies have shown that dual practice is common worldwide – 43% in Great Britain [23], 20% of all doctors in Spain [24], 79% in Australia [2], 80% of doctors from the public sector in Egypt, Indonesia and Kenya [25], and almost 100% of doctors in Austria are holders of dual practice [26]. A similar study in Serbia [27] showed that the employees at the tertiary and the secondary level of healthcare are more often holders of dual practice, as well as the doctors employed in hospitals, in comparison with other professional groups: the approximate prevalence is 90% of doctors in the public sector in Ireland [26], 60% of doctors in Great Britain and Northern Ireland [2], and 25% of clinical doctors in Norway [28]. A recent study from Serbia [27] points out that holders of dual practice are mostly older than 55 years, while other studies worldwide have also confirmed that senior staff [26] and specialist doctors [28] are more often holders of dual practice than their colleagues; for example, almost 100% of senior specialist doctors in Austria are engaged in dual practice [26]. Studies conducted on other continents also point to the prevalence of dual practice. Nurses in Australia show a preference for casual employment [29], while the demographics of the nursing workforce who are employed temporarily or casually is unknown, as well as how these groups are distributed in relation to other staff and how many contracts of employment they have achieved through health services, either through private health agencies or occasional hospital engagements [30]. The aforementioned indicates that the phenomenon of dual practice is not only present in the category of doctors but is also common among other health professionals. According to data from 80 hospitals in South Africa [31], 40.7% of nurses reported working outside the institution where they were officially employed or working for an agency in the previous year. Among those who had multiple jobs, 11.9% took a holiday so that they could work for an agency, 9.8% reported conflicting schedules between their primary and secondary jobs, while nurses who had dual practice were significantly more often on sick leave and paid less attention to their primary job [31]. Some studies indicate that health system managers have fewer opportunities for dual practice than clinicians [2], while the results of a study that researched the presence of dual practice in developing countries on a sample of 138 doctors with a degree in public health management indicate that 87% of participants earned extra income in at least one of the following ways: by working for non-governmental organizations or development agencies, by having private practice or doing another activity that supplemented their income; so, with an additional job they increase their income in the public sector by 50% to 80% which results in resource drain from the public sector and a conflict of interest [13]. The previously mentioned research from Serbia [27] indicates that individuals who work at tertiary health care institutions are 1.97 times more likely to be engaged in dual practice compared to the employees of primary health care institutions. In addition, according to this study, individuals who are dissatisfied with their jobs and male individuals are more likely to have dual practice, whereas medical staff (especially doctors and nurses) are almost twice as likely to be engaged in dual practice than non-medical personnel [27]. In this study [27] it is also stated that individuals who do not have a managerial position are more likely to have dual practice in comparison with individuals appointed to a managerial position. Dual practice is thought to be more common due to cost containment strategies or staff shortages [2], while some researchers point out that better equipment, employee performance evaluation, and available working hours are important for highly educated employees and senior employees who believe that dual practice increases their clinical autonomy and enables their skills to be used to their full potential. [32],[33].

REGULATORY RESPONSES TO DUAL PRACTICE IN SERBIA AND WORLDWIDE

At the international level, governments have different reactions to the phenomenon of dual practice [26]. Certain studies indicate that dual practice is a mechanism in regulating limited resources in the public health sector [7], but on condition that it is regulated by a contractual agreement [16]. The most common regulations that control the phenomenon of dual practice refer to three types of interventions: (1) offering regulatory contracts to employees in the public sector, (2) banning dual practice, and (3) limiting the level of participation in income and private activities [26]. The results of this research point to the need for adapting the regulations to different economic systems [26]. Dual practice is recommended in the form of contractual arrangement [33] and is constantly monitored so as to prevent healthcare professionals from paying more attention and putting more effort into their private practice [2],[3],[34],[35] or from using their position or resources in the public sector to improve their own reputation [2],[12],[15],[29],[35] and direct profitable patients to their private practice [15],[29],[36],[37],[38]. In a study conducted in Bangladesh [15], which surveyed physicians employed in the public sector at different institutional levels who were also engaged in dual practice, most participants reported at least doubling their income by entering private practice. In the Republic of Serbia, the current Law on Health Care (Article 199) and the Employment Act (Article 202) [21] enable full-time employees (in either public or private sector) to have an additional job up to 30% of the total working time in addition to their primary position. Employees are legally obliged to inform their directors and the Ministry of Health of the Republic of Serbia of holding dual practice and to pay tax, but they are not legally limited in relation to the sectors where they can apply dual practice (e.g., in private practice, in education, or in other sectors), and there are no official estimates on the prevalence of dual practice. As there are no strategic solutions, some steps have been taken to mitigate the outflow of healthcare professionals from state healthcare institutions, such as the possibility of working for two or more employers (dual practice) or working overtime for one employer [20], voluntary residency, scholarships, and employing the best students. In Croatia, an EU country, if the institution has a joint contract for dual practice, all employees except for the director, deputy director and assistant director can work at these institutions for a year [39], while some researchers clearly stated that Croatians were well aware of the consequences of unregulated dual practice, because holding dual practice without clear regulations could result in a serious conflict of interest [40],[41]. In the Federation of Bosnia and Herzegovina, dual practice is allowed in the scope of up to one third of regular working time, and with the approval of the responsible chamber and employers [42]. In this country, citizens receive health care from public and private healthcare providers, and a study that examined the way of providing healthcare services, especially with regard to the relationship between public and private service providers, indicates that the public sector has numerous weak points such as ineffective service providing, poorly motivated staff, high prevalence of dual practice among employees in the public sector, poor working conditions, and geographical imbalance [43]. The main method used by the authors was to review and analyze the main legal, political, and strategic documents on healthcare system that are relevant for determining the public sector and the private sector in the healthcare system of the Federation of Bosnia and Herzegovina. The authors also analyzed technical documents, project reports and publications produced by agencies that had operated in the federation of Bosnia and Herzegovina or managed projects in that country. Very scarce integrated data on the composition and activities of the private health sector in the Federation of Bosnia and Herzegovina made the analysis and comparison more difficult. In Montenegro only employees with a written approval signed by the director can be engaged in dual practice [44]. In the Republic of North Macedonia, the terms and fees for dual practice are regulated in advance by a written agreement/contract and they relate to participation in meetings, consulting, market research, medical and scientific studies, clinical trials or trainings [45]. Reviewing the literature on dual practice shows that limiting dual practice without offering better working conditions can result in brain-drain among healthcare professionals [24],[32]. Limited dual practice, dissatisfaction caused by personal and organizational factors very often make healthcare professionals opt for cross-border mobility [24],[32],[33].

CONCLUSION

The review of literature indicates that in Serbia, its neighboring countries and in most countries in the world there is an unfavorable trend in the field of human resources for healthcare where unsatisfied professionals do jobs outside the institutions where they are employed or plan to leave the country in search of better opportunities. Dissatisfaction of healthcare professionals and the tendency to mobility can have an influence on the efficient functioning of a healthcare system in general. In order to recognize the role of dual practice and other types of mobility on health workforce market, it is necessary to emphasize the importance of systemic monitoring, data collection, reporting and evaluation of workforce, distribution and current situation in Serbia and other countries. Supplementing data and strengthening evidence on the healthcare workforce are preconditions for effective improvement of population health and fruitful international cooperation in the field of public health. There is a need to expand research by examining the reasons for dual practice which would fill the gaps in the scientific literature in some areas related to this phenomenon in terms of prevalence, real consequences, and its management. Researching the assessment of the impact of implemented policy measures in the neighboring countries and worldwide, relying on the experiences of other countries that have previously gone through the period of transition, is of great importance. The impact of the current regulation of dual practice in Serbia requires an adequate assessment so as to determine to what extent this practice affects the efficient deployment of health workforce to public healthcare institutions, e.g., the efficiency of working hours, productivity, salaries and replacement costs, an increase in patient waiting time, patient costs, and reduced quality of service. In addition, it should be determined to what extent it is possible to make international comparisons (e.g., making comparisons with European legislation or policies of other countries) and it is necessary to upgrade accordingly. International experts advocate the existence of more data on dual practice among workforce and the need for integrating these data into national health workforce accounts [46] in order to help managers to create and use the necessary capacities of health workforce so as to achieve universal health coverage. Complementing the indicators on health personnel, which according to the WHO [47] contribute to good management and decision making in a healthcare system, as well as creating an information system and a quality database, would enable international comparability. The need to create a national health policy for monitoring dual practice in Serbia and to develop strategies for mitigating negative effects has been highlighted [48].

NOTE

This paper is a part of the doctoral dissertation defended in 2021 within the joint study program of the Faculty of Organizational Sciences and the Faculty of Medicine of the University of Belgrade.